A good comparison is veterinary medicine in the US. All the functionality is fundamentally the same, but insurance isn't common. Prices are vastly lower, and it's all super-convenient. Typical for an injury requiring stitches: $150, plus $15 for some antibiotics, which they hand you as you walk out.

Every time I go to the doctor I wish I could take myself to the vet instead.

Even more importantly: When you walk into the vet, they can estimate what your options will cost, so that you can make an informed decision.

When it was our cat's time too, I was struck by his end of life experience versus that of a human. Whereas a human could have exhausted their life savings on futile treatment or end of life hospice care, Denver cat went quietly into that good night on his favorite blanket surrounded by his loved ones.

I'm currently in need of some very common medical treatment, but the maze of providers I need to go through in order to get a referral just ain't worth it. Versus, if I were a cat or dog, I could simply go to the area university veterinary hospital and likely get my answer same day.

I had to get medical attention in Thailand and it was wonderful. I walked into the hospital, explained my symptoms to the nurse, got wheeled to a private waiting room, met with a specialist 10 minutes later, got some scans done on state of the art equipment (newer than what you would find in an American hospital), had a consultation, prescription, settled up for ~$90 and I was out of there in just under an hour.

I plan to go back if I ever need a major medical procedure.

The major difference is what happens when something goes wrong - you really want to be in a situation where you can be transferred to a research hospital that has the guy who has handled the three other times X has happened before.

I've always opted to be treated locally when needed - but I also pay for an emergency evacuation service that puts my butt on a jet back to the states if things go pear shaped.

This experience is often available for humans too (even in countries without risk of medical bills bankrupting oneself) - it largely depends on how far the religious right has embedded itself in government.

Pieter Hintjens (of ZeroMQ and AMQP fame) chose this option when diagnosed with terminal cancer, and wrote about it extensively at [1] and [2].

[1]: http://hintjens.com/blog:116

[2]: http://hintjens.com/blog:115

Euthanasia is commonly banned, but palliative hospice (morphine until you die, combined with caloric reduction) is allowed.

I'm cautiously optimistic that euthanasia will become widely available by the time I'm old. It seems to preferred over dementia by most people I've spoken to in both my generation (late twenties) and my parents.

Starvation at hospice is a slow and expensive way to go. It’s only appealing in comparison to hospital stays.

Anecdotally - it seems like a non-trivial percentage of my mom's trips to the vet end in euthanasia.

I suspect there is an order of magnitude in the difference in level of care that goes into the average person vs dog. I mean, for one, it is very common to hear things like - "well, you have to remember, their lifespan is short. They only have a year or so left to live." This just isn't a discussion that is had with people.

I think you need to stop taking your mom to the vet

> They only have a year or so left to live." This just isn't a discussion that is had with people.

Except doctors. Doctors refuse life extending treatments at a much higher rate than general population of patients.

I'm with them. I have no desire to transfer my assets to an already-wealthy bunch of doctors and healthcare conglomerates in exchange for dragging out the inevitable.

You are currently thinking with the rational part of your brain.

Find a 4-5 story parking garage and stand up on the edge. That part of your brain that kicks in and tells you to get back down to safety will also tell you to pour every cent you have in to buying a few more weeks.

> Find a 4-5 story parking garage and stand up on the edge. That part of your brain that kicks in and tells you to get back down to safety will also tell you to pour every cent you have in to buying a few more weeks.

This can change when there is no "back to normal" available. When your quality of life is shot and you know that tomorrow won't be better than today.

In a suicidal person who jumps off that building we consider this a tragedy because there's usually no physical reason that those feelings couldn't have passed, why their life couldn't have been normal again.

But in someone with a terminal condition and a body that's just done... and especially if they're well informed about the realities of their medical condition... yes, there can be things you care about more than throwing every cent you have into extending the pain.

A person who's in such a state usually does not have the physical ability to do this.

But I think there's truth to both points, and every single case will be different.

I believe the only blocker to allowing euthanasia in the developed world is a potential for abuse.

I'm pretty sure you're wrong, but time will tell I guess. I've already watched both my parents die of the inevitable effects of getting old, and I have pretty firm ideas about what parts of that process I want to avoid for myself.

That is the sort of discussion that happens around old or terminally ill people. Some people prolong things as long as they possibly can, but in my observations this generally only seems to cause misery to everyone involved.

> Anecdotally - it seems like a non-trivial percentage of my mom's trips to the vet end in euthanasia.

Part of this could be that pets are limited in their ability to communicate details of their feelings to humans, making it harder for humans to tell the difference between a pet that is acting off because of something that they will recover from without a trip to the vet and one that is acting that way because of something that is serious and is going to go downhill fast if you don't take them to a vet soon.

This leads to vets first going to the vet for a given illness later into that illness than a human with a similar illness would have went to the doctor, hence a greater chance of it being too late.

I’m not a religious or spiritual person, but I assure you my cat told me when he wanted to fight, and when he was ready to go. I’ve never seen a cat so happy as when he saw me again after that long week in the hospital, and likewise when he was on the floor of the bedroom in pain, his face and his little weak voice told me he was ready to go the same as each person I’ve been with in their last moments.

Maybe that’s part of the problem? I mean - my grandmother lived to be 96, was “healthy” nearly to the end, but realistically was ready to go a good decade before that.

With my cat (and this would likely be the case with any of my cats...) we took a reasoned look at the medical options and the quality of life choices. It wasn’t exactly cheap, but we basically bought him a year of life. If it had been a human family member, we would have gone through exactly the same decision, IE: do you want to keep fighting and do you want to go through this procedure or not?

It isn’t but it should be. Being Mortal is a phenomenal book about end of life care that I would recommend to anyone and everyone old or young.

In Canada (at least in my experience) it's the opposite. Vet clinics look a lot like US medical centres, including the state-of-the-art equipment and corresponding prices. Meanwhile the limited for-profit medical services are (mostly) affordable because they do general procedures with relatively low barriers for competitors. Generic drugs are dirt cheap when available; non-generics cost as much as the US. Dental care is all over the map from very affordable to ridiculously overpriced.

Another Canadian here with a similar experience— friends with dogs even pay for insurance because of the potential for frightfully expensive private surgeries down the road. Though I do wonder if there's a psychological thing there where dogs form stronger bonds and so people go to greater lengths for them, whereas other animals are easier to let go of if circumstances indicate that the time has come.

And yes, dental care is all over the map— it feels very much like what I imagine US healthcare to be, with co-pays and mystery charges and having to log into my insurance company's online portal to do stuff. The NDP made a bunch of noise in the last election about a national dental plan, though even that effort would only have covered family incomes up to CAD$90k [1], so it wasn't anything like the universal no-questions coverage we have for core healthcare.

1: https://www.cbc.ca/news/politics/ndp-dental-plan-fact-check-...

> And yes, dental care is all over the map— it feels very much like what I imagine US healthcare to be,

Funny enough, dental insurance in the US is very straight forward. I have always gotten quotes up front with very clearly explained charges. The way it has worked is dentist talks over with me what they want done, billing person runs the numbers and gives me paper with estimates, and if I agree I pay whatever balance I owe on the way out.

Amazingly straight forward, kind of like how everything else should work...

FWIW Eye doctors and insurance on glasses works just as well.

Ha, I mean that's basically what it is in Canada as well— it's just so much more than going to the doctor, where you never even see a bill.

An example of my frustration with dental: I went to my usual dentist for a checkup, but then he referred me to a specialist. The specialist appointment wasn't going to be for a month, but then they call suddenly and have a cancellation the next day. I end up having to pay full price for the specialist appointment because my insurance doesn't like that I had two "assessment" appointments back to back.

On another occasion, I was quoted a procedure, and my decision for when I wanted to have it done was driven entirely by which insurance-year it was going to fall under, rather than by my convenience or how urgent it was, or anything else.

I know these are fundamentally "insurance issues" and I suppose better supplemental insurance could make them go away, but at the end of the day, just like with Americans, my insurance is chosen by my employer and I have basically no control over it.

How much do you pay for dental insurance?

It's uncommon here in Norway, unheard of in fact as far as I am concerned. I have a checkup once a year that includes a really thorough cleaning procedure and x-rays. That costs about 120 USD. If I need a filling that will probably add about 100 USD at the most and the two crowns (milled ceramic done on site, on demand) that I have cost about 500 USD each so over the last thirty years I have spent about 6000 USD on dentistry, so an average of 200 USD per year.

I don’t even use insurance for dental, I just pay directly for my services.

Immigrant to Canada, from the US, here.

Do people in the States not pay for pet insurance?

We sure did go for it in Toronto. Vets seem to charge by the pound (wait, sorry, kilogram, immigrant…). Large dogs seem to come with large medical bills, and we were strongly advised by friends and family to go for pet insurance.

Now, I am not actually sure that pet insurance, versus setting up a dedicated savings account that we sock money into, was the best idea. If anything, we went for it because I am from the States, and I assume any non-trivial medical issue will be cripplingly expensive.

I don't. Part of the reason is I'm ok with a small chance of a few thousands dollars bill, but a bigger reason is I don't trust insurers: their standard contract would first explain how I have no rights and then add that if I have a problem with that, I can go to their pocket court (arbitration) to learn that I really have no rights.

It's available, and some people pay for it. I would be very careful to read all the fine print though.

For me, the cost of routine care, spay/neuter, and a certain amount of unforseen expenses should be part of what you plan for when you get a pet. Beyond that, it's a judgment call as to whether the cost of some treatment is worth it. I know people who have spent thousands of dollars treating cancer in an old dog, and others who have euthanized younger pets who developed expensive but in theory treatable health problems. I don't think either approach is wrong, it's up to the owner.

My dog just had major knee surgery (TPLO). Its cost will be total of about $5k when we have some x-rays in a few weeks. I don't have pet insurance, however, most companies don't cover it. There are tons of loopholes, like human insurance.

Vets vary widely in the US. Vet clinics are wildly expensive in many locations here, with veterinarians earning well-paid doctor wages and using modern vet equipment.

