What boggles my mind about the US system is the blatant way it makes working people dependant on employment for health coverage. In a way it's a form of feudalism, tying people physically to their employment.

uhh, what? Is employment in general "a form of feudalism" because people depend on it to fund their basic needs?

Cobra will allow you to keep your current plan, for my family that would have been ~$800 per month.

Healthcare.gov rates are based on your income, or what it was, or what you expect it to be. Which for me was ~$700.

So there is no way to get affordable insurance to cover the gap in employment in a way that preserves cash reserves.

It's one or the other.

Or you can claim the price makes it effectively tied to employment.

I agree the cultural ties it has to employment ought to end, but that's a peculiarity of the american system, not a fundamental feature of a private healthcare system.

I fail to see how it's any different than "there is no way to get affordable housing/food to cover the gap in employment in a way that preserves cash reserves". I suppose you could argue that with housing/food your costs stay the same regardless of your employment status, but from a finance perspective it's still the same. There's no difference between losing a $6000/month paycheck and losing a $5500/month paycheck and $500/month in insurance subsidies.

Maybe if that system had VERY strong economic regulations (like, the government would set prices for everything and let private carers compete in "value added".)

This is a feature, as far as major companies and lobbying organizations are concerned. It's a major reason behind the resistance to universal healthcare because the duress of losing health insurance is the only way some companies keep their employees.

I'm Canadian, now living in the US, and I'll be honest: for the first couple of years, where I had some medium sized health issues, the US system felt so much better. The hospital I was treated at was leagues better than anything I saw in Canada. The amount I had to pay on my paychecks was lower than the complementary insurance I had in Canada. I had dental insurance everywhere I worked! My teeth are a trainwreck from the years I didn't have access to good dental insurance).

So if someone was to dig in my old social media posts, they'd see my old stance of "I would prefer universal healthcare because its more fair, but if I was only thinking about myself, the US system is better".

Then, as anyone who knows better could have predicted, it went downhill and I was proven wrong. If you have something that's hard to diagnose, the insurance starts fighting against you/your provider to get lesser care (eg: getting a full sleep study is super hard because insurance companies will just want you to take a cheap at home sleep apnea test. If you have a sleep disorder that's not sleep apnea, good fucking luck).

Some providers will not talk to you if they're not in contract with your insurance. Good luck getting behavioral health care. Lots of clinics are in bed with very specific insurance, and will not even take self pay. So you have to call 15 of them because even the ones on your insurer's website may not want to speak with you.

The paperwork. Holy shit the paperwork. I had surgery once, and I was still getting bills for it 6 months later. SO MANY BILLS. Some of them were absolute bullshit, but who has time to call insurance and hospitals over and over and over to fight every single one when there's douzens for a single procedure. So I just paid the co-insurance fees and suck it up. I never had a way to tell when I was getting "the last bill".

In the end, I'm reasonably well off, and I have pretty much the best insurance one can have (no deductible, no employee contribution on paycheck, covers virtually everything), and it's STILL a pain in the ass. A pain enough that I've offered some providers to just pay cash to avoid the bullshit. THEY SAID NO and sent me on my way.

Oh, and if I want to start a business, work for a pre-seed startup, or just want to take some time between jobs, I need to coordinate with my significant other to make sure they are not planning on quitting any time soon so we don't have to deal with COBRA or worse.

Yeah, give me the Canadian system any day now.

Said entrepreneur can also buy a plan from an exchange

My grandmothers neighbor is in her 70’s and not great health. She needs a hip transplant and the doctor is basically like “nope, you don’t have many years left, better to prioritize a 50 year old”. Which makes perfect sense from a population perspective but sucks balls at an individual level.

Ehhh. Insurance will pay for what they want to pay. That means some treatments will be completely covered, and other treatments that your doctor really think should happen, won't be approved. Sometimes its because the doctor's out of wack and the insurance is calling bullshit on them (that's good!), sometimes insurance are just cheap (that's bad).

The biggest issue to me is getting far enough to even diagnose the cancer. In the US, they tend to just want to go through as many patients as possible. Maybe toss you some pills, but that's it. It's hard to get doctors to go through the more advanced diagnostics.

I had gallbladder stones for a while and it took FOUR YEARS of every doctor I talked to dismissing it as GERD (wtf) and countless ER visits before one lost patience and did the ultra sound here and there. "Oh, look at that, its not just plain stomach pain".

But who cares about finding the root cause when you can just keep billing patients after patients for GR visits where all you do is take their vitals and prescribe PPIs. If I had cancer, I'd be dead.

