Note that many of the European systems are semi-private, so you retain choice of providers. It doesn't need to be a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from).

There's also an informational problem; in a fully free speech environment it's much easier to sell people unreliable cures, Theranos passim.

Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded. The "in large parts" is important here: A community should agree on what that means and let the market play out on the edges, or the bureaucratic costs become too heavy _and_ unfair. Decentralization is key here.

I've never received significant health care in another country, so I can't say how the US system differs from others with any expertise. But I can say how US health care differs from just about anything else I spend money on:

1. I don't really get to shop for health insurance providers. My employer picks one, maybe two plans, and I can take it or leave it. If I leave it, I am leaving at least $10,000/year on the table, so I generally take it.

2. Even when I am on the market, the phenomenon in #1 does weird things. Once upon a time, when I was choosing my own health insurance, I started a new job with health insurance benefits that I did choose to take. But my start date was toward the beginning of the month, my old insurance wouldn't let me do a partial month, and the new employer wouldn't let me delay opting for coverage. So I was essentially forced to own two health insurance plans simultaneously for a period of time.

3. Nobody knows what care will cost ahead of time, which makes it impossible for me to make any informed economic decisions. I need to see a physical therapist. I called a few places to shop for prices. They all know what the rate for uninsured people is, but the only way we can find out what it will cost with my insurance is if I receive care, they submit a claim, and then we all find out together what the price was, after the fact.

4. #3 creates a situation where they can hide all sorts of excessive charges. When my first child was born, I got lessons on how to give him a bath and change his diaper. Both of which I already knew; I was really just going along with the lessons to be polite. I certainly wouldn't have said yes if the hospital had been transparent and up-front about the price tag on this lesson: about $2,000.

5. And sure, insurance covered most of it... but that didn't make it free; it just means the price was amortized over a large number of health insurance premiums. Unfortunately, I think that this setup makes it all too easy for us to think of these things as free, which, in turn, reduces public scrutiny over where the money comes from or where it goes.

And it just keeps going like that. Compare with signing up for cell phone service. It's a famously sleazy business, but, even with all the hidden fees they like to tack on, at least they're up-front about the basic price of service. With US health care, every fee is a hidden fee. That makes it impossible for consumers to make free, informed decisions, which is the most fundamental precondition that must be satisfied in order for a capitalist market to form.

First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time.

And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and...

I don't remember each one specifically at this point, but I believe it was 7 separate bills.

Edit: typos

The way this plays out is that if I hand over my insurance card, the provider will attempt to extract as much money as possible and bill an outrageous amount. The insurance provider has maximum limits it's willing to cover for each billing code and so only covers some lesser amount. You pay the difference.

This is such scumbag behavior.

https://www.usnews.com/news/best-states/articles/2021-07-09/...

Apologies for asking, but when faced with a medical situation do you have any idea when you have insurance what your maximum liability could be?

NB I'm not from the US so I very little understanding of how the system works.

It looks like all plans sold through the healthcare.gov marketplace is required to have out of pocket maximums.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

Is that a hard limit and you'll never have to pay more than that?

- Balance billing - there is no guarantee that the insurance provider will actually pay what the hospital bills. Insurance companies usually have negotiated rates with some providers. So, if you end up at an ER that's out of network (no negotiated rates), your insurance might pay what they think is reasonable and the hospital bills you the excess. Several California-based hospitals are notorious for this. It also happens with helicopter ambulance transport - frequently, they'll bill $50,000 for a ride, insurance covers $25,000, and the patient is stuck with a $25,000 balance (again, made up numbers).

So it is not an absolutely hard limit in all cases, no.

Edit: originally wrote year twice.

There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while:

1. Expand the government to achieve universal healthcare coverage.

-- a. ACA public option.

-- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.)

2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand.

-- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory.

-- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest.

Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage).

I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).

I like everything here except this. Won't a significant amount of healthcare (grouped by specialization, hospital, etc) still be funded by insurance and be outside the reach of market forces?

I am also curious whether there are barriers to producers of medicine, healthcare supply, etc from disrupting existing overpriced producers.

If I understand your last point, I really like this approach in the context of my proposal: https://www.rubio.senate.gov/public/index.cfm/2021/3/rubio-s...

>> Re: prisons - This isn't necessarily the case. Florida's private prisons have air conditioning and the public ones don't in part because of democratic control and the private ones have fewer deaths from heat stroke as a result.

> Extremely suspicious comment. Please elaborate on “democratic control.”

Yeah. Also the GP weirdly collapses "more efficient, less corrupt and of higher quality" into "has air conditioning: Y/N." You have to evaluate those things holistically, and it's quite possible that he holistically-better solution is actually worse in some specific areas.

Also I don't have any specific knowledge about Florida prisons, but private prisons are a new(ish) phenomena [1], and "hav[ing] air conditioning" might simply be an unintended consequence of that, because building standards have changed.

[1] You know what I mean, don't nitpick with some ancient example.

But that never actually happened. Externalities were never part of the market.

> But that never actually happened. Externalities were never part of the market.

But isn't the essence of an externality that it's a social cost not factored into the market price?

It may be that some of these cannot in principle be accounted for, and even more which cannot in practice be accounted for.

But I imagine the majority of externalities could be accounted for if we tried.

The irony is if you actually came close to achieving that (e.g. accounting for all externalities in the market price), you'd have something like central planning. That's why externalities are usually managed through other mechanisms.