Doctor wages and modern equipment are a small portion of human care, though.

> non-generics cost as much as the US

They can, but they vary. I'm a citizen of both countries and there's one allergy medicine I take where the generic price in the US is the same as the name brand price in Canada. The name brand in the US is 7x higher than the name brand in Canada.

Not disagreeing, but one factor that complicates it is that they're allowed to take bigger risks with pets (both with regulations and potential civil liability) than with humans.

Indeed, treating for cost of liability (insurance) vs best outcomes. Doctor's conflict of interest built into the system.

Whatever markups are there are not linear, interestingly.

I had to get an MRI from a vet hospital in the past. It was still over a thousand bucks, and in the range of quotes I'd gotten for human MRIs before.

I wonder what similar stitches in an urgent care vs a primary care office vs an ER for a human would cost.

As the other reply mentioned, I wonder if this is just the human cost insanity infecting veterinary costs -- MRI tech could be used for humans, so the machine is absurdly expensive, and vets have to charge more to justify the cost of having a dedicated pet MRI.

MRI machines also require superconducting magnets and liquid helium, high-amperage utility hookups, etc., so they might just be expensive regardless.

True, but in my experience getting a few MRIs, the price from various imaging centers nearby varied (for the exact same MRI) from $500 to $2000.

The $2000 place is associated with a local hospital chain that is well regarded. I guess that is how they could negotiate $2000 for an MRI with insurance and the other place (that I went to) was only able to negotiate $500.

Honestly, the price for health care in the US is all funny money. I've gotten a single shot, of a very common drug, that was billed at $20k, knocked down to $10k with the "insurance discount", so my 10% co-pay ended up $1000, with insurance!

I had a surgery that was billied at $250k where the "discount" was over $150k. That $250k price is clearly not real.

And theae kinda of prices are why I'll probably never choose to live in the US. How do people live with the possibility that a freak accident could completely and permanently finacially ruin them.

The highest medical bill I've ever paid is £8.50. Of course I pay National Insurance to cover the costs of the healthcare system. But as far as I can tell that's no more expensive than what people in the US pay despite their insurance having not nearly the same coverage.

> How do people live with the possibility that a freak accident could completely and permanently finacially ruin them

They have insurance. And if they don't, they declare bankruptcy. It's not permanent. It's a seven-year ding on your credit rating.

Yes. This is the piece people don't seem to understand. Bankruptcy doesn't ruin your life. It just makes it hard to get credit for seven years.

I think the piece that people don't seem to understand is how you can live in a country where bankruptcy is presented as a normal part of life.

I have never declared bankruptcy and there isn't really a situation that I can foresee where I will need to.

Do you sell all your assets, like realty where you live in, personal possessions, car, tickets to vacation you happen to buy beforehand? Or declaring bancrupcy is really harmless and easy?

I am genuinely interested.

It varies by state. There's a list at https://www.nolo.com/legal-encyclopedia/bankruptcy-exemption.... Basically you can keep stuff like the house you live in, your not-flashy car, household goods, tools of your trade, a small amount of personal property (if you own, say, a nice musical instrument or some jewelry worth $2k or whatever). As a general rule, anyone rich enough to have to sell property in a bankruptcy already has health insurance.

And please don't take any of this as a defense of the current abominable US system. I lost my dad to complications of untreated diabetes because he didn't have health insurance. What I'm saying is that people who should declare bankruptcy often don't, because they think bankruptcy will ruin their life. It won't. It protects you from predatory lenders and gives you a fresh start.

> As a general rule, anyone rich enough to have to sell property in a bankruptcy already has health insurance.

Isn't the issue that health insurance often doesn't cover everything. And that it's very difficult to get health insurance at all if you have pre-existing or chronic conditions (exactly the people who need it the most).

It also costs you all of your assets.

Maybe, but MRIs in India (in better machines, no less) are MUCH cheaper.

Pets tend to be smaller than humans, so manufacturers could ensure that pet MRIs don't drag down human MRI prices by making smaller MRI machines that only work for pets. They probably do.

There are "small animal" MRI machines, which are mostly intended for research.

The bores are really small: 55mm or so is not uncommon, so a mouse would fit, but nothing much bigger. Other animals are usually scanned on a machine meant for humans (sometimes even the exact same ones, very early in the morning or late at night).

Tend to be, but it's not that rare for someone to have a dog that's a hundred pounds and five feet long. That's in the range for an adult human.

My dad, a radiologist once had patient that was so large that they couldn't fit them on a conventional CT scanner. Luckily this was a university town, so they were able to access the vet's large animal scanner.

Makes sense. Horses and cows get much larger than humans!

I suppose that does make sense.

Re: the large patient, yikes!

Part of that is probably the lower volume, so they have to amortize the costs over fewer procedures. Most pet injuries don't need an MRI or if the injury/illness is that bad the euthanasia or palliative only option is more considered.

Human MRIs are also pretty expensive, and human MRI machines are generally booked solid. MRI machines cost a lot and also cost a lot to operate.

Last time looked at the costs of imaging I got the impression that there are a monopoly and other captive market effects at work.

You'll hear medical professionals claim imaging is expensive because the machines are expensive. Which just says to me that medical professionals aren't accountants.

Consider a dental w-ray machine. $15-30k. That's the cost of Prius used as a Taxi. You don't pay a couple dollars for a 15 minute Taxi cab ride.

An MRI machine, I forget how much those cost. But whatever, lets compare one with a modern passenger airliner. Cost is about equivalent on a 'per passenger' basis. And an airliner requires highly trained professionals to keep it running.

You are on the money.

My dog had MRIs and ultrasound recently. Each event was $700-$900 a pop.

I take my dog for routine full checkup that includes MRI and Ultrasound whenever I travel to south america. They use the same machine brand as in the US, with same diagnostics. I pay $50-$85 over there for the same tests.

Vets over in SA (not business owners) make about $500-$1000 USD per month.

It would seem the huge cost is not from the machine. Its the labor. I think these are the 2 key differences:

a) Based on my understanding, getting licensed in this SA country is a nonissue. There is in fact an oversupply of vets because its easy to practice.

b) The price for the vet studies is on the 2k-5k year for a private U. Compare with US Colleges.

Regarding quality: Our vet in SA diagnosed my dog after seeing the US diagnostic test reports , over whatsapp. She was correct on her diagnosis from the start. It took 4 different US vets, 3 separate facilities, 4 days of hospital bills ($5000) to arrive at the same conclusion that I got from a whatsapp.

It is not the machine problem. It is a captive market with huge costs related to labor.

A new 787 is 200 million and carries up to 300 people and has a working life of 44,000 flights, for a total of 13 million people trips.

A new MRI costs ~3 million, has an operational life of 10 years, performs 5000 scans per year, for a total 50,000 people trips.

The people operating the MRI machine are probably payed more than anyone working on the airplane and take vastly more time per passenger.

MRIs are principally taken by technicians then a doctor will interpret them but the bulk of the operation isn't done by doctors and the techs are well paid but are paid less than a first year commercial airline pilot. IF you include all the maintenance and support around in airplane and around an MRI machine I think the airplane will be even further ahead.

[0] https://www.careerexplorer.com/careers/magnetic-resonance-im...

Thanks, I learned something today. I think the point still stands if you include the time of the radiologist and tech, capital and employment costs for MRI in the US are substantial.

I agree that it is a very strange comparison between MRI and a plane, I was just chiming in on the capital and employment cost for each could be comparable on a per trip basis, not that MRI prices are where they should be.

In my personal opinion, a major problem with US healthcare is a race to the top, where the newest and best care is sought irrespective of the price. A judgement call needs to made somewhere on cost/marginal benefit, and post-procedure reimbursement debates is the worst way to do it. CT machines can cost between 250K and 14 million, as I mentioned in a sibling post. Similarly, MRI costs can range from $170-$5,500 [1]. In the current system, almost nobody is incentivized to keep costs down. Doctors and insured patients want the best care, as costs are externalized to the insurance pool. Insurance companies want to maximize costs, because their profit margin is limited by a % of spending.

https://turquoise.health/service_offerings?q=MRI&location=90...

> A new MRI costs ~3 million,

You seem to be off by a factor of 5 or 10.

https://info.blockimaging.com/bid/92623/MRI-Machine-Cost-and...

I was quoting the number for a modern 3 tesla MRI machines, which would fall into the 500k+ range on your link. These are high end but not necessarily rare. For example, UCSF has 4 of these machines. These can easily be on the order of 3 million+ with installation

https://www.pasadenanow.com/main/lab-in-emerging-biomedical-...

Here is a link for a 7 million suite to house one of the machines https://www.dignityhealth.org/sacramento/about-us/press-cent...

While costs for these machines are going down, even more expensive 7 and 10 Tesla machines are starting to be installed, going up to $14 million

https://www.nature.com/articles/d41586-018-07182-7

3 T machines are not necessarily better, it depends on what they're trying to look at, getter a sharper image of noise is not useful.

Anyway, your estimate seems to be way off, basing it on a 6 year old puff piece for a cutting edge model that was deployed in a lab. The cost for a typical new MRI is more like $500k.

Do have any personal info here, because the first ten articles I read were up there and your article doesn’t negate it

Doesn't negate what?

If you ask "How much does a car cost?" The answer is not "Here are some articles about people buying Lamborghinis that cost $250,000".

Most people are using a middle of the road 1.5 T machine.

https://lbnmedical.com/how-much-does-an-mri-machine-cost/

I never said I was talking about averages ct machines any more than a brand new 787-9 is the average plane. You can get a 20 year 737 for a lot less than 200mil, and is probably closer to the average.

If your point is that MRIs less than 3T exist, I agree. If your point is that cheaper MRI exist, I agree. If your point is that nobody has spent 3 mil on a CT, then I disagree. A link showing the price of used machines 10-15 years old isn’t going to change that.

Very similar in developing countries, as well. I've gotten stitches in Mexico and Colombia for less than $40 USD each time which healed comparably or better to the stitches I've paid >$500 for in the US. Consultation for an eye infection along with the antibiotics in Mexico was $23 USD.

