They're most obvious with "basic" products like energy and comms - in theory what is delivered is mostly undifferentiated kWh or GB but through the magic of "confusing plans", marketers have succeeded in making comparisons very difficult for regular people.
(You can do it, but you need OCD, a year of billing data and a spreadsheet - which greatly exceeds the cognitive effort most people will invest in choosing a mobile or energy provider).
The US healthcare sector seems to be the largest, most intricate and most successful (in terms of gdp extraction) confusopoly in history.
The USA healthcare price gouges via run away prices. Healthcare corporations corrupting congress is the fuel that forces this on people (and breaks a free market).
That being said, Canada has a huge health care problem right now. Frequently they need to close emergency services in major (& minor) cities at night due to staff shortages. The wait times for basic diagnostics is on the order of months (not days or weeks). For example, a relative of mine has lost 90 pounds since the start of the year, complained of chest pains and couldn’t (still can’t) swallow. They just got a basic scan after 6 months of waiting to confirm a baseball sized tumour in their lungs.
For many years we ran with just the bare minimum of staffing and equipment to keep costs low, and now, due to a number of factors our system can’t keep up.
Waste is not good, but a little bit of extra capacity (and cost) isn’t a bad thing when it comes to emergency services.
We are now reaping what they have sown.
This is a classic "underfund to prove the system doesn't work thus we must privatize it!" move.
Governments of the last 20 years have held the status quo, which leaves them equally culpable.
Second sentence: explain people’s motivations
You don't have to assume. It costs twice as much as the most expensive health systems on earth, but delivers Afghanistan-level life expectancies. The problem isn't that we're spending too little.
Afghanistan is a whole decade off that cohort.
Life expectancy is a particularly bad metric to use to compare health care systems, because it's heavily influenced by (1) how much people drive, (2) how much violent crime there is, and (3) how much drug addiction the country has. None of those are health care metrics.
I don't believe there's any credible critic of American health care that premises their complaint on America delivering bad health care. We deliver pretty excellent health care, and we deliver it faster than a lot of countries with better health care outcomes. We are in many places in the US overprovisioned for care (by measurements like empty hospital beds, or overprescription of elective procedures). The chief complaint about American health care is how expensive it is, not how good it is.
That distinction is especially important because getting costs down may involve confronting the ways American care is better than it needs to be or should be. For instance: we do a lot more elective surgeries than countries with better outcomes, in part because we do them outpatient here, and they're inpatient (a much bigger deal) elsewhere. For example, my understanding is you're much more likely to get a hernia repaired (probably needlessly) here than in the UK.
Ref: https://www.fao-on.org/en/Blog/Publications/interprovincial-...
It's being underfunded by at least 10-15%, which is a lot for a system expected to run as cost effectively as possible. I'm getting that number from the average of $5336 vs ON at $4800. 4800/5336 = ~89%
I don't think we should aspire to US levels of GDP share. That seems quite excessive.
I think the solutions to our issues are structural changes and adequate funding.
The NHS is still wildly popular so it's politically impossible to privatize from the outside in but it's becoming less popular as its effectiveness declines due to expanding mismanagement, underfunding and corruption when awarding contracts.
The frog has to be boiled slowly though.
The crazy thing to me about this is, most Americans simply skip medical procedures, or tests due to cost.
So American wait times aren't lower because their hospitals are better, they just server a much smaller pool of people due to so many being priced out of being healthy.
And honestly, the longer you go without doctor visits, more expensive, complicated and involved the process is.
That is an atrocious number and something that needs fixing but we don’t need to exaggerate it to make that true.
The 1/3rd is people avoiding treatment recommended by a doctor. 43% of people reported to have avoided healthcare due to costs.
To me "Not most people, only 43%" isn't what I would consider too much of an exaggeration.
We don’t know how many people skip healthcare because a doctor is inconvenient (in the states or in other regimes) either. So it seemed the most appropriate comparison to make.
This seems like a completely reasonable approach and I’m always surprised that it’s not the default.