Also, externalities are only one kind of market failure.

Edit: updated 1960s to 1950s per info in replies

Roosevelt also tried to institute a national scheme in the 30s but labor unions were split on notional vs. employer provided and it became a wedge issue that scuttled the plan. Truman's push for that same national health insurance plan was shot down in ~1949, partially killed by AMA lobbying.

Employers can raise wages, and have been able to for some time, so that's not why we still have it.

We still have it because of tax and other incentives, and because government keeps making policy decisions to protect, and even extend it (e.g., the ACA employer mandate), not because of the employers need to offer health benefits to compete because they can't offer more wages because of WWII-era wage controls.

The fear of losing healthcare coverage a severe fear that people in other countries don’t have to worry about.

Heaven forbid “wage inflation!”

Was the AFL pushing for employer-based and the CIO pushing for national? I don’t even know where to find history like this. It’s virtually impossible for an average person to learn about the history of the American labor movement.

I realized after double checking that it was actually a 1942 Roosevelt bill, and they were trying to figure out how to keep a lid on rising prices during the war. It's also not uniformly good if prices also rise quickly. Inflationary spirals are real, and very bad for regular people.

> Was the AFL pushing for employer-based and the CIO pushing for national?

I'd have to double check.

> It’s virtually impossible for an average person to learn about the history of the American labor movement.

A bunch of this stuff is available in more popular history and online now. "The Devil Is Here in These Hills" is supposed to be good, but I haven't read it.

Emergency services aren't a good fit for markets. For markets to work, people really need the luxury to shop around with some leisure.

Wasn't there some Roman oligarch that ran a private fire department, and basically just used it to extort property owners when they had a fire? Truly market based emergency medical care without legal restrictions would likely frequently resemble that with some frequency.

Edit: Yep: https://en.wikipedia.org/wiki/History_of_firefighting#Rome

> The first ever Roman fire brigade was created by Marcus Licinius Crassus. He took advantage of the fact that Rome had no fire department, by creating his own brigade—500 men strong—which rushed to burning buildings at the first cry of alarm. Upon arriving at the scene, however, the firefighters did nothing while Crassus offered to buy the burning building from the distressed property owner, at a miserable price. If the owner agreed to sell the property, his men would put out the fire, if the owner refused, then they would simply let the structure burn to the ground.

And that's the open market; it gets even more cloudy when we talk about employers being involved, so we have an agency problem as well.

It's a system unlike any other, and I don't think general theories really apply very well as such.

Hospitals increase rates to cover the overhead of dealing with hostile insurance companies. Insurance companies raise rates to match increased hospital billing. Ironically both industries are incentivized to raise rates on customers while trying to gouge each other.

Is it any wonder healthcare is a scam?

Everyone gets funneled to healthcare.gov where they can choose.

The whole buying things (life insurance, gym membership, retirement savings) with pre tax income if it is bought through an employer system needs to go in the trash.

That's more because we've had decades of deliberate underfunding due to the "austerity"/"capitalism++" lunatics in charge than a natural consequence of a state-run system though.

But in the medium term, the NHS was doing pretty well until Austerity became the dominant U.K. policy:

https://fullfact.org/election-2019/ask-fullfact-nhs-waiting-...

https://ifs.org.uk/publications/15557

(That said, I don’t have longer graphs to hand, and I am slightly concerned by the convenient start date on the graph in the second link).

But… it works.

The NHS is cheaper, but — and here I wander dangerously into opinion — I suspect that’s short-term benefits with long-term problems which will bite the U.K. in the backside rather than better overall cost-benefit decisions.

Note that I'm not saying that people are not/ cannot be generous, selfless etc. I'm saying that relying on them being so is a crappy strategy. You need a system that continues to work in the presence of greedy people.

In the real world what will happen is the malbehaving dominant party will capture the market by any means available to them. In thoroughly corrupt countries they will bribe legislators, in less corrupt countries they donate to the legislators' election campaigns.

Instead I'm forced to reluctantly support single payer healthcare, despite it being a huge corporate giveaway. It's really saying something when "have the government take it over" is the clearest path to restoring a more functional market.

Hospitals now are required to make pricing transparent and surprise bills (out of network charges) are now prohibited, both are recent reforms.

As far as I am aware, you're still unable to get straightforward answers for questions like "how much will this procedure cost?". Furthermore, this "transparent pricing" revolves around publishing a fake list of inflated prices that nobody actually pays and so is effectively useless.

Meanwhile in every other industry you either get a flat fee ($30 for an oil change), or at the very least an estimate and a contract that fixes the rate (the shop rate is $80/hour, we think this will take 2 hours). Materials are often overcharged (eg $140 for a part that is easily available for $100, because it's delivered from a special supplier) but still within a workable bound, unlike say fraudulent aspirin.

This is a straightforward reform - the reason healthcare doesn't operate like this is they bought laws creating the ability to charge you without needing to establish a contract.

Amazing what a little competition can do. The city was smart enough when the competitor moved in to install the capacity for more ISPs to utilize the existing conduits in the future.

One area where markets do poorly are where the cost of service exceeds profit, like rural areas. This is an area where government intervention in the form of subsidies can help, but these can also cement single ISP marketplaces if not managed well.

Along with healthcare

People don't seem to have issues getting electricity service or telephone service in those regions. In this case, the special treatment of those services means that people don't get left out

Rich people aren't the only ones who deserve healthcare or good internet

In the case of the NHS, my understanding is that neoliberal politicians have been pushing to privatize it, and have underfunded it to make it look like it's not working in order to make privatization more appealing. The same is true for many programs in the US too.