"Every time I go to the doctor I wish I could take myself to the vet instead." Kramer thought that in a Seinfeld episode; it was a great episode. Season 8 Episode 10.

Veterinary care has been increasing considerably more than core inflation (quick search turned up https://www.in2013dollars.com/Veterinarian-services/price-in...). I'm not sure how that compares to inflation in human healthcare.

I feel like the demand for veterinary services has gone up drastically. It shocks me how my millennial friends will spend $5000 without a second thought to keep a dog alive. Older generations often seem to put pets down in that situation.

I haven't come to that yet, but when our 3 year old GSD went blind, even though it was an elective surgery it wasn't a super difficult choice to spend that much to restore his sight (cataract surgery) given that the same problem basically can't come back. He is six now, and it has really improved his quality of life (he enjoys chasing sticks in the lake again). If he was 10, we would probably not have made the same choice to spend the money; because he would get much less benefit from it.

You spend more time with your dog than most people, and I certainly care about him more than any person who is not in my immediate family.

Older generations had a lot more children.

Vet care and pet products generally have been a target of private equity lately. Of course so has private (human) practice.

It would work fairly well for minimal routine care and relatively minor trauma, as long as euthanasia is on the table for major long-term care, major trauma, and for those who cannot pay.

Well that sounds like a Black Mirror episode — “Crowdfund your schoolfriend to not be euthanised”

My PPO pays my GP about $75 for a regular visit. A zpack is $6.50 at my local grocery store, $15 at CVS.

The vet always guilts me into some sort of stupid test. Usually I walk out of there $300 lighter.

> For example, in 2011 in America, the average charge for an office visit for an established patient, level 3, requiring approximately 15 minutes with a doctor, was $104. The average total paid was $69. Some more examples: a cholesterol test has an average submitted charge of $72; and a glucose tolerant test (GTT) has a submitted charge of $60.

Seems pretty similar to the vet. But that's just an office visit. The expensive stuff is at a hospital when the CYA care shows up.

> My PPO pays my GP about $75 for a regular visit.

Which is why they spend 5 minutes on you, 90 minutes after your scheduled appointment time.

Hmm, I'm not sure how I feel about that comparison. Most vets double up as pharmacies, restrict access to prescriptions, and sell at least some prescription drugs at prices that have been marked up by at least an order of magnitude by the manufacturer.

Some of the bills that I've run into have still managed to approach the cost of routine visits at some specialists when billed to my HSA.

My experience conflicts with your assertion. Costs for veterinary care have sky rocketed over the last 15 years, and costs for procedures without pet insurance are sometimes 75% to nearly the same price as the same procedures on humans. Prices for MRIs, X-rays, surgery and drugs are all very close to human medical care costs.

FWIW: I wonder if you are in an urban area? When I compare the cost of vet services with my friends in an urban setting relative to what we pay here in rural, small-town America, I'm shocked at the difference. We have a university about a two hour drive away with a noted vet hospital - even their services were priced better than those I've heard anecdotally on the other (more urbanized) side of the state.

I'm guessing vets take advantage of the ever growing tendency to consider pets as family members to inflate the price. Especially since (from very anecdotal evidences) it seems to be mostly middle/upper class people who are so invested into their pets.

In the countryside people tend to have a more utilitarian view of animals and would simply get a new one rather than wasting money keeping a sick animal alive.

> FWIW: I wonder if you are in an urban area?

I'm not.

An human ACL surgery is $20-$50k, 10x the price for dogs.

Is it the same for studs or thoroughbreds?

What I’m getting at is that for most animals the owner can be compensated for accidental death easily. (How much is a head of cattle at auction?)

Not that this explains all the discrepancy, but it may explain a non trivial percentage.

Also your dog probably needs 1/10th the dose that an adult needs.

It's way more complicated than that: there are differences in metabolism as well as size. It varies from drug to drug too, but as a rule of thumb dog needs about twice the human dose (in mg/kg). A 60 lb dog therefore needs about the same as a smallish adult.

Here's some FDA guidance on how to translate doses from animals to humans: https://www.fda.gov/media/72309/download

Even more than twice. My dogs, despite weighting 5th of me had similar to mine dosages of antibiotics and antihistamines

Large dogs can be the same weight as small humans, so I'm not sure what accounts for 1/10th. Even medium-sized dogs like labs are about half the weight of a healthy, average-sized person.

Depends on the drug, but their metabolism isnt identical to ours, and humans can often require significantly higher doses compared to other animals when controlling for dosage per weight unit. But again it depends and there is no hard and fast rule as far as I’m aware.

Having just put down two pets with costly late in life medical conditions I'm kicking myself for not getting health insurance. We were able to afford most recommended procedures but not many can. In fact, there are several programs locally for people who can't pay for their vet bills which I've considered contributing to now that I've seen first-hand the anguish people have to face when considering procedures they can't afford for animals they love like children.

Me too. I suspect some of this is regulatory overhead and compliance. I can give pets injections (inoculations and antibiotics) without even talking to a vet. The only exception I ever ran into was antibiotics for a snake, as the feed store didn't carry that. To get those things for myself would require a prescription from a doctor.

It can be the opposite as well. I work in a vet clinic, but I also am in New Zealand- where there is free/subsidized public healthcare. Thus you get people who go to the vet expecting things to be free or cheap.

You can certainly go to Farm and Feeds and get penicillin amongst other pharmaceuticals. Plenty of farmers hours away from metro hospitals and providers commonly use these sources.

The last time I needed stitches, it cost between $70 and $80 AUD (unsubsidised - this is what an international visitor would have paid), and was wholly covered by the government.

Actually pet health insurance is very common. Everybody that I know with a pet has one and even work has discounted pet health insurance as part of employee perks

Just learn aseptic technique and suture yourself.

I generally agree with your sentiment - regulation and insurance overhead are big costs. I do think some people should be able to do the basics at home if they wanted. Basic sutures are a pretty good example, you could even save that $150 that you mentioned.

While I'm usually a DIY kinda guy, giving this advice on a large scale is a perfect recipe for disaster and really encapsulates the dark-ages dystopia that the current US medical system has become.

While looking for moldable plastic material ("Sugru" and similar) on Amazon, I was a bit taken aback by the reviews for one such substance. Multiple reviewers were stating that they were using this stuff to make their own dental crowns or some other DIY tooth repair because they couldn't afford a dentist. I found this quite shocking and I'm not sure if these people were serious.

See the reviews on this product page: https://www.amazon.com/InstaMorph-Moldable-Plastic-6-oz/dp/B...

The teeth reviews on that product are pretty crazy. I kept reading them thinking "they really thought they could do this themselves??"

If someone self-studies basic things, it shouldn't be a big problem. Just look at first aid. There are many people who have no idea what to do for minor injuries because they never took the time to learn. Suturing is on the borderline of of falling into first aid. There are people today who learn the basics of it for emergencies or because they live in remote locations.

Specialization of labour is what's primarily responsible for the industrial revolution - while this is a hyperbolic comparison, is the only reasonable way to fix healthcare to throw away all specialization and go back to "do it at home"?

The service needs to be available in some form at least for folks like me that have an essential tremour or otherwise are limited in fine motor skills.

I'm not saying do everything at home for everyone. But if some people did minor things (first aid type stuff) at home, that would free up the system for more important cases. Just think of all the people that fo to the doctor with a cold. A little education could go a long way.

People keep talking about patients going to the doctor for frivolous reasons, but what I see is that it is much more common for patients to ignore symptoms or take some over-the-counter medicine, and take too long to see a doctor.

This, I think, is a natural result of the US insurance system. Being sick is quite expensive and not being sick but being proven to not be sick is also rather expensive so people will naturally tend to avoid formal treatment longer in the hope that everything just magically goes away.

This also contributes to the amount of emergency room treatments that could have been trivially handled with earlier intervention. A boil that has gone septic is a very serious medical condition, but nearly all boils can be trivially resolved with a short regimen of antibiotics.

True, it does go both ways. I would still say it comes down to a lack of education/knowledge either way.

This is insane. Mess up with this and you could end up with a serious infection

You could end up with a brain infection, very easily.

If you cannot afford US dental care, and you are not super poor, get a 1 way ticket via Kiwi.com to a more “eastern” European Union country like Croatia or Poland. If you use scripts from GitHub or are very good at searching you can get such tickets for $200-$250. You can find extremely excellent dentists with great qualifications and reviews in countries like that, and many have amazing reviews and are super cheap.

A lot of people from EU countries, that do not have “socialized dental care” go to countries like that a couple times a year to get dental care.

This is totally bizarre to me.

> If you use scripts from GitHub or are very good at searching you can get such tickets for $200-$250.

This is the average cost, per tooth, of the work I had done here 2 years ago, in the US, at a dentist where I paid cash.

> You can find extremely excellent dentists with great qualifications and reviews in countries like that, and many have amazing reviews and are super cheap.

I’m wondering how cheap they have to be in order to make it cheaper to fly to europe. How much would be an extraction or a filling replacement?

Well, I am a dual US|EU citizen, currently living in Croatia. So, I do travel abroad a lot.

When I lived in the US, I had an individual plan through Costco (Delta Dental) that was quite a good deal. It was a Dental HMO plan, though. Really, the only thing I noticed that it did not cover was implants. However, Costco only offers it in a handful of states: https://www.costco.com/dental-insurance-services.html

Alternatively, you can get an individual dental plan through Delta Dental Plan in any state here: https://www1.deltadentalins.com/individuals.html

In both cases above, if you get the Dental HMO, it has no annual or lifetime maximum dollar limits, no waiting periods, or pre-existing condition clauses.

Anyways, I used my American dental insurance to get cleanings, X-Rays, and fillings. I go to Europe a couple times a year at minimum anyways, so I use that to my advantage by getting more advanced dental care there.

Dental implants, especially Swiss implants, can be 8 times cheaper than what some dentists charge in the US. A Swiss implant, when all said and done, costs about $1000 USD in the more eastern EU countries.