But yes, on the other end of the spectrum, my grandmother in Canada almost died because of critical and time sensitive heart surgery she needed that got cancelled and rescheduled over and over and over...

Of course this means they'll also push incredibly expensive but dubious interventions for all patients (even those that are clearly terminal).

I have no idea whether Canada etc are better in this regard, but all the incentives line up to treat all patients in the most expensive way possible to the "bitter end." I've seen this personally with terminal patients, resulting in them squandering their final months on brutal and ineffective treatment as they follow that "false hope" to gain some "extra time," but it also means expensive (and high risk) surgery is encouraged way more often than e.g. physical therapy for minor issues.

I guess if you're a very savvy consumer this system could work for the better, because you would only opt for the truly necessary and likely to be effective expensive procedures, but it's incredibly difficult to make clear-eyed decisions in moments of health crises.

This absolutely does happen in the UK, although I'd pick our health over the US's any day of the week.

Individuals still get the choice to go to any private doctor they want, they'll just have to pay for it themselves. Just like the US, except the NHS provides an excellent safety net for everyone without private insurance or the means to pay for private care.

Private options tend to be better in situations like having multiple treatments available where one is significantly more effective or more reliable but also costs a lot more. Sometimes the NHS will only offer a cheaper but inferior alternative, which sounds horrible until you think that there is a huge but ultimately pooled budget and any time policy allows more spending on one treatment there is always someone losing out somewhere else.

Obviously there will always be limits and the available resources will run out if one of them is reached. In the aftermath of a major incident or an unusually busy period it can happen. I expect a lot of us from the UK might agree that the limits need to be raised further by investing more into the NHS. But I would still choose this type of system over a US-style one every time. I've never heard of anyone here dying because they couldn't afford tens of thousands for routine medication to treat a common condition.

Everywhere I've lived (except the US) has had a totally free public system, and every time I've still paid for private insurance. I'm not rich by any means, and I don't have any particularly special requirements. I'm not even looking for better doctors or machines, since they are mostly shared or equivalent between public and private care.

The only reason it's worth it for me to spend money on private insurance is waiting times. On the private system, I can see a consultant in one month instead of six, or get a surgery in three months instead of three years. This is all for non-emergency care of course.

There are lots of elderly people waiting on operations like hip replacement on the public system, and it's expected that some will die before their turn comes up. It's a compromise that's built into the way the government operates their national health system. It not obviously the wrong way to do things, since carrying out all these operations would be very expensive and have limited benefit in terms of quality and quantity of life. It also sucks for the people waiting, especially since others who can afford to skip the line by paying (usually through private insurance) may even be seen by the same surgeon in the same OR.

I don't mean to argue for or against this system, but just to point out that people often die waiting for (non-emergency) care in at least several large public healthcare systems in highly-developed countries in Europe.

Have you considered that you are essentially jumping in line just because you have a larger wallet than other people?

I don't know of any public health care system in developed countries that have really these issues. I do know so, that a lot of that comes from a PR campaign run by US insurances against the Canadian system.

I'm more familiar with the Spanish, Irish and UK systems. I tried to find a nice document giving numbers for what I was describing, but most of what I can find is anecdotal, and the official reports are weren't quantitative.

Here's an article from an Irish newspaper last year that gives a rough guess (though of course there are other factors): https://www.irishtimes.com/news/health/are-patient-waiting-l...

I'm certainly open to US insurance companies paying me to shill on hn against Canadian healthcare, but right now I'm only saying these things out of the goodness of my heart.

And no, I don't see a direct link between public health care and wait times. The German issues are mostly caused by a bloated bureaucracy.

I also think that these (some several year) wait times aren't unavoidable. Management of these national public health systems is fabulously complicated and difficult and expensive, but it could certainly be done much better. In the end I think a country that really wanted to, and was willing to pay, could have a public system at least as good as what a 1%er in the US gets.

Theoretically I could switch to Germany's private insurance scheme. I have no willingness to do so.

Coverage is very important, but it must be done in tandem with cost transparency and freedom to choose different insurance plans.

They are now status quo, but in another version of history, where such systems would have to be introduced today, I am not certain whether they could clear the political obstacles, much like the U.S.

https://www.healthcare-now.org/legislation/national-timeline...

A difference between balloons and 747s.

Ironically it is because of the USA that many Europeans are keenly aware of the davistating consequences of allowing for a hyper-capitalistic approach to healthcare. People here often assume the worst about that system, and are completely bewildered when I tell them how it actually works. (Especially in regards to having children, parental leave, and childc care.)

The problem is specific to USA.

list them?