- individual freedom will be suppressed (because "public good"; can't have greedy people doing greedy things, them weeds need to be killed early).

- since individual freedom is suppressed the regime is naturally going to be autocratic, which means that "the state" is actually a handful of people... who now get to freely decide how they define "public good".

The fundamental error of communism is that in any implementation, it doesn't really have mechanisms to "punish" greedy leadership, only greedy individual citizens. Which is an idea as good as it sounds.

Cuba is the best example of a successful communist-ish state. Most if its struggles are due to sanctions imposed by the US and enforced via its allies across the world.

"if the entire world is a sh*thole, nobody will be able to tell it's due to communism"?

I fail to see what "needed technological developments" would West Germany give them.

> Cuba is the best example of a successful communist-ish state

Successful as in "not completely failed, unlike all the others". Look, I sympathize with their struggles being so close to the US & all, but the fact that this is the best-case for you have should give you a bit of pause, because Cuba is by no means close to being a paradise.

To put things in context, both the largest & most populated countries in the world used to be communist. They both had to abandon it & switched to a form of crony capitalism, which, as bad as it is, seems to actually work better for them than the alternative.

Using insurance, government or some other centralizing layer (e.g. the church) for routine activity would raise massive "you're pissing money away" red flags in literally any other context. We shoehorn so much economic activity (healthcare) though a middle man (insurers) and then act surprised that they take a fat cut. The solution isn't to government-ize the middle man. That will almost certainly just be a wash. It's to get rid of the middle man where possible.

There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.

Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?

  > Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?

  Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

https://www.healthcare.gov/coverage/preventive-care-benefits...

These are the cases where insurance is a perfect fit. The issue with letting it be market-based insurance is that (as you say) it allows insurance providers to take a fat cut. The obvious solution is to regulate insurance costs. At which point you might as well state fund it. Which leads us to the system we have in most of Europe.

As these system seem to work quite well, why do you think a market-based approach would be better?

> Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

I think most people are interpreting this as “market is a fine fit for every healthcare need [except for those that start in the ER] which is the overwhelming majority...”

I.e. that you’re advocating the market for the majority of healthcare rather than the majority.

I think your actual recommendation is the opposite. Maybe this would be clearer if you just laid it out like, “Most healthcare is non emergency, cost is a primary concern which insurance makes worse, markets are good at solving cost issues.”

Responding to your actual argument, however, I see many people claim that insurance companies are taking a “fat cut”, but I see very little evidence of higher than expected ROI/ROE in Aetna / United / etc. (ref: United’s net margin is ~5%, ~15B in net income on 300B of revenue). ROE is ~20% which doesn’t seem ridiculous for an insurance business.

The bigger problem seems to be personnel spending in healthcare (admin, support staff, billing), and generally a systemic culture that’s not even knowledgeable about what prices they charge, let alone price conscious in the services they deliver.

I think the issue with healthcare insurance companies in the US is that they collude with the hospitals to artificially inflate the cost of things so that their 20% is 20% of 10x the actual value of the treatment.

But as you observe yourself, that's not the majority of healthcare, which is emergencies and unforseeable needs. Hence there has to be an insurer of some kind.

> There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.

Sure, whatever, the small part of the healthcare market that actually functions like a market - consumer choice, legible prices - can be left to get on with it. Let's not let that get in the way of a functioning provision of necessary care to the majority of people.

I would strongly disagree with this. Healthcare in the US is currently a cartel system, not a consumer product/market system. If healthcare were a consumer product then:

  1. It wouldn't be tied to or dependent on my employment.
  2. Prices for medical treatment wouldn't be hidden/obfuscated by medical providers.
  3. Insurance providers wouldn't be restricted by arbitrary/geographical boundaries.

If you think healthcare is a basic human right then a single-payer system is probably the most reasonable solution, although I don't think single payer isn't without it's share of problems.

If you think healthcare is not a basic human right then I think a real free-market solution is the most reasonable solution, again I don't think this is without problems either.

I don't believe there is a "perfect" solution. But I think either a true free-market system, or a single-payer system would both undoubtedly be 100x better than the current system in the US. I would be in favor of moving to either of these solutions as my political stance isn't D or R but "lets make improvements" regardless if those improvements are seen as left or right.

Japanese system does have a public option and much tighter price controls, which we are missing here.

Obviously we shouldn’t just exactly copy the system of other countries, but it’s equally shortsighted to not learn take away anything from other existing systems. The possibility for universal coverage and higher cost efficiency without the need for single payer I think is a valid thing to take away from those examples.

For optional surgery or cosmetic treatment, sure. You can argue a free market option, but that's why I always think there should be separate baskets, for lack of a better term.

It is sort of strange it needs to be explicitly written out, at the same time for those of us not from US we just took it for granted and never think much about the system.

So, the other important question to ask is the following: how feasible is it to create a well-functioning market for this product?

So far, we don't have an existence proof that such a well-functioning market is possible to construct in the healthcare space.