You may want to check out this website: https://www.whatclinic.com/dentists/worldwide

I would stick to European Union countries, as the quality of materials is very high. There is some website like the link I posted above, that has implant success rates posted, by dentist. I just do not remember the website's name. Anyways, you take your time and do extensive research before you choose your dentist.

Anyways, I have a very rare immune-mediated disease affecting my autonomic nervous system, which affects salivation, so my teeth are totally jacked up, even though they look really nice. I also have type 1 diabetes, and it makes my teeth naturally more prone to infections. So, cost-wise, I am screwed when it comes to dental care. I know somebody with the rare disease I have, that has about 20 implants in her mouth.

But, if your teeth are really jacked up, and especially if you need implants (of course it is better than dentures), it is way cheaper to go to European Union countries. This is even for 1 implant. If you may need thousands of dollars in dental care, you may be better off going to the European Union to get that care.

Thanks for your detailed reply and I’m sorry to hear of your medical conditions. Please continue to take good care of yourself.

Mess up cutting your toe nails or not disinfecting minor wounds and you can end up with a serious infection too.

If you really want to be frugal, why not go all John Rambo style and just cauterize the wound with some gunpowder? It's probably <$2 for enough to make sure you don't bleed out.

If you're cauterizing a wound, you wouldn't use gunpowder.

A sterile suture kit is about $2 as well.

No lidocaine?

Nah. It doesn't hurt too bad in most locations.

Yeah, just ask any cutter. For a version that most will have experience with—weightlifting/working out sucks and is "painful" but can feel great too.

That's what insurance is supposed to be: coverage for the catastrophic cases. This use of insurance for ordinary, everyday medical care is ridiculous. I have insurance on my car in case of a catastrophic collision; can you imagine if I had to deal with them for every oil change and brake job?

I make the same argument and people don't get it. We are so brainwashed about the whole health insurance thing in America. Get rid of insurance middleman in EVERYTHING and see how prices drop.

Because it's not valid. Ignoring routine and preventive care makes those catastrophic cases almost inevitable.

I don't understand your argument. Even on insurance, a lot of Americans routinely ignore preventive care because of the hassles, overhead and out of pocket costs even after insurance. Unless you are lucky to have great insurance by your employer. The point is that insurance should NOT be involved in preventive care. It should be a direct free market cash exchange b/w just 2 parties. Patient and doctor. That's it. NO premiums, no copays, no coinsurance, no claim paperwork, no calling insurance companies to figure out the charges etc etc and most importantly, no dependency on having a job to be able to afford going to a doctor even for preventive care.

You will see a lot of people using the (expensive) ER to treat their health issues. The reason they are there in the first place is that they couldn't pay for preventative care, so naturally they can't pay for the ER either. As a society when someone who can't pay ends up in the ER we have two options: treat them anyways, or turn them away.

Yes but that is due to our current expensive healthcare system where out of pocket costs are just some insane arbritrary number. Most hospitals cannot even tell you a "cash" price until you really push. My whole point is that it is all so expensive BECAUSE of insurance. If insurance was not involved in preventive care for example, all hospitals and doctors would have to compete on cash price and that would lower the out of pocket costs significantly. I bet less people will need to got ER because now they don't need to pay $10,000 for a doctor visit.

Even if a check up were $20 what I've described above would happen.

And then even fewer people would use it.

BTW, there's no out of pocket cost for preventive care for those with insurance in the US. There hasn't been since the Affordable Care Act became effective.

No one is saying to ignore routine and preventable care. We’re just observing that you can’t use insurance to lower the cost of it, in aggregate.

yes, and if routine procedures cost money, then people won't do them until they are emergencies. Why? Many people feel that they "shouldn't" "have to" spend money on those things.

Until it comes to dental work and hearing aids. Then people wish the insurance middleman was there.

Not me, I pay cash for my dental work. The only way insurance would help me is if there was a catastrophic event.

The problem is that your catastrophic costs are likely to be massively higher if your problems are not caught by routine checkups and standard screenings. But if we make people pay the full costs for routine checkups and standard screenings, they won't bother getting them. So it is in the interest of your insurance company to make sure you get those checkups and screenings.

By contrast your odds of a catastrophic collision have more to do with drivers and driving collisions than they do with whether you got an oil change recently. If they were insuring your cost of major repairs and buying a new car, then they would have an incentive to get involved with routine maintenance as well.

I have good insurance from my employer but I haven't been to a doctor in at least 10 years. I don't think it's a given that people get routine care just because insurance covers it, or would avoid it if they had to pay (a predictable, modest amount) for it out-of-pocket.

It is not a given. But there is a correlation. And the correlation is enough for insurance companies to statistically benefit from their attempts to encourage people to do it.

There is a middle ground (this is how most dental care in Germany works): Regular cleanings are not covered by your insurance, giving an incentive for price competition. However, if you need major dental work your insurance might not cover it if you skipped the regular cleaning.

> But if we make people pay the full costs for routine checkups and standard screenings, they won't bother getting them.

Alas, those checkups and screenings still cost the same, regardless of who is paying for them. So when you decouple payment from benefit, you create adverse incentives.

I fully agree that at least in principle it seems wrong to have insurance for routine care, when most insurance only covers catastrophe.

I think the two practical problems with this view are (a) what's routine to you might be catastrophic (or at least seriously detrimental) to someone else, and (b) missing routine care often leads to catastrophic outcomes.

> what's routine to you might be catastrophic (or at least seriously detrimental) to someone else,

Whether a cost is insurable is not subjective. The gp observed that insurance only works to manage risk. Insurance against a risk of 100% certainty costs more than managing the risk itself. Insurance that covers doctor’s visits takes a certain expense and runs it through a system designed for uncertain expenses, thereby adding essentially parasitic loss.

> missing routine care often leads to catastrophic outcomes.

As a sibling comment observed, this is already something that insurance companies deal with. Failure to obtain regular and preventative care makes one more likely to need intervention, which means the cost of insuring the patient is more. Therefore people who are actually paying for catastrophic insurance can save money by going to checkups. This would decrease costs, rather than cause them to baloon like insuring high probability events.

Auto insurance does give discounts for things like taking a defensive driving course. Some will give discounts for installing a tracker on your car to show that you don't speed.

So it's not entirely out of the question that they could give discounts for properly maintaining your vehicle, if that were a major cause of accidents and it could be tracked.

Such a service does, in fact, exist for cars. https://www.nadaguides.com/cars/articles/pros-and-cons-pre-p...

And yet pretty much all of the developed world manages to do this much cheaper than the US whether or not there are insurers involved. This is not an insurance problem in the US.

It's a healthcare regulations being used as corporate welfare problem.

You’re completely missing chronic conditions, which as a whole are very common and expensive.

They’re also not insurable, by the definition of insurance.

What are you talking about? You’re suggesting things like diabetes isn’t covered by health insurance? That’s just not true. In fact, making sure “pre-existing conditions” are covered is a signature act by Obama to keep most people insured.

You’re using a very narrow definition of insurance that doesn’t cover health insurance in the US.

I completely agree with you. That is why we started Tangerine Health (https://www.tangerinehealth.co). We charge a flat rate of $25 per visit. With new policy changes to Telehealth, we also launched virtual primary care with the same pricing model. If you have insurance we accept Aetna and UHC. We are in the process of getting Blue Cross as well. I believe also doctor's office visits are covered by HSA (not 100% sure but here's a link found: https://www.foley.com/en/insights/publications/2020/03/covid...).

This is actually the idea behind Direct Primary Care[1]; basically the idea is that by not taking insurance the overall cost of care goes down due to the decreased overhead around the claims process.

My dad is a PCP who switched his practice over to that model several years ago. From what he's told me he prefers it a lot over the traditional model specifically because it allows him to have a subscription based model rather than charging per-visit. That means that his revenues are more consistent but also has the benefit of aligning the patients' and doctors' incentives more directly: the doctor makes more money when their patients are healthy than when they are sick so they're incentivized to do a better job.

It also meshes well with telemedicine and chat-based consultations. He was offering both of those options to his patients well before covid because it tends to save both doctor and patient a lot of time, and there's no concern over "how much do I bill for telemedicine vs a normal visit, and how do I bill insurance for it."

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

I don't know if it's because of this, but as a European I was flabbergasted the first time I went to a pharmacy in US with a prescription and they told me "come back in an hour". Like what? In Europe you talk to the pharmacist, give the presciption and 5 minutes later you're out.

That varies by location quite a bit. I can generally walk in my local pharmacy and have a prescription filled in a few minutes. Maybe more like 15 minutes if it's a controlled substance. But as a practical matter I just walk in, pay, and pick it up, my doctor sends the prescription over electronically. And lately, any recurring prescriptions are handled by mail anyway.

Have I ever experienced that "come back in an hour" phenomenon? You bet. Then I went to a different pharmacy.

That's not true at all. I've been told to come back in many hours multiple times in Germany.

Then sub that with Italy, Spain and UK.

The problem is many people don't have cash either.

https://www.federalreserve.gov/publications/2019-economic-we...

There is always an amount “billed” to insurance companies which is strictly imaginary. There is this billed rate, the negotiated rate per insurance provider, and a cash rate.

> a cash rate

An equally imaginary number that gets hauled out during debates so that health care providers can pretend that insurance companies are the ones responsible for price inflation. If you actually try to obtain the cash rate, they'll give you a 2% "lol nice try" discount off the billed rate.

So it winds up you pay for everything. Your “drug plan” too.

No, there’s just a base rate that nobody pays used as a negotiation tactic that’s still published on bills for whatever reason, you can see what your insurance provider actually pays as well.

I’ve seen that and I don’t always trust it.

It depends on the drug. Under my insurance, I get certain drugs for $0.

Yea and for people who cannot even afford the lower costs out of pocket, subsidize the HSA card for them. This could work better than trying the big bang Single payer approach which btw I am for if that's the only option. I am desperate to try anything other than what we have right now in the US.