I like poking around through here to compare and contrast options: https://www.commonwealthfund.org/international-health-policy.... Some things I notice mainly are that the countries with private health insurance have at least two other things the US lacks:

1. They provide universal health care.

2. They have regulations of the market.

How they go about doing that varies a bit, but I believe these are critical points we miss for all the various reasons we see in this link and in many other discussions on the topic.

I think often in the US when we talk about private-sector, we also implicitly also mean for-profit, whereas many of the other options require them to be private non-profits. I think it's notable they are de-prioritized or outright banned, though I'll admit I don't really know if this is a critical detail or not. So I think to the GP point, perhaps this is a way to change private sector options for the better?

People are exposed on a regular basis to the DMV, the SBA, to Social Security or to Medicare. Then they compare that experience with the avg experience with a commercial insurer, and it does feel like a better experience (of course, if their employer can afford it)

Worse, there are stories of friends in places like CAN, where insider doctors hurriedly email their friends about a new doctor X that is available for appointments, in order to skip a 6 month wait...

The system in the US is a mess, but those people reason that its the least worst option of the available choices.

If they could be given a 3rd or 4th choice, like for example, make take health insurance companies and turn them into public utilities so the "CEO" is not getting his "yatch fund" from taxpayers, that's worth talking about (as longas you don't forget to look to CA, and their wonderful brownouts + utility-enabled wildfires)

That’s not what surveys show:

> Americans' satisfaction with the way the healthcare system works for them varies by the type of insurance they have. Satisfaction is highest among those with veterans or military health insurance, Medicare and Medicaid, and is lower among those with employer-paid and self-paid insurance. Americans with no health insurance are least satisfied of all.

https://news.gallup.com/poll/186527/americans-government-hea...

CMS also publishes assessments of its own performance:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Res...

It's like my charcoal Weber. I found it on the side of the road. Its dirty, dinged, and the wheels are falling off. But it was free and I can grill on it, so I'm extremely happy with it

On the other hand if I paid for a Weber and got that, I'd be pissed.

And yet, people will also defend SS and Medicare/Medicaid till the ends of the earth. I personally find the only people that endlessly rag on social services, and to a large extent, government services, are people that have money and usually a lot of it. It's fine to argue for stopping inefficiencies, but to argue that the only way to stop inefficiencies is the complete abolishing of a government service is the peak of a particularly American argument. The argument usually comes from a place of "I have money, why do I have to put up with this, why do I deserve this?", which is an odd position to take. Americans usually carry the view that quality of service should scale with how much money you make or have, but that leads to a perverse view where worse off people, or low wage earners "deserve" the care they get in a dog eat dog world. When you have socialized healthcare options, that mindset comes across as bizarre if also irrelevant. "Deserving" never comes into the discussion aside from the idea that everyone deserves healthcare, which is the starting premise/assumption anyway.

> Worse, there are stories of friends in places like CAN...

> The system in the US is a mess, but those people reason that its the least worst option of the available choices.

The odd thing is, Canadians might criticize the Canadian healthcare system, but I have never met a single Canadian who would suggest the American patchwork is the "least worst option". It's that kind of reasoning that a lot of people from outside the US find nearly delusional.

This probably varies regionally.

My local - upstate NY - DMV is quick, efficient, and the folks there are pleasant and competent.

My private health insurer hasn't been able to fix my website login for four years, routinely denies care for chronic conditions, and fulfills most of the nasty stereotypes about government bureaucracies.

So how to reign costs in? Cut physician salaries? Not likely. Limit procedures? Maybe. Stop paying for the latest cancer drugs the day the FDA approves them? Probably.

Not exactly easy to accomplish.

"Universal coverage" is not "we pay for everything without question or approval process". In both systems, there are people who decide what's covered, and for whom. As for "exploding costs", the US is more expensive - in both public and private spending - than the "universal coverage" spots. https://data.oecd.org/healthres/health-spending.htm

And who the hell has an 8k deductible?

This choice isn't 8k deductible or "free" healthcare. That's a farce.

Less. https://data.oecd.org/healthres/health-spending.htm has a chart of all OECD healthcare spending, both public and private. The US clearly stands out at the end. Employer-provided healthcare "gets taken out of your paycheck" all the same, just less visibly. This is a significant part of the political problem in the US; the true costs are hidden.

> And who the hell has an 8k deductible?

Most folks on an ACA Bronze plan.

https://news.ehealthinsurance.com/insights-blog/lower-premiu...

"For a family of four, average Bronze plan deductibles are rising by 3% (from $13,017 to $13,394), while the average maximum out-of-pocket limit is increasing 4% (from $14,916 to $15,462)."