Because if there is a public option funded by taxation (whether you use it or not) and a comparable or even marginally superior private option which you have to pay use fees for (on top of the taxes), the public option will win every time. Simply put, do you want to pay once or twice for the same service? It's not like one car taking the toll road instead of the public road reduces that driver's tax burden by any noticeable degree. In antitrust terms, the government is using its monopoly in one area, "protection" (mostly from itself, as with any protection racket), as leverage to create a monopoly in another area, transportation. The surprising part is that there are some areas where the public roads are just so bad that you can actually run a profitable toll road alongside them. Level the playing field by requiring the government to fund the construction and maintenance of its interstate highways exclusively through use fees and I expect you'll see a very different result.

It's the same with any other bundled service. Having decided to subscribe to a certain service package one tends to stick with the included services, even if on an individual basis there are better services available at lower cost elsewhere. It only becomes viable to switch to the better service provider if you can replace all the bundled services. Except in this case that isn't even an option since there is no opting out of (paying for) the tax-funded package.

Who knows, it might have even achieved a reasonable balance between the two, instead of forcing a car-centric environment everywhere like the public option? ;)

This is a big /part/ of the "worst outcomes" in the "highest cost, worst outcomes".

It is possible that you can spend a ton of money on healthcare - yet smoke and drink, drive everywhere and not exercise at all, and eat trash - that the healthcare spending is doomed to fail.

Europeans walk & bike more and don't eat as much garbage. Most Asians exercise much more, eat healthier, AND smoke and drink less.

Maybe the healthcare part is secondary to just generally taking care of your health?

It is well understood how terrible obesity is for you. Why should we expect the US to have better healthcare outcomes than Vietnam when Vietnam is 2.1% obese and the US is 42% obese. You can take all the heart medicine in the world. It would be better to simply not be obese in the first place!

This never seems to be a talking point. Have the statisticians controlled for all this when they come to these conclusions??

Tobacco consumption in Asia is incredibly high: https://en.wikipedia.org/wiki/Tobacco_consumption_by_country

https://worldpopulationreview.com/country-rankings/alcohol-c...

Though I suppose China and India, which combined probably comprise the biggest block of population, are a slightly better shade of red than the US and Europe.

But I think this point also opens another subject, preventive healthcare. Many modern healthcare systems are starting to focus on prevention for 2 main reasons: increase quality of life and reduce long-term healthcare costs.

For example, in Finland public tobacco smoking is(was?) considered a public health issue. The government got actively involved to reduce consumption and this resulted in better overall outcomes in their healthcare systems for diseases caused or exacerbated by smoking.

IMO, obesity is a problem affecting the healthcare systems of many developed countries (Vietnam is not yet considered a developed country) arguably not at the same levels as in the US. But this again is part of how government chooses to get involved in fixing the healthcare system by enforcing policies or passing laws that help with prevention.

https://www.theatlantic.com/health/archive/2012/09/big-gover...

My father is getting old and our healthcare system has done a great job at keeping him alive while he can still eat shit loads of pizza, drink beer and be a 80lbs overweight.

All this medication and treatment he takes is not just to keep him alive but to keep him alive without having to change a single bad habit.

Maybe you want to control for the cold weather too?

57% of the USA is white, compared to 73% of Canada. Nearly 20% of the USA is hispanic, compared to 1% of Canada. There are many more Asians in Canada and much less people of African origin.

I'd like to first see evidence that people of different race has a causality effect on healthcare consumption.

Per the CDC:

Among men, the prevalence of obesity was over 8 percentage points lower in Canada than in the United States (24.3% compared with 32.6%) and among women, more than 12 percentage points lower (23.9% compared with 36.2%)

In the United States, the majority of the nonwhite population is black or Hispanic for whom the prevalence of obesity is higher than it is for the white population (3). Among nonwhite Canadians, the largest group is comprised of East/Southeast Asian persons for whom the prevalence of obesity is lower than it is for the white population

And yes we absolutely should control for climate, or at least for incidence of extreme heat waves. It's well known that heat waves kill a lot of frail elderly people.

US is also a super bad infant mortality rate compared to other countries:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856058/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844390/

Access to healthcare is quite low in the US compared to most of the 50 countries ahead of us. We also have higher levels of poverty, ESPECIALLY for a lot of parents/children.

GDP is irrelevant. The paper says:

> In 2013, the US infant mortality rate (IMR) ranked 51st internationally, comparable to Croatia, despite an almost three-fold di erence in GDP per capita

If you have high GDP per capita, and more poor people per capita, and health care is not free - you're going to have more people not accessing health care and suffering the consequences.

In this world - I would expect infant mortality to be much higher even when the healthcare systems are equal.

> Consistent with past evidence that has focused on comparing the US with Scandinavian countries, we find that birth weight can explain around 75% of the US IMR disadvantage relative to Finland or Belgium. However, birth weight can only explain 30% of the US IMR disadvantage relative to Austria or the UK

I never see this as a talking point of folks who are in favor of universal / state-funded healthcare, but it is often a talking point for those who are opposed. They point to the links between state-funded healthcare and the soda tax in the UK as an example of how allowing the government to control your healthcare results in more aggressive and manipulative social policy to control health outcomes societally. Many people opposed to state-funded healthcare feel rather strongly that you should be able to do pretty much whatever you like with your body as long as you're paying for it yourself. I consider this take to be missing quite a lot, but it does seem to be a common one. I am personally in favor of universal single-payer healthcare systems, so I've had this conversation a lot due to my surroundings and have heard just such this argument many times.

In what way is it the worst-performing? I mean, what are the outcomes that are measured to determine its performance?