There's a cash-based medical practice in my town. They don't accept or file insurance claims (they will give you an invoice with billing codes so you can file your own claim if you want). Their prices:

New patient visit: $400 MD or $300 PA

Follow up visit: $200 MD or $150 PA

Labs: $25 draw fee + laboratory cost

That's significantly more than my doctor - who is part of a major hospital/healthcare network and works primarily with insured patients - charges out-of-pocket...

(I know this because they screwed up billing the insurance company and got denied, and tried to switch me to cash and bill me the higher amount instead. I love our healthcare system.)

Yeah it didn't strike me as especially cheap either, and I have not used this practice myself, but as I understand it he does spend a lot more time with the patient discussing their questions and concerns than most docs do. He also pretty clearly markets to an upscale clientele, not people looking for bargain price medicine.

We can fix a lot about with a few small changes that don't even require raising taxes. The #1 and easiest change is for the government to just pass a law mandating reference based pricing. This is not M4A, the government just says you can't charge more than Medicare plus 20% (e.g.) and cash gets your Medicare flat. This gets rid of brokers, negotiations, out of network and any of the other nonsense. Probably removes 20% of the national healthcare spend. The other changes are straightforward too and again require no new taxes and are not single payer.

Medicare already get gouged because of restrictions on leveraging their market power to negotiate best possible prices.

Medicare + Medicaid costs US taxpayers as much per capita as the NHS costs UK taxpayers per capita. Only the NHS provides universal cover for that cost.

US taxpayers are in effect paying twice.

> I've wondered for a long time

Wonder no more:

https://www.theatlantic.com/magazine/archive/2009/09/how-ame...

This tragic case of a hospital-acquired infection has nothing to do with the parent comment.

The article has much more than that. Scroll down to "There’s No One Else to Pay the Bill" where it says:

"For fun, let’s imagine confiscating all the profits of all the famously greedy health-insurance companies. That would pay for four days of health care for all Americans. Let’s add in the profits of the 10 biggest rapacious U.S. drug companies. Another 7 days. Indeed, confiscating all the profits of all American companies, in every industry, wouldn’t cover even five months of our health-care expenses."

Lot's of private hospitals work like this in Europe and you can get really cheap care, plus the standard is quite high.

I wonder if concierge medicine ( https://en.wikipedia.org/wiki/Concierge_medicine ) would fit what you describe. I don't personally know enough to discuss its pros/cons extensively though.

From some of the studies that I've seen of primary care practices moving to a cash only model, I think its in the range of 15-20% reduction in overhead costs. These were for the most part smaller independent clinics, so the number is probably lower for large health systems.

Generic manufacturers don't have anything to do with insurance companies, though, do they? Other than perhaps trying to convince insurance companies to put their drug on the formulary. It would be between the pharmacy & insurance.

I’ve been buying my drugs for cash for a decade. I’m lucky, I’ve got 5 prescriptions that run me ~$1000. I started when I found that open market pricing was lower than my insurance (UHC Optum) pricing.

The main issue with this is people avoiding care they should get so they can save $200. It's one of the reasons I don't recommend HSAs for people.

Do drug companies get involved with insurance companies? I thought the pharmacies purchased the drugs, and then they handled that at the point of sale.

Yes, they do but the insurers don’t touch the drugs (unless they own a pharmacy too).

You know how a drug can be tier 2 ($25 copay) or tier 3 (20% coinsurance)? That often the manufacturer offering a lower price in exchange for easier and cheaper access for patients.

Drug companies can also rebate on the back end. If an insurance pays for 1,000 vials of drug, they get a 10% rebate. 2,000 vials, a 20% rebate.

I would bet my life that costs would be lower. Insurance middleman in everything drives up the cost a lot due to so many overheads involved.

Say you managed to remove these costs, what would all those newly unemployed people do?

Find useful jobs somewhere else.

Counterpoint: this seems to not be a problem ANYWHERE but the US.

The problem is that most people don't have $10k that they could pay directly.

You might find this interesting too. https://slatestarcodex.com/2020/04/20/the-amish-health-care-...

Edit: why is this downvoted?

Why do we need a system as complex as this instead of just funding healthcare through tax dollars and giving it to everyone like many other developed nations?

Can you show where the tax funded systems are not complex? It might remove some issues, but it can create others. I don't think a simplistic solution exists anywhere in the modern world.

You're right that the back-end of any healthcare system is complex, but a government-funded single-payer system is simpler for the end user (every citizen), that was my point.

I must be missing something then.

In the current system you walk in and hand them your card (insurance, Medicare, medicaid, etc) and they treat you. You get mailed a bill later.

Tax funded systems would be similar. Walk in, give them your ID/card and get treated. Get a bill if it's a taxable condition (like Italy).

Obviously there are other non-payment related differences like scheduling and what's covered.

Here are some things in the current system I'm hoping a single payer system would fix:

* I walk in, and they can tell me right away whether I will be billed or not. There's no "we'll see" and then maybe I get a bill in a few weeks.

* I walk in to a different doctor's office and the answer as to whether I'm billed or not is the same as at the other doctor.

* Because of these first two items, I walk in and they can tell me ahead of time what my bill will be.

* We can now replace "walk in" with "check their websites (or call) and comparison shop".

Maybe they can't tell me if my treatment is taxed until I'm diagnosed, but that still gives me the option to find out my bill before treatment. Once I'm diagnosed, if it's non-urgent I can shop around.

Price transparency is non-existent in US healthcare. There's no big mystery as to why that would cause inefficiency and absurd costs.

Insurance companies do have tools to price compare between facilities. I've used it on my insurance company's website. Manh states have price transparency requirements for cash payers too.

Edit: Why downvote? It's all true.

The fact that there is a need for tools like that demonstrates the complexity of the current system.

Apart from being extremely expensive.

In the current US system, if your employer does not provide (any|sufficient) insurance coverage, you have to get your own and there are a million options all ready to fleece you. It is almost impossible to comparison shop and choose between 100 bad options.

Yes, the mechanics are the same (go to doctor, get a bill), but your purchasing power as individual patient is really small compared to a whole country.

"In the current US system, if your employer does not provide (any|sufficient) insurance coverage, you have to get your own and there are a million options all ready to fleece you. It is almost impossible to comparison shop and choose between 100 bad options."

I've been using the ACA marketplace here in good ol' Alabama, and I've had the opposite problem. There are four choices, all from BC/BS.

Note: I love the ACA. I will fight for the ACA unless and until I'm presented with an actual better option. Prior to the ACA, I had options from other companies, none of which covered my major problem.

I believe we have two choices here in MT (yay it used to be one).

I agree many options are bad. Even employer insurance is expensive.

Where is the individual's purchasing power a part of that scenario? Regardless of the group or person paying the provider, the bill is still substantial. The main money saver between the types is in system efficiencies like removing overhead, or instituting restrictions.

>The main money saver between the types is in system efficiencies like removing overhead

I agree, we should remove the overhead created by the existence of private insurance companies.

And replace it with what? Government has overhead and inefficiencies too.

I know decades of conservative rhetoric say otherwise but governments often run things efficiently and effectively.

Maybe other governments. Medicare has billions in fraud each year. The process for signing up for Medicare and Medicaid can be complicated. If you've ever served in the military or government you know how much waste can be involved.

American exceptionalism is fascinating in that it includes the belief that the American government is uniquely incompetent among developed countries.

The difference is in the NHS everyone is "on the same side", so the amount of bill inflation and money juggling that happens is basically zero.

The NHS does demand management with waiting lists instead. Basically it's amazing for things that can be easily identified and given cheap medication for (insulin, antibiotics etc), amazing for emergencies which can be resolved with surgery, OK (but variable) for obstetrics, does a decent job at screening for common conditions, but tends to leave anything that won't actually kill you to wait.

I've never had to think about billing.

At the same time you can get super-cheap private insurance in the UK because they are effectively a "queue-jumping service" that leaves most urgent and lethal conditions to the NHS and gives you access to private treatments for the things the NHS would put on a waiting list, while cutting their costs by renting excess capacity from the NHS (some private clinics are even run by NHS trusts, as the trusts are allowed to derive some income from private treatments).

I think the best demonstration of the quality of the NHS is that despite the low cost of private insurance in the UK, and despite the fact many companies offer health insurance as a perk, only about 10% of the population has any kind of private cover.

"I must be missing something then."

The part where you are one of the people who doesn't have a card from insurance, Medicare, Medicaid, etc.

Is that a real concern though? The ACA provides income-based funding and expanded Medicaid.

The state I live in did not accept the expanded Medicaid/Medicare funding.

If you earn the poverty level or higher (to a point), you're eligible for subsidies. If you're below that level, you qualify for Medicaid, even without the expansion.

>In the current system you walk in and hand them your card (insurance, Medicare, medicaid, etc) and they treat you. You get mailed a bill later.

The thing you're missing is that the current system in the USA is in no way like this.

That's completely false. I've had to deal with many medical bills in the US last year.

You must have good insurance if you think your experience is typical. Most people aren't so lucky.

It's this way for everyone I know, except for medicaid recipients.

You are healthy and not self-employed, I take it.

Do you have insurance? I fail to she how being healthy and not self-employed affects the scenario as described (present card, get treated, recieve a bill).

If you are not self-employed in the US, typically your employer provides insurance coverage, most of which is pretty decent. If you are healthy, it doesn't really matter either way; unless you are involved in a serious accident or something, your interactions with the health system are infrequent and relatively simple.

I have, among other things, asthma. I'm a 1099 contractor; I buy my own health insurance. Prior to the ACA, which people keep threatening to revoke, I could not buy insurance that covered my asthma. I tried. I shopped around a lot. The same company that provided complete coverage at a previous employer had a pre-existing condition rider on the same policy.

After the ACA, my policy now covers my pre-existing condition (Yay!), but I'm paying $750 or so per month for it. If I could not afford $750/month, my options would be considerably narrowed. (And that's before the prescriptions for my pre-existing condition.)

Yes, I go in, I get treated. But my situation demands a pretty hefty bill anyway, or potentially a very large bill. Possibly enough to make me consider not going to get treatment.

I’m sorry you have a chronic illness. Do you understand that this is not about insurance, but about your ability to share the cost of your illness with society?