My family's ACA Platinum plan costs me $2,200/month this year, and there's still $4k of copays a year to meet.

I am healthy also, young somewhat, and wanting to be in healthy young risk pool to lower my costs not be in giant all-nation pool where I am accepting more financial burden.

There’s no country with universal coverage where a child with little chance for survival would have received this level of care.

https://www.lancsteachinghospitals.nhs.uk/latest-news/happy-...

https://www.theguardian.com/science/2018/mar/14/i-would-not-...

> As the Obama administration sought to reform the US healthcare system in 2009, the US Investor’s Business Daily argued that Stephen Hawking “wouldn’t have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless”.

> It was duly pointed out that Hawking was not only born and educated in England, but received more care than most from the nation’s health service. “I wouldn’t be here today if it were not for the NHS,” Hawking told the Guardian at the time. “I have received a large amount of high-quality treatment without which I would not have survived.”

This sort of thing goes both ways

And the American system that is systematically bankrupting sick people for profit is a damn sight less perfect than the European authorities issues.

Yes, it goes both ways, but it goes much further one way over the other.

That's fair.

For gene therapy, I was referring to Zolgensma, which was delayed substantially in Europe and forced many to seek treatment in America. The delay was mainly due to cost savings, and the delay was clinically meaningful (since treatment is time sensitive).

That's available too.

> delayed substantially in Europe

In the meantime, between when FDA approved v NHS, children became debilitated.

Anyway. At least with the NHS you won't be expected to pay the millions per dose fees, via insurance or other means.

A recent example is health system paying for Zolgensma, the most expensive medication in the world, leading to millions of expense per year[1][2] on this medication alone for a very small amount of babies.

[1] https://tvi24.iol.pt/sociedade/saude/estado-gastou-4-1-milho...

[2] https://www.politico.eu/article/europe-eyes-arrival-of-world...

You have a source for that claim? Two weeks in the nicu is not that long tbh.

The folks at the poverty line with a "free" fully subsidized Bronze ACA plan has an enormous deductible that may be $6-12k before that coverage actually starts paying out. The ACA's max out-of-pocket for a family in 2021 is $17,100. (https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...)

That's not meaningful access to healthcare for someone making $30k a year.

http://www.healthreformbeyondthebasics.org/cost-sharing-char...

Regardless, this is arguing over the burden that Obama, Pelosi, et. al. decided was appropriate for Americans. It's not a question of whether there is universal health care in the US. There undeniably is.

Because I have zero faith that it will end up costing me less, and have a similar level of quality. I’m in tech. Combined HHI is something in the $200s. I pay about $300 per month for the entire family, $5K out of pocket max. So in a worst case scenario, let’s say healthcare costs me $9K per year. That’s what, 4% of my HHI? Will a universal healthcare plan hit me via taxes for 4% or less? Fat fucking chance. And again, we’re not even talking about quality of care, just price.

In the end, the poor will benefit greatly, the rich will carry on as usual, and people in the middle will get squeezed to death.

The US spends 2-3x per capita (counting both public and private spending; https://data.oecd.org/healthres/health-spending.htm) than the rest of the OECD, with remarkably similar health outcomes.

> I pay about $300 per month for the entire family, $5K out of pocket max.

You're just paying your healthcare tax to your employer (in the form of lost salary; they're not chipping in the other $1-2k/month out of charity) instead of the government. It's silly to only count your contribution instead of the overall per-capita cost of healthcare.

It's hard to believe it could possibly still end up worse than the current system, but I worry that it would be a 'hold my beer' moment.

It turns out 8% of GDP is almost exactly what the UK spends on health care in total, including public and private spending. So your taxes to the federal government are paying about the same proportionately that we are for health care here in the UK, and you are also paying thousands of dollars a year for private health care on top. There's no way to spin this, you are getting utterly and completely shafted.

As it happens I also get private health care through my employer in the UK, but it only costs me £380 per year because the vast majority of my health care needs are met by the NHS promptly and to an excellent standard. The private top-up care only matters in truly exceptional situations, and even then it's mainly about comfort and maybe bypassing a queue for non-urgent care. Bearing in mind all the care I and my family have received over the years, and the zero stress I have ever had about affording it, I pay my taxes to the NHS with a happy heart.

From my experience, a decent insurance for the family is somewhere in $20k-ish range per year, which is closer to 10% of your income.

This lines up with 10% UK National Health Services charges HM's subjects.

It will not have a similar level of quality though, forget it. The lines will get longer and the definition of "medically necessary" will become way more frugal.

And for your income level it probably won't cost you less. Neither for mine. Nor for that of many HN users. But it will solve SO MANY annoying problems for so many people at once that I still think it's justified.