Yes, healthcare is a lot cheaper in Europe (even if your employer wouldn't pay their part) compared to the US, but the quality of the service is rather poor with very long waiting lists, stubborn doctors who don't want to perform certain tests (as simple as a Vitamin D or a testosterone test) so they don't have to justify it to the insurance.

Here's a recent report that measures: - Access to Care - Care Process - Administrative Efficiency - Equity - Healthcare Outcomes.

US comes last in all but Care Process among developed countries. https://www.commonwealthfund.org/publications/fund-reports/2...

That's exactly like US healthcare if you aren't either a wealthy private-pay client or someone with top-flight private insurance; we just pay twice as large a share of GDP and even a higher multiple per capita to have the same normal experience and many more people uninsured than any other developed economy (and we've only recently through the ACA, gotten it so the that your top-flight insurance plan wouldn't look to retroactively cancel your insurance when you got an expensive-to-treat condition, leaving you uninsured and uninsurable.)

My local very not fancy clinic schedules within 48 hours (within 8 hours if you pay the $10 convenience fee) and has always done a very good job.

Do you have any citation that US healthcare typically has very long waits?

This one is pretty messed up indeed. What's the purpose of being insured to begin with if it will fuck you over when you need the insurance?

Affordable Care Act (ACA) outlawed denying insurance to anyone, regardless of how much their future healthcare expenses will be.

It is one of the reasons that everyone complained about ACA increasing health insurance costs - it had to because more people were getting more healthcare.

ACA also outlaws pricing insurance on anything other than age, smoking status, and location. Even the pricing due to age is capped so that the premium for the oldest (riskiest) age is only allowed to be 3x the young age premium.

ACA also implemented out of pocket maximum for in network care, so that there is a maximum cost per calendar year you would be responsible for. Recent law that went into effect Jan 1, 2022, extends this out of pocket maximum to all healthcare providers in the US if it is an emergency.

Finally, ACA also instructed an appeal process if you think the insurance company is denying payment for treatment justified with evidence:

https://www.healthcare.gov/appeal-insurance-company-decision...

As a separate issue, there is now significant clinical evidence that hypovitaminosis D is a major risk factor for COVID-19. So I hope that medical guidelines will be updated to make those tests a routine part of preventive care screening, in the same way that we test for lipids and blood glucose levels.

https://vitamin-d-covid.shotwell.ca/

I can get in to see an Urgent Care doctor in any major US city within 30 minutes of walking in the door. If it's not urgent, who cares what the wait is?

The government may not pay for the actual service but there is huge government involvement and mountains of regulations to climb.

> So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.

Healthcare and Big Pharma have captured regulators at various federal health institutions. The mission is maximizing profit outcomes not health outcomes.

Health issues are bad in the US, and people use that as 'evidence' for quality of the Healthcare system, but that's not fair.

People shooting each other, not eating well or exercising, isn't so much a function of the US Healthcare system.

The US system is probably the most economically inefficient, but that's also expected at the highest end of quality.

The US has most of the best quality systems in the world, it's just expensive and messed up financially, but the quality itself is something to behold.

While I share your reservations about 'privately backed things' - for example, advertising arcane drugs in the US is ridiculous, this whole 'Ask Your Doctor' is an excuse for pushy patients to 'prescribe themselves' over the will of tired Doctors caving in ...

... that said, Theranos is the opposite example. If it had worked, it would have been because of VC backing and it would have been very beneficial to people. And there are many things like that.

Like anything, it's complicated, and we need nuanced thinking about it.

We probably should welcome a lot more VC spend, think of ways to empower doctors with the deluge of information, to empower individuals but at the same time get them to understand that they are not medical professionals and shouldn't be self-diagnosing, etc..

US health outcomes also aren't so bad for those who have affordable access to the system, as I understand it.

But the spending is something to keep in mind when anti-healthcare-for-all advocates say things like "do you want to have to wait months for procedures like in Canada" - if the US continues to spend more money per person, there's no reason it can't continue to have more capacity.

For instance, per https://ourworldindata.org/grapher/total-covid-cases-deaths-... Canada has seen 66K cases per million and 807 deaths per 1M cumulatively. The US is at 180K and 2515. Slightly different numbers than yours, but close enough. Deaths/cases to date is very similar, 1.4% in US and 1.2% in Canada. So the difference in total deaths is largely policy and behavioral, the aggregate policy across the US has largely been one of "at this point we can't eradicate it so we need to live with it as best we can" where even the liberal US states remain quite open compared to initially in 2020 in the face of recent surges. Whether or not that's the right policy is separate from whether or not that policy would've even been realistic without as much health care capacity.

You still aren't engaging with the point under discussion, though, which has become publicized due to COVID but exists independently of it. Spending more on healthcare contributes to having an overall better health care system, but the US suffers due to large problems of access and distribution. Regardless of payment structure, I would argue in favor of continuing to spend more on health care than other nations; we have the money, it's a good use of it.

My favorite example of this is when I had to get an MRI. The lab imaging said it would be $800 if they billed it through insurance, or it would be $600 to just pay for it directly out of pocket. So the cost of having to deal with my insurance (which always advertises the "discounts" they negotiate and the "lowest cost") was actually more than what the insurance would actually cover.

Pay $800 for MRI with insurance, you'll then pay $2200 for the procedure to hit the deductible + 10% of the remaining $3300, so $2530 total for the procedure. $3330 total for the year between the two things.

Pay $600 cash for MRI, you'll then pay $3000 for the procedure to hit the deductible, and 10% of the remaining $2000, so $3200 total for the procedure. Now you've paid $3800 total, so you've spent $470 more despite the MRI being "cheaper"!