Plus, $750 per month is not that expensive for healthcare (unfortunately). My wife was paying $600 per month under the ACA and was completely healthy.

Another point is that the people with lower incomes qualify for subsidies under the ACA.

Youve skipped the step for obtaining a card in the first place. Something which is trivial here in Canada (easier than a drivers license, and free).

Also theres none of this in-network vs out of network chaos. Emergency care always covered, doesnt matter where you go.

It feels like youre trying not to understand how a public option could be better.

"It feels like youre trying not to understand how a public option could be better."

This statement assumes a public option (which varies wildly depending on the one) is better.

The parent comment wasn't about a public option or getting a card. It was a complaint that recieving care at a provider is extremely complicated. At that stage of the process, that claim is incorrect.

That bill can be for an amount that varies wildly based on your insurance, the doctor, who helps the doctor, what lab they send things too, and a large number of other options. If things work out well, your bill could be for $30. If you don't remember to ask the right questions, the bill could be $30,000.

Insurance companies have web portals that you can comparison shop for providers.

However, if your in-network doctor sends your bloodwork out to a lab that is not in-network, you're now paying a lot more.

Or (until recently), you go in for surgery where the surgeon is covered, but then get billed for an out-of-network doctor that consulted without anyone asking you.

One of the recent situations that I've heard about are nurse practitioners and doctors at your doctor's practice, contracted by your in-network doctor. The person who comes into the room to ask you what you're there about may not be in-network even though the ostensible doctor-in-charge is.

I haven't seen that lab issue. I suppose that could be an issue in specific circumstances.

How am I supposed to do that in the back of an ambulance?

You can't. You should select a plan that covers you at all the local hospitals. If you look it up before hand you can usually specify which hospital you want to go to from memory. I do this not just for the network, but also for quality.

What if you're injured while visiting a different city?

Then you should do research before going or accept that it is an unlikely scenario. This is what people do when travelling, especially internationally. You can also select a plan with the most extensive network to reduce the likelihood.

>In the current system you walk in and hand them your card (insurance, Medicare, medicaid, etc) and they treat you. You get mailed a bill later.

I'm glad we now agree that the current system in the USA is in no way like this.

> If Cuban's idea is "we don't do insurance but you're free to pay with an HSA card or seek reimbursement from your insurance company" then this could be a huge winner.

This is the way it works for a lot of therapy and mental health services and it’s horrible. Prices are absolutely insane, practitioners are not accommodating to patient schedules, and patients have absolutely zero bargaining power.

In some ways doing it through insurance is kind of like a union. You all agree to accept certain inefficiencies, bureaucracy, etc., (and associated cost) in order for better collective bargaining terms.

Of course people with great jobs usually don’t care about unions. They don’t need the collective bargaining power and thus figure the bureaucracy cost is just a loss they don’t need.

Same thing with very healthy people and insurance. If you’re healthy you just figure, give me cheap catastrophe insurance, what do I care? But if you’re in the depths of the medical industrial complex because you need frequent treatment for chronic conditions, you quickly learn that papering everything over with lots of bureaucracy to adhere it to better collective bargaining for patients is way better, and I’d rather take the nasty, churning quagmire of price inflating insurance than deal with spartan libertarian mini-insurance that essentially just results in rich-get-richer (i.e. genetically lucky healthy people just get to save money while everyone else suffers).

I'm sure individual experiences vary widely, but I know several people getting frequent treatment for chronic conditions, and none of them talk about how happy they are that an insurance company is collectively bargaining on their behalf. Most of them curse their insurance provider with every breath, and are firmly of the opinion that it would shoot them in the head if it thought it could get away with it.

They clearly haven’t tried navigating treatment options in markets without insurance. I’m glad they are privileged enough (from the insurance) to make those complaints.

The supply and demand imbalance in clinical psychology and psychiatry is why they can choose to be out of network. Demand is not only wanting a good or service but being able to pay for it. Mentally ill people tend to have less or much less money.

The long term trend is not good; why become a psychiatrist when you can earn more as almost any other specialist? (With exception of pediatry). Jails are collectively America's largest mental health service providers. If there was money in psych work you'd see even private equity pump it up like urgent care chains.

Even with single payer or heavily regulated universal insurance schemes there's often a mental health services gap.

> This is the way it works for a lot of therapy and mental health services and it’s horrible. Prices are absolutely insane, practitioners are not accommodating to patient schedules, and patients have absolutely zero bargaining power.

I think that is more a supply/demand issue.

I am not sure why people aren't rushing to become psychologists, it seems like it'd be a profitable field, but there is certainly a huge shortage, at least in major metro areas.

I'd really like to read a proper analysis of the situation...

Is there any data to support this? I was talking to my therapist about it recently and she suggested the opposite. There’s a huge glut of therapists, they just only want to have clients who pay out of pocket because then they offload the work of any insurance reimbursement, paperwork or other overhead to the client. She also suggested therapists want good filters to avoid difficult clients, like low-income clients that have a hard time paying and have more difficult social or behavioral issues.

As I understood it, she was saying basically this:

1. therapists typically just want to work freelance, make their own hours, and don’t mind having very few clients / taking extended breaks from working many hours.

2. therapists don’t want to deal with “challenging” clients (who generally are the most in need of therapy in the first place). “Ability to pay out of pocket” is a good filter to implicitly reject “undesirable” clients.

3. therapists want to externalize the labor burden of coordinating with insurance onto the patient

4. None of this has any connection to charging higher prices - that’s a separate supply & demand phenomenon based on the talent of the therapist, population & demographics of the area, and specializations that deal with issues more correlated with wealthy clients.

My impression from all this has been a massive negative opinion of “working class” therapists and counselors, to the point where I believe they should be required to accept insurance and they should be required to manage the paperwork process of insurance claims as a regulated condition of practicing therapy - it’s a matter of public health that’s in all our collective best interest to enforce with regulation.

> Is there any data to support this? I was talking to my therapist about it recently and she suggested the opposite. There’s a huge glut of therapists, they just only want to have clients who pay out of pocket because then they offload the work of any insurance reimbursement, paperwork or other overhead to the client. She also suggested therapists want good filters to avoid difficult clients, like low-income clients that have a hard time paying and have more difficult social or behavioral issues.

Try to find a psychologist, not therapist (there are many paths to get qualifications to become a therapist, and not all of them are exactly HQ), in the pacific NW some time.

The wait time is in months.

I don't know, maybe the government should regulate the predatory behaviors or business instead of weird libertarian strategy that is already not working for people who have no insurance and their life is destroyed when they get sick?

What? I went to a specialist today. My doctor scheduled the appointment. I had no say in it. This doctor is at one of two offices that I am allowed to choose from based on my insurance's negotiated contracts. This is insurance that is provided by my employer that I had no choice in. When I first saw the doctor, he prescribed meds that I had no choice in. The specific meds he prescribed were chosen as these are what the insurance company would prefer from a clinical perspective although they were extremely unlikely to help. And, on top of all of this, not once was I informed of the cost prior to services being rendered and if I had asked, I would have been told this wasn't possible.

How is any of this libertarian? The libertarian solution would be that only individuals would be allowed to purchase insurance, that insurance would distribute funds to the individual (not the doctor or pharmacy), all fees would be provided prior to service being rendered and individuals would purchase meds without a prescription.

> The specific meds he prescribed were chosen as these are what the insurance company would prefer from a clinical perspective although they were extremely unlikely to help.

I work close enough to healthcare that I can say that while insurers do take cost of treatment into account they are looking to minimize ongoing treatment costs - if there is a 5$ pill and a 500$ pill available for treatment the insurer may prefer to trial you initially on the 5$ pill if it's been proven effective for a good proportion of patients, but they do use calculations to minimize those ongoing costs that includes costs from condition escalation (i.e. if you have a boil you're absolutely going to get antibiotics covered since dealing with a septic boil is an emergency room visit.

That's pretty much what I described. I was prescribed antibiotics for a chronic issue. It made no sense at all, but the DR said it's what he must to do to follow the hospitals guidelines (which are determined by what the insurers want to see). I have gastro issues and modern antibiotics cause me all sorts of problems, so of course I had to deal with the pain and discomfort for 2 weeks all for something that made no difference whatsoever.

Did you try saying no, that you weren't comfortable with this solution, and you'd like to discuss other options? You can always discuss what options are available with your doctor and then reach out to your insurance to see what and why they will do about it. You may not get the answer you want, and it will use up a lot of your time, but it is an option.

Note: I've spent on the order of 30 hours on the phone over the past couple months trying to get things sorted out between my doctor, my insurance, and the provider of the drug that I need for my vision. The folks at the insurance can't always help, but they've always been willing to discuss things and see what they _can_ do.

Given the issue I'm dealing with, I'm more interested in getting it resolved than dealing with debates between insurance, dr, etc. This was the quickest path to getting an ultrasound scheduled, so I complied.

What should have happened is that they should do the ultrasound right there, on the spot. But, the dr's office can't do ultrasounds. That has to go to the imaging department, which had to be scheduled 4 weeks out. Sigh... I won't keep going, but this whole situation is stupid and engineered to extract as much money as possible.

I'm sorry to hear it was so difficult for you. I agree that it seems like every step along the way is there just to add more money (to what they can charge you or, for the insurance, what they can get you to pay instead of them). The long hours on the phone I mentioned are another expression of that (maybe if we keep giving him the runaround, he'll just go away). The fact that you're dealing with said issues just makes you more likely to give up, and they know that.

The next time something like this comes up, if you're feeling up to it, try pushing back. If you have the time to throw at it, the worst outcome of trying is usually just staying where you started.

At the end of my many hours on multiple phone calls getting everyone to agree to pay for treatment I need... the company in charge of making it called to let me know they've been retasked to making COVID vaccine and won't be making the drug I need for at least 3 months. So no treatment for at least that long. So that's fun.

What?? You had no say in it?? Your doctor forced you to accept the pill he chose??? Didn’t even talk to you about it?? Give you options?? That is weird.