First, losing job does will not mean you're losing your medical coverage. You probably have not lost a job for a prolonged period of time. Neither did I. But the fact that it might potentially happen gives me uneasy feeling. If (when?) I lose my job, medical insurance will be the single biggest charge on my account, probably more than all other stuff combined.

Second, all these infamous cases when someone with insurance was admitted into the hospital, but then it suddenly turned out some junior aide to the senior anesthesiologist is out of network, therefore the insurance won't pay him. This doesn't happen often enough for most people to start pestering their congressmen, but it nevertheless happens.

Third, it will make the gap between salaried employees and contractors smaller. There are a lot of talks about whether such-and-such is actually not a contractor, but a salaried employee. And usually it all drills down to the benefits the person receives. One of the ways of solving this problem is making the benefits the same for contractors and for the employees. While it will not close the gap completely, it will make it more palatable.

Fourth, those willing to get a higher level of service will be able to buy private insurance. In countries with national healthcare private medical insurance is cheap - may be 10% of what we're paying now.

I can keep going. The trick is that none of these cases on its own is big enough to affect the majority of population, but combined I'm sure each of us will eventually be hit by one of them.

Mind you, that kind of belief is super common amongst people (like me) who are in the top decile of income.

A typical health insurance plan for a family of 4 costs closer to $1,500-$2,500 per month in the US if you are looking for something close(r) to the level of coverage available in socialized medicine countries (or in the parts of the US medical system that are socialized). That cost is on top of the automatic taxes we pay to cover Medicare, Medicaid, and the VA medical system (these 3 together account for a majority of US healthcare spending).

> In the end, the poor will benefit greatly

"The true measure of any society can be found in how it treats its most vulnerable members." -Gandhi.

While I disagree with nearly all of your post, I can find reason in the closing statement.

I feel like this logic often evades the people asking for higher taxes to support their causes. It’s always the middle class that ends up paying for it. It creates a lot of resentment which is exactly what fuels the rest of your post.

I wish there was a way this could be avoided, but obviously, it’s by design.

It’s definitely systemic/systematic, but it’s also intent?

The tax system is intentionally designed by the ruling/wealth classes to extract the working classes money. Each individual tax may not have this explicit intent, but the sheer number of loopholes and bypasses are omnipresent.

Do your family and friends have the same insurance plan? What will happen to them if they don’t?

Seems short-sighted, yet telling, to talk only about the present time, and only about yourself.

When people retire, they are automatically covered by the socialized Medicare insurance program. Medicare is extremely popular among its recipients, many of whom nonetheless oppose socialized medicine for the general populace.

I remember hearing some stories coming out of the 2016 election similar to what you mentioned, the hypocrisy/irony is palpable.

One of the proposed means to improve our healthcare system is to reduce that age from 65, potentially to as low as 0.

edit: I do love echo chambers, someone asks a question about why a certain groups thinks a certain way, you answer and you get downvoted. Why bother being on a discussion forum if you don't ever want to hear what the other side sees things as even when directly asked? Especially amusing since I do support universal healthcare but actually try to understand why people oppose it rather than covering my eyes and ears whenever they talk.

The wait time for an American at the poverty line seeking care for an expensive but non-emergency chronic condition can be effectively infinite.

My wife receives treatment for chronic pain. Getting treatment at a pain clinic started required five visits (including being able to physically get there in the first place), lab work, etc. Each of those required a hefty co-pay, and someone on a Bronze ACA plan will have a multi-thousand dollar deductible to meet before even those kick in.

If you're working minimum wage and have a pain condition, treatment is likely inaccessible, even if you technically have fully subsidized health insurance.

Anything that requires ongoing treatments or regular doctors' visits is going to be largely inaccessible to a low-income person on a high-deductible plan.

To me, the NHS in the UK is run by the NHS (chiefs, trusts, executives, etc). It's funded and meddled with by the government. But it outlives each successive government.

You'll hear far more positive stories than negative ones if you ask any one in the UK.

My kid spent a week in infant ICU. Cost to me zero. Total cost of pregnancy zero. Time thinking about the cost until now zero.

Money and healthcare are two exclusive concepts to the average British person. If we thought more about cost and healthcare maybe people would be willing to pay more tax for it. But they think it's free.

The same applies in the US in terms of health coverage. The outliers are more vocal and more screwed but not a majority by far.

In reality, "negative stories" aren't much of a strong signal. There are likely as many "positive stories" that don't get as much traction, particularly because there is quite a lot of effort invested in the US into spreading FUD about single-payer healthcare systems. Though I do agree that this effort is effective on many people.