If you have other expenses so your out of pocket max comes into play, that difference approaches the full $600.

For example, am I going to do something major like have a baby this year. Then yes it probably makes more sense to get me to my deductible and pay the extra money to go with insurance. Or if you (or someone on your plan) has an ongoing medical issue where you know you will meet your deductible. Or on the flip side, I met my deductible one year and was going to physical therapy. Since I met my deductible the physical therapy visits were cheap, but going in to the next calendar year now my deductible reset. Could I have used more PT? Maybe, but the visits were about to be 5x more expensive.

But "expected medical expenses" is just the dumbest thing.

But we have to pay the bills after the insurance company does the calculation, which often results in annoying surprises.

The better your insurance, the less nasty surprises, which largely in the US means "the better you're paid, the less you have to pay out of pocket for health expenses" which is a nasty thing because then the people most likely to be hit with a big bill are those who can least afford it.

And then wonder why they get shit care for a huge price BUT swith nice marketing and a smiling "health dealer" getting you a 0% lease... oh sorry, we got you confused with a Chevvy!

And also, "we have the best care in the world because our docs are better selected". This one never fails to make me laugh, as a swiss MD

of course Iceland has more hospital beds than 80, but it cannot handle a disease that may put 80 people in ICU ( not counting ventialtion here at all, just intensive care ).

I think many in Iceland, myself included, are a bit in shock of exactly how poorly managed and starved the health care system is.

Up until 2019 I laughed at the dumb americans and their awful health care, man did I get my sit-upon whopped in the past 2 years.

Icelands is so bad that we are regularily filling hospital break rooms and garages with patients. THat is on a normal non-influenze season. Let alone sars-cov-2 introduction.

I suspect Canada is having a similar realization as we are. Free care in all its honour. Starved free care, heh...... Shame on us. Really. Shame on us.

Not that your thesis isn't correct but be careful there. You're combining the cost of care for the people who get care with an average outcome that includes people who don't get care. The quality of care for Americans who can afford care is excellent.

As a Canadian who knows many Americans, works for a US company and has extended US family, this is not quite true.

Most Americans "who can afford care", maximum 70%, have access to medical care that is on par with Canadian health care, but is fraught with peril; "booby traps" such as out of network costs, high co-pay fees that can bankrupt, surprise billing (though 2022 is starting to deal with that). Care may be excellent, but losing your house if you get cancer seems unnecessary.

A few percent of Americans (the rich and the very well insured; FANNG/MAMAA, investment bank employees, etc.) have access to the possibly best health care in the world.

20% of Americans are uninsured or under-insured and have access to the worst healthcare in the G20.

I think it's strange to want to only include the first two categories in the outcome calculation. Strange may not be the right word here ...

Well that's the point, I think everybody should be taken into account in order to paint a comprehensive picture of the quality of the system at country level. The resulting stats reflect the health of a society as a whole not just of the part that can afford it. Not having universal healthcare is still part of the system, even if we don't like it.

I get it that health outcomes of those left out are probably very different. But leaving those numbers out of the comparison doesn't really work with these type of statistics.

At that point how could you compare it to the other countries that take everyone into consideration? The stats are GDP/capita percentages, should I remove the ones who can't afford healthcare from the GDP stats as well to not skew the ratio? I don't really like where I might end up taking this route.

I don't have any experience with US healthcare and I'm sure the quality of the services is really high, but the fact that you need to afford basic healthcare and it's not guaranteed by the government for everyone makes me see it as closer to just another "consumer product" compared to other systems.

There is a sad trend where the small doctors -- who can't survive without group power -- join conglomerates, the conglomerates buy hospitals, and finally the conglomerates close the less performant facilities. You get large states with vast underserved geographies.

The OP headline is we are careening towards a luxury retail arrangement like Trader Joes: they will only have "outlets" in the richest areas. There's no regulation around closing hospitals so this is coming fast. Two in my county closed this year and I am far from rural.

You can't just say you can't close this hospital, you have to find a way to pay the bills on it.

I have family in Canada with family members the same age on both sides.

Canada is great if you are a healthy broke college student.

No one in their right mind would ever pick Canadian health care over the US though if you are 60+.

There is no way you would rather have cancer in a country with free health care.

Unless you can't afford for-profit healthcare. Then any sane person would 100% prefer one of the fifty or so developed nations with free healthcare.

Considered by whom?

That is only true if you cherry pick statics that over sample for life style choices, and under sample of actual health care.

If you look at statics that are directly attributable to the care provided, not the life style choices of the patients then the US Healthcare system is far better than any other nation

The government is involved in every step of American healthcare. As you can imagine of a system that gets all of its funding thru companies completely overseen by regulatory bodies or thru social programs.

Please note that the wording implies that 18% of GDP is spent on health care overall not that the US Government is spending all that money out of its pocket directly on yearly budgets. The way I understand it is that it includes both money spent by public and private actors for all health related service.

I see this type of stat a warning that something might be dysfunctional within the system, and it's the government's job to get to the bottom of it.

If instead we use health insurance like home insurance for unforseen major issues, and had price transparency. Then prices would go down as people would shop around.

To be fair, I suspect your definition of capitalism is very different from mine...

Even getting a price quote is often impossible.

Government should enforce the same pricing to all parties or allow everyone to get the same prices Medicare negotiated.