There's nothing libertarian about the US healthcare system. If anything, it's a great example of regulatory capture by the AMA and insurance industry.

The "weird libertarian strategy" came about through 20th-century gatekeeping by the AMA to prevent mutual aid societies and unions from paying for medical services, and it makes actual libertarians furious: https://reason.com/2020/04/05/how-doctors-broke-health-care/

In general, the US has a problem where it pretends to love free markets, but when you look under the hood there's horrific regulatory capture and crony capitalism.

You really think the current situation is libertarian?

There is so much regulation around anything even remotely medically related. Just look at the HIPPA mess.

Edit: why are you downvoting without rebuttal? Its utterly false to claim the system is libertarian.

Healthcare already is the most regulated industry in the US.

Calling it libertarian shows you know nothing about either healthcare regulation or libertarianism.

The libertarian angle does not work in real life, even if we ignore the regulatory capture practiced by insurers. Because there are not enough doctors/nurses in the country, you as a patient will always compete for medical attention with other patients. This will only drive prices up.

Libertarians would also allow more doctors to be educated. We don't have enough doctors now because the AMA acts as a cartel to limit supply of doctors. Libertarians don't like that either.

The free market has decided that they don't want more doctors educated though. Guilds are very free market, do you not believe in freedom of association?

I guess the true libertarian answer is that we don't really need certification at all, or that anyone should be able to start their own certification board. Like Rand Paul and his fake ophthalmology board he started to give himself credentials.

Nothing is ever libertarian enough until we've removed all the regulations and let quacks practice medicine, is it?

What about this is the free market?

https://www.washingtonexaminer.com/thanks-to-doctors-there-a...

In a free market we’d be able choose a non-guild doctor.

Which is exactly the “libertarians want to be able to make up fake credentials like Rand Paul’s fake ophthalmology board he made up for himself” I mentioned.

Essentially, yes. People refuse to understand that it is impossible for there to be a "health care market" in the usual sense because (1) like cable, running a hospital or clinic is expensive enough that many people have only one option, whether or not it is regulated, and (2) unlike cable, many people cannot choose whether or not to participate.

I doubt this.

To me, libertarianism is simply “might makes right,” with the liberty part being everyone has the opportunity to grow into a bully. I’ve never seen a SINGLE libertarian policy that couldn’t be interpreted this way, and I’m quite open to being corrected.

Here's a handful of typical libertarian positions (though certainly there's some variance): pro-choice, anti-war, pro-civil rights, pro-immigration, anti-drug-war. They don't seem to match your description of "might makes right".

I respect your position. But these to me are window dressing positions cribbed from the Left.

With respect, this feels like moving the goal posts. The position has to disagree with the Left to count?

How about Kelo vs New London? This was the Supreme Court case establishing that the government could use eminent domain to seize people's homes and hand the property to private developers, in the interest of raising tax revenue for the city. Libertarians were against it; liberals were for it. Is that "might makes right"?

What?

Libertarianism basically sees two possible crimes: force and fraud. Totally incompatible with "might makes right".

So libertarians support laws making legal subtle force and fraud, ca. carried interest, private prisons, private ownership of everything, with no commons.

Libertarianism started on the far left, explicitly opposed to private property, largely overlapping with anarchism. Modern US-style right-wing libertarianism basically cribbed most of it but added a property right fetish.

(Dejaque, the founder of libertarianism called Proudhon, the founder of anarchism, a "moderate anarchist, liberal, but not libertarian")

The last time this came up, several people responded that they would be happy to go to a 'doctor' educated on YouTube.

Which is lovely and all, until those doctors tell you vaccines are worthless and dangerous, and to slather a mixture of beef tallow, garlic, leek, and honey on your injuries.

I'm not sure how you made the jump from the AMA limiting med school enrollments to "youtube doctors".

We could split the difference and expand existing med schools or start new ones with similar standards.

The issue is how you, as a (potential) patient, is going to interpret the fact that Doctor X graduated from a given med school. As a reader of libertarian stuff for 30 years, the usual answers are some combination of:

   1) independent rating agency for med schools
   2) independent rating agency for doctors (i.e. med school was irrelevant)
   3) patient reviews for doctors

25 years of amzn have helped established serious questions about (3)

(1) and (2) have the usual "who watches the watchers?" problems, which are fairly isomorphous to the problems with (3). And even without those issues, who wants to have do this level of research? Yeah, I know, libertarian nerds (meant with all possible respect). But almost nobody else.

Part of the point (not all of it, to be sure) of things like the AMA, the FDA and other governmental regulation is to make people's lives simpler. Stop worrying about whether the doctor you're going to see has even met a basic level of medical qualification, and focus on whether you like their personality and approach, for example.

> (1) and (2) have the usual "who watches the watchers?" problems,

Since we already deal with “who watches the watchers” problems in our current system, I see no problem here.

> And even without those issues, who wants to have do this level of research? Yeah, I know, libertarian nerds (meant with all possible respect). But almost nobody else.

Anyone who wants a good physician.

> Part of the point (not all of it, to be sure) of things like the AMA, the FDA and other governmental regulation is to make people's lives simpler. Stop worrying about whether the doctor you're going to see has even met a basic level of medical qualification, and focus on whether you like their personality and approach, for example.

If those things worked, this would be a point. Currently people can’t even afford to go to medical school, or afford to see a doctor, and when they get past the gatekeepers they are so desparate to get treatment that they can’t really even fathom rejecting a doctor because of a poor bedside manner.

> If those things worked, this would be a point. Currently people can’t even afford to go to medical school, or afford to see a doctor, and when they get past the gatekeepers they are so desparate to get treatment that they can’t really even fathom rejecting a doctor because of a poor bedside manner.

Other countries with socialized health care systems (i.e. doctor credential gatekeeping) do not have these issues (certainly not to anything like the extent that we do). I suspect therefore that changing the credentialling process is unlikely to have much impact on these issues and/or is not the most effective way to impact these issues.

> Anyone who wants a good physician.

I'm 57 years old. I've never, ever met anyone who isn't a libertarian nerd (I have friends ...) that checks to see what medical school a physician attended. If they are "checking" at something approximating that level, they do so via clinical affiliation (e.g. "anyone at the Mayo has to be great").

> Since we already deal with “who watches the watchers” problems in our current system, I see no problem here.

Not really. The "watchers" in our current system are government agencies, not private (potentially for-profit, or at least for-big-salary) corporations. The incentives align in significantly different ways.

> I suspect therefore that changing the credentialling process is unlikely to have much impact on these issues and/or is not the most effective way to impact these issues.

The easiest way to expand medicine access would probably just be to remove government restrictions on the number of medical schools, the number of hospitals, and the number of physicians. I don’t think we need to dismantle the credential system.

> I'm 57 years old. I've never, ever met anyone who isn't a libertarian nerd (I have friends ...) that checks to see what medical school a physician attended.

This why we have to be careful about generalizing from our own experience conclusively :)

> If they are "checking" at something approximating that level, they do so via clinical affiliation (e.g. "anyone at the Mayo has to be great").

There’s how things are, and how things should be. People ought to take more responsibility for their healthcare and that includes who provides it.

> Not really. The "watchers" in our current system are government agencies, not private (potentially for-profit, or at least for-big-salary) corporations. The incentives align in significantly different ways.

Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”.

> The easiest way to expand medicine access ...

This seems to suppose one (or both) of two things:

   1) access to medicine is limited because of the supply of health care providers, so more providers would help
   2) access to medicine is limited due to cost, and more providers would force the cost down, as per "supply and demand", "the market" etc.

I'm not aware of much evidence for (1), though I don't deny that it is possible. For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care. Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits. Just increasing the number of doctors will (a) not necessarily drive down the cost of health care nor (b) expand access to health care.

> This why we have to be careful about generalizing from our own experience conclusively :)

Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that.

> People ought to take more responsibility ...

This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally).

> Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”.

Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure.

> For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care.

I’m really not sure what to make of this, there is already a market for things such as emergency care. Even with all the regulation, when you get in an ambulance you can tell them to take you to a specific hospital.

When people are treating non-emergency conditions, the same regulated market offers them even more options. Ikm not really sure what you mean here.

> Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits.

Many volumes have been written on how the four humours can be used to diagnose and treat disease. However modern medicine no longer uses the four humours model. Perhaps it is also time for modern medicine to embrace the scarcity management aspects of markets rather than looking for answers in musty old volumes.

> I'm not aware of much evidence for (1), though I don't deny that it is possible.

It is not only possible, it is the case. The bottleneck is at schools, at residencies, and at licenses. Possibly elsewhere. In a basic simple mathematical way, fewer providers means less access to care.

> Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that.

Certain values of “want” may not be sufficient, as with anything else. Anyone who wants a good physician enough to look for one would perform the due diligence required to obtain one. Kind of like now, actually.

> This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally).

Yes, its a moral statement. And its an interesting question whether people who entrust bureaucrats with healthcare have taken reaponsibility or shirked it.

> Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure.

The problem is that things like social planning of healthcare provision are evidently flawed in every respect due to the belief that they can’t be trusted to markets. We don’t want to believe we are getting competent care because the government says so, we want to have confidence we are getting competent care because the incentive structure is aligned witn the outcome from the patient’s perspective. We don’t want to believe we are getting the best price for drugs because a bureaucrat claims to negotiate on our behalf with his cronies, we want to know that we get the best price in drugs because they are sold in a competitive market where companies are rivals for the business of patients.

> Even with all the regulation, when you get in an ambulance you can tell them to take you to a specific hospital.

A) you may be unconscious B) you may not know anything that would allow you to differentiate ER facilities C) you almost certainly have no information on the current wait times at an ER facility, let alone specific physicians on call D) you may be unaware of the intersection between your insurance and hospital choice (for example, I had insurance once that only covered care at a (very fine, major urban) hospital that was unable to treat my amputation accident).

So really ... just no.

If you're going to start dismissing the fact that smart people have written smart stuff on a topic by saying that we revise what is considered smart, then I'd just do the same in reverse, and say that none of the worldview/policy view that you're arguing for is supported by anyone worth paying attention to, since it's all just out of date and/or will be consigned to the trash heap of history very soon.