The US healthcare is an example of the government being massively over-involved and creating massive inefficiencies.

The NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US.

“Better outcomes” needs more detail:

Medical bankruptcies per year: ~200k in US, ~0 in UK. Caveat: bankruptcies often don’t have one clear root cause, the other ~600k bankruptcies per year in the US may or may not have an aspect of healthcare costs.

Cost of triple bypass heart surgery: US: $110,000, UK: £8,500 (paid by the taxpayer, not by the patient at the point of care - free for them). (P.s. private healthcare is available in the UK too - the procedure costs around £20,000 privately, payable by the patient or their insurance)

Life expectancy… you get the idea.

The American system’s problem is exclusion, not quality of care. If you get care in America, your outcomes are among the best in the world.

"American healthcare is the best in the world like sportscars- Ferrari, Lamborghini, BMW, Bugatti, etc. are the best cars in the world. Surely they both are the bests in the world- but only for the small percentage of people that can actually afford them."

This is sad.

(Many, including me, wouldn't buy a sportscar even if they could afford one, and sportscars aren't the "best" in their opinion. But this comparison drives the point home.)

Regardless of that, high quality care isn't much good if you can't access it.

The incentives for insurance are to ensure that I don't quit, not that it is good healthcare or a good deal.

How does the government ensure that?

  > I don't get to choose my insurance, the government has ensured that instead my company does for me.

I didn't look into details of the insurance market plans, but there were 40 different plans available there for me to choose from (as opposed to the 2 my companies gives me). I suspect that something similar to my work plan is more expensive than the one I listed above. I also suspect that if I was to look at all 40 plans I would choose something that wasn't not similar to the choices I have now. However with the amount of money I'd lose it isn't worth my time to examine my options.

years later that transitioned to comprehensive benefits packages

It really isn't underfunded. It's grossly inefficient, which is what happens to most if not all publicly funded bodies. It is actually ok to criticise the NHS organization.

They're a monopsony, so actually get absolutely gouged by the pharmaceutical companies. They (currently?) refused to recycle crutches, plastic casts and so on. They'll use their own (hospital pharmacy) drugs if you get admitted, and then discharge you with them, even if you have your own dosette box and refuse to take theirs back. My father was discharged with something in the region of £3-5000 pounds of drugs that we threw away on several occasions.

As a percentage of GDP, it's roughly the same as most other western countries.

Of most interest though is figure 3 in [2] - 80% of UK (NHS) funding came from public money, i.e. tax, and 20% from private money (e.g. insurance). For the US, it's 50% public money (tax), and 50% private money. I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed. And compound interest (increase the NHS by 10% per annum!!) means we'd spend all our GDP on the NHS at some point rather quickly.

[1] https://www.statista.com/statistics/317708/healthcare-expend...

[2] https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...

You've got that exactly back to front. NHS's immense buying power lets them negotiate lower prices for drugs, exactly as medicare used to (before pharma lobbying stripped them of that power).

Pretty much any trade deal negotiations with the US involve the UK being asked to dial down NHS buying power on behalf of pharmas by making hospitals responsible for purchasing.

>As a percentage of GDP, it's roughly the same as most other western countries.

50% of the US - not because the UK is especially efficient but because the US healthcare is essentially legalized extortion.

>I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed.

The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises. It's very very popular. In no small part because we can see how much of a racket the US is.

The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years. Part of this has been done by handing over chunks of the NHS to be run privately and incompetently by friends and donors of the party. The problems caused by this backdoor privatization will later be "fixed" with privatization. Whatever the problem, privatization will forever be the answer.

The tories argued for an American style healthcare system in 1948 and while they give tacit acknowledgement of the popularity of the NHS their views havent changed (Christopher Chope is a good bellwether of their more unsightly "hidden" views), they still want a US style system.

In principle, you're correct. In practice the fact that they're the only buyer, means in many cases that they pay at whatever a drugs company sells at since there's no "but company X is only paying Y, why are you charging us Z" as a comparison, particularly in the case of non-generics.

> The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises.

And that was exactly my point. The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded. If the government kept funding the NHS by an extra X percent every year, we run out of public funds.

> The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years.

The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years? And who on earth would buy a loss making healthcare system that's funded to the tune of a billion or so a week? Apple?

Lets say the uk gov allocated 10x to the nhs in the next budget - to be clear, this would put just nhs spending at more than total govt income for the year. If this were a company we’re talking about, they’d be insolvent.

But we’re talking about a govt with a sovereign currency. So what would happen in this scenario? It doesn’t go bankrupt…

How is money created? What is fractional reserve lending? How is money destroyed? Can a country issue a fiat currency without an associated public debt? Or to put that last bit another way - could you settle your tax bill in GBP if there was £0 public debt?

That leaves tax or private money to fund the NHS, and we can't tax people much more. So in your comment "how is the money created?" Answer, tax, and there's a maximum limit to how much we can fund the NHS.

Yeah it does. The UK govt has had 6 different sets of rules in only the past 10 years.

The current rules followed by Rishi Sunak are actively opposed to what you say - he’s been celebrating beating borrowing forecasts of the OBR by £26bn, and he makes a big song and dance any time he can stating excessive public borrowing is immoral. He found the magic money tree instead…

The scope of quantitative easing has increased massively since it was introduced. On top of this, the bank of england does not publish a report on which govt bonds have matured - but we know some have already without having been sold.

So, the govt borrowed from the govt (bank of england bought out uk govt bonds held by non govt entities) then held them to maturity (so the govt paid the govt back), while remitting the coupon payments back to the govt. All while we can’t see inside the machine - none of this is available via public reporting.

It’s not quite “printing money” but it definitely qualifies as a magic money tree.

It’s how govt’s corona responses are paid for today and it’s the reason NHS funding is constrained not by tax receipts but by policy, political decision.

It sounds like you are disputing empirical evidence as well as standard economic theory regarding monopsonies.

>The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded.

Not really. It's mostly funded with taxation.

They are not so aware of the corruption going on underneath with taxpayer money.

>If the government kept funding the NHS by an extra X percent

"X" percent? Is this a serious point? That "X" is demanded by the public and X is also too costly? Where "X" is undefined?

What is even the point of that sentence?

>The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years?

A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.

>And who on earth would buy a loss making healthcare system

Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.

Richard Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).

When there are multiple sellers of generic drugs, you're correct. When there is one seller of a non-generic, life saving drug with no alternative, the NHS is going to pay whatever the one seller, which by definition is a monopoly, is going to charge. [1]

> What is even the point of that sentence?

That we cannot keep increasing NHS funding exponentially. Some people seem to find that fact hard to grasp - there's an upper limit. Another commenter talks about the UK raising debt to fund the NHS. Thank goodness there's a set of rules for government borrowing in the capital markets.

> A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.

Both parties campaigned for the NHS in the 1940s. Labour won. Blair, in power for over a decade promised to "fix the NHS" whatever that meant, but he didn't do it. Thatcher/Cameron/Johnson, all in charge for 2 decades or so, still haven't "sold it off".

> Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.

Except it will never happen. The government would not introduce a commensurate tax cut since they're no longer funding the NHS, so your cost of living would go up, and even in the UK, I think people would get rather upset.

> Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).

Did he really? Evidence? 2 billion of private money paid by companies into Virgin Healthcare, sure. But did he take £2bn from the NHS?

> They are not so aware of the corruption going on underneath with taxpayer money.

What corruption? Surely the police should be involved if there's true corruption?

I won't defend the NHS. I'll defend the staff that treated my father, but the organization itself needs fixing.

[1] https://www.bmj.com/content/368/bmj.l4627

This is incorrect. If the price is too high they refuse, depriving the company of all income. This has been done for certain cancer drugs.

Even if they dont refuse their pricing power lets them beat down prices.

>That we cannot keep increasing NHS funding exponentially

It's barely even increasing in line with inflation.

>Some people seem to find that fact hard

They really dont.

>Both parties campaigned for the NHS in the 1940s.

This is provably false. The tories wanted an insurance based system rather than the system we have modeled on the soviet union.

I think Im gonna leave this discussion here. We clearly dont live in the same plane of reality.

Relevant: Private Eye on "24 Hours to Save the NHS": (<https://twitter.com/KulganofCrydee/status/833654730849136641>)

I think it’s more nuanced than that. There’s inefficiencies for sure but we need perspective to assess them against.

E.g. A triple heart bypass, the most common major heart surgery in the world, costs:

Approx 110k USD in the US system

Approx 50k EUR (56k USD) in Germany

And just under 9k GBP (12k USD) in the UK

>> I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money

Can you clarify what you mean by “come up with” in the context of the GBP which is a fiat currency?

The figures i can find ignore people who can’t afford to become cancer patients in the US - there’s an unknown, but suspected large, number of people cut out of the figures in the US making that stat unfairly stacked vs UK (where everyone regardless of affordability gets access). The people who can’t afford in the US are typicslly the ones more pre-disposed to adverse outcomes in that statistic.

Not bankruptcy statics, or costs

What is the 5 year survival rate for someone who cannot afford cancer care?

The question of affordability is different from the question of quality care, we can solve the affordability problem with out having to lower the over all standard of care which is what you are advocating for, the bringing down of the overall quality of care in an attempt to increase accessibility of care. Ironically putting that faith in the US Federal Government will only result in 1 of those happening.

What exactly is disingenuous about wanting more people to live longer with higher “quality of life” for less overall spend on healthcare? You can’t achieve this without resolving the affordability issues.

>> which is what you are advocating for, the bringing down of the overall quality of care

With all due respect, you’ve made that up to fit with your world view. It’s certainly not something i’ve advocated for.

Those triple heart bypass operations i started the thread with - the 10x more expensive US procedure results in 3 year shorter life expectency post operation.

It costs more, and it’s not as good a result?

(I am being slightly disingenuous at this point - the reason the US outcomes are poorer despite being 10x more expensive for the same operation are due to differences in the health of the average patient - in the UK because healthcare is free at the point of access, there tend to be earlier interventions, in the US there is a marked difference in severity of presentation - ostensibly people wait longer until they’re really unwell before accessing healthcare)

American healthcare has the least involved government of any first world country.

Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.

> Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.

Not an appropriate tone for HN discussion.

The point I was trying to make is that government involvement is needed to make sure that the right incentives are in place at all times for all involved actors (public or private). And if the system becomes dysfunctional or is abused it's the government's job to fix it.

Most of the countries that have universal healthcare in Europe have their own take on how it should be done: - France has state funded insurance and (mostly) state funded services - Switzerland private insurance and private/public services

Two totally different takes with arguably very similar (good) results.

The goal of government involvement should be to make sure everyone has access to basic healthcare and avoid double standards and abuse.