The books I am talking about are not "musty old volumes".

Here's Forbes from 2017: https://www.forbes.com/sites/chrisladd/2017/03/07/there-is-n...

Somewhat older, here's Krugman from 2009: https://krugman.blogs.nytimes.com/2009/07/25/why-markets-can...

Here's (supposedly) a libertarian on the problems in 2018: https://thehealthcareblog.com/blog/2018/08/02/a-libertarians...

And here's perhaps the oldest (recent) paper that got things rolling, "way back" in 1963: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585909/

> In a basic simple mathematical way, fewer providers means less access to care.

That's a response to a completely inverted point. If there are already enough providers, then more providers doesn't mean more access to care (certainly not based on access to providers, rather than cost).

> The problem is that things like social planning of healthcare provision are evidently flawed in every respect due to the belief that they can’t be trusted to markets.

You're on the edge of a no true scotsman argument here, which means I'm going to bed.

Insurance companies are a symptom of the problem but the real solution is either single payer, something NHS like or something like the German model (which is probably the most similar of the major countries to what the US has now - though it’s still three quarters state funded).

The NHS was to an extent a statistical fluke (right politician in the right place, just post-WWII) that the right wing has been trying to dismantle for decades, without WW2 I’d be surprised if we had anything like the NHS.

Basically you need politicians to ignore the lobbyists and do their job of regulating this shit for a better society.

Sadly I don’t see it happening though there are some hopeful trends.

I don't buy the single payer/Obamacare/more regulation speech as the single healthcare fix. NHS has a ton of problems of their own.

We need a lot of doctors, more than what we are producing. It's baffling you need 100s of thousands of dollars to become a Dr in the US.

Remove the undergrad requirement to apply for med school, like most of the world, and fix the college affordability problems.

If the amount of money to produce doctors keeps escalating, it's not surprising medical care only goes up.

There is no single solution, the world isn’t that neat however the NHS problems and it does have them are a result in large part to it been a political football for decades.

Even with those problems we spend about half per capita on healthcare with about equal outcomes, also the US gov in one form or another already foots about 50% of the bill itself.

> Results The UK spent the least per capita on healthcare in 2017 compared with all other countries studied (UK $3825 (£2972; €3392); mean $5700), and spending was growing at slightly lower levels (0.02% of gross domestic product in the previous four years, compared with a mean of 0.07%). The UK had the lowest rates of unmet need and among the lowest numbers of doctors and nurses per capita.

https://www.bmj.com/content/367/bmj.l6326

They do more for less with less and mostly do it well.

Compare that to any other major country and it’s good, compared to the US system it’s very good.

Does the US have amazing doctors, hell yeah of course but do they have a fair system when on average everyone gets what they need if not always what they want, I’d argue no.

Ironically, the US Employer-Oriented health insurance also exists in large part because of the US response to WW2.

During the war the US froze wages in order to try and prevent skyrocketing salaries due to the extreme demand for labor.

To compete, most employers started offering generous benefit packages in lieu of the raises they were no longer able to offer.

After the war, the larger employers found that the generous benefit packages were more cost-effective at retaining employees compared to higher pay, so they became "fans" if you will, and have supported the employer-based benefit programs in the US ever since.

One concise reference: https://www.nytimes.com/2017/09/05/upshot/the-real-reason-th...

The German model is really quite interesting, even though some aspects are extremely strange (like high income earners opting out of the public system or public servants mostly using private insurance). I like that public insurance companies still need to compete with each other on customer service etc. America is probably beyond help but I could see a system where 5% of your income HAS to go to an insurance company that you can choose gaining acceptance.

The Australian private insurance system also works like that. Private insurers have to offer pre-defined tiers with pre-defined coverage.

The average American can’t afford a 400 dollar expense and you are advocating a post pay insurance model? That seems very regressive.

Unless you have a better source, that claim has been debunked. It still persists though because it's incredibly catchy:

https://archive.is/WGoir

> The average American can’t afford a 400 dollar expense

The average American has $432,000 in net assets, is the second richest in the world (behind Switzerland), and can trivially afford such an expense.

Did you mean that around 12-16% of the population can't afford an immediate out of pocket $400 expense? Because that's the real figure according to the Federal Reserve study that's constantly misquoted.

The median American has a higher net worth than either Germany or Sweden, and among the highest disposable income of any nation.

Now that’s just being petty with stats. You knew I was talking about the majority of Americans not the richest. Sure if you take the arithmetic average of assets it will come out very high. But that’s because the millionaires and billionaires skew the numbers.

Exactly. A bond trader steps into a subway car and the other people are some college students, a hobo, and some essential workers. The average wealth doubles.

"Poorer" countries than the US like Portugal, France, Japan, UK have far better health outcomes including lower infant mortality, lower chronic diseases, better life expectancy than the US.

The US is the only "developed" country where 10 are uninsured: https://en.wikipedia.org/wiki/List_of_countries_by_health_in...

Another N% are under insured, or hampered by high deductibles, copays, limits etc.

Whats the point of having a "high median net worth" if the basic needs of the people aren't met?

As far as infant mortality and life expectancy, the picture is a lot more complicated than you portray.

The US is including in their life expectancy data cases of stillbirths or nonviable fetuses at birth, which are not recorded in EU numbers, for example.

" measurement problems arise in international comparisons because the data are not consistently gathered or reported. Although the World Health Organization (WHO) has a formal definition of what should be included in the infant mortality statistics, anecdotal evidence suggests that countries do not use consistent practices in measuring these data (Haub and Yanagishita, 1991; Hartford, 1992). "

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193257/

https://www.nber.org/bah/2015no1/why-infant-mortality-higher...

Not even remotely accurate:

https://en.m.wikipedia.org/wiki/List_of_countries_by_wealth_...

The US is 22nd by median net wealth.

The biggest problem is that most of the money in healthcare actually goes to pay salaries, mostly those of nurses and doctors, but administrators are up there too. Pharmaceutical companies are not as profitable as one might imagine, and drugs are a relatively small fraction of total healthcare costs.

That is a pretty vague statement which I've not seen born out. I work in tech loosely associated with healthcare and I've needed to learn how the different companies involved in the charging process interact and it's super murky - there are a lot of "preferred rates" offered by HCPs to insurers. These "preferred rates" end up leading to the outrageous out-of-network charges some folks have been exposed to. These only seem to exist to justify the constant spending into marketing and sales on both sides to make it appear that negotiations are saving companies 80% of the "cost" in their partnership - while nobody ever ends up paying full price except really unlucky patients. Additionally the system of manufacturer rebates on prescriptions appears to exist solely to bump up the price to insurer - so a 80$ med sold for 160$ with an 80$ rebate might trigger the insurer to pay out 80$ as half the cost of the medication before the patient receives the medicine for free due to the additional rebate - this ends up squeezing the insurer who will squeeze the patient all that much harder when it comes time to settle the monthly fees.

The US system is absolutely lousy with corruption and ends up diverting a large amount of money toward marketing which is rather baffling - whether a treatment is appropriate or not is a decision I'd rather my doctor made on the basis of efficacy - not because one of the companies had a catchy jingle or because one of them recently took him out to lunch.

Hospital administration does cost a fair amount, but be careful here - it's like education - some of those administrators have moved up the seniority chain to positions where they essentially do nothing and get paid for having their ass in a chair - but a lot of that administration goes to fighting against the extremely aggressive tactics of insurers and manufacturers. While those administrators would ideally be unnecessary due to better regulations being in place they do provide justifiable savings for the hospital (it's cheaper than not having them in many cases) under the current system.

It's all really complicated and murky.

Pharmaceutical companies are actually far more profitable than I imagined.

Pharma companies enjoy a profit margin averaging 26%, medical device companies 12%, and hospital groups (which includes non-profits) 8%. Insurance companies are closer to 3%.

https://www.americanprogress.org/issues/healthcare/reports/2...

Then why the same drugs are incredibly cheaper in other wealthy countries? They don't pay salaries there?

Healthcare in the US is a scam. There's no other way to look at it.

Salaries are certainly a part of it - medical staff are paid much lower in other countries.

Because they don't have to pay for their education. Governments there recognize that having lots of doctors is a public good and don't saddle them with hundreds of thousands of dollars of debt from medical school.

Doctors aren't the ones who pay that medical school bill (if they get a job). It's their patients who pay the medical school bills.

The problem of medical expenses in the US is a very complex one. It's essentially at the nexus of a whole bunch of problems with our society. Higher education is too expensive. We have too many middlemen. Strong intellectual property laws make drugs and devices expensive. Patent laws make evergreening more profitable than innovation. Intense regulatory requirements for approval make competition very limited for pharmaceuticals. The government doesn't maintain control of the products resulting from the blue-sky R&D it funds. etc etc.

This will partially ignore your attribution that the US problem is a complex multi-faceted issue (I agree with that but wanted to focus in) - you mention that higher education is too expensive and suggest that there are many other societal factors that make the US noncompetitive. This can cause an effect like we're seeing with the US healthcare market but the US does well in a lot of the more transferable industries (like software development) and I'm not seeing how the factors you're highlighting for healthcare wouldn't equally apply to all of those transferable jobs.

Software scales extremely well. Healthcare suffers the same baumol's cost disease as education and any other labor intensive industry including construction.

This is like saying that filet mignon from French laundry is expensive because he has to pay his wait staff top dollar. Fine. But.I can still go to costco and buy a great steak for a reasonable price and cook it myself. And if I want to I can buy a whole cow.

The company sounds predatory.

A lot of countries have much better health systems, with people fully insured (this is really designed for people who are underinsured), with significantly better outcomes, than the US. The US lifespan is also significantly trailing compared to other developed countries, and we are not a “normal” country at all. It’s going to be more appalling by 2040.

Anyways, the place to study this data and information is https://www.HealthData.org

You can spend hundreds of hours studying the data on that website, along with extreme specifics about medical care. I used it to inform my decision of where to live in Europe with rare immune mediated neurological diseases and type 1 diabetes.