It's also impossible to get a 2nd opinion. The specialists all tend to belong to the same groups so you'll call a different doctor and eventually get shunted back to the exact same doctor you started out with. Where the the competition?
(Ridiculousness not being the pandemic itself, but inadequate resources, planning, and political cover from all levels of government.)
Part of this is COVID burnout. It wasn't this bad in 2019. Wife works in healthcare and sees the difference every day. Nurses crying etc.
For many years Canada (and similar countries) have relied on cutting costs by importing health care professionals from other countries. That pipeline has now shrunk considerably, resulting in the exposure of the underlying problem.
This says 10.2% as of 2020 : https://www.aihw.gov.au/reports/health-welfare-expenditure/h...
Any improvement in efficiency would mean those people lose out on jobs. A new use for them must be found, or there will be massive unemployment (at least, short-medium term).
I mean I don't want anyone suffering either (one would hope you'd have adequate social safety net to take care of these people until they find another job) but it's such a bizarre exemption to carve out
For a theoretical based on what actually happened where I live, Hospital X is contractually obligated to use a specific kind of infusion pump from supplier Y and order blood tests from specific supplier Z in order to get Blue Cross Blue Shield coverage. Meanwhile the state university pushed out the other hospital in the city and heavily expanded the surviving hospital campus they sponsored to take on the increased capacity and introduce the services they were previously lacking compared to their now dead competitor. So Hospital X is just following the policy of University Network A. All of which is a common practice.
In many states the state university sponsored medical care networks are the or are close to being the biggest employers. The University Of Iowa medical network, the West Virginia University network, and University Of Pittsburgh Medical Center network all have taken over a majority of medical care functions in their states, leaving mostly specialists and those in mental health to independent practices. That exacerbates the issue of insurance and supplier contracts, because these small places that are competing with the university networks often don't bother with insurance unless it's government provided and just prefer patients pay up front instead. They lose too much time and money sorting through the myriad private insurance providers, plans, and coverage obligations without full time staff to handle that for them. Medical billing is a massive industry for a reason.
Now, if everyone wasn't chained to private insurance and juggling all of these providers, coverage limits, and contractual obligations the number of inefficiencies and thus the overall cost would decrease. We have historical examples of this even in the U.S., by comparing what happened between 1960 to 1975 and it's modern equivalent of 2005 to 2020. Healthcare costs were increasing rapidly, doctors were dwindling in number, and there weren't enough medical students for generalist fields in the 1960s just like the 2010s. The major difference is that while quality of care continued to increase through the 1960s and early 1970s, both the efficacy and quality of care has gone down since the 2000s. The several minor differences were that nationwide coverage was rarely available in the 1960s compared to the 2010s, that Medicare was spending more than it was receiving in the early 1970s thanks to how Medicare was funded in the 1960s, and that privatization of entire hospitals was uncommon and frowned upon in the 1960s because of the income impact it had on the doctors. The U.S. barely survived the 1960s medical crunch with enough government intervention, but it is dying under the weight of the 2010s medical crunch because the government can't easily intervene and is lobbied to maintain distance.
So the reason the lead figures in the American right are worried about single payer is because they won't make as much money. And they're very good at convincing people to vote against their own interests because they know those people don't care to look into complex systems too deeply. As a result many of the regular voters and workers are worried because someone told them a lie about where the money is actually being wasted and what the actual history is.
Just picking this point out - how can lobbying stop something? As in it's worth too much lobby money to politicians to change it?
For instance, Germany is producing the Leopard 2. They may export most of them during peacetime, but should they need to, they could start pumping out those tanks for the Bundeswehr instead. Furthermore, with the skills available domestically, it would take much less time to repurpose VW/BMW/Audi factories to also produce weapons.
The first economist says to the other “I’ll pay you $100 to eat that pile of shit.” The second economist takes the $100 and eats the pile of shit.
They continue walking until they come across a second pile of shit. The second economist turns to the first and says “I’ll pay you $100 to eat that pile of shit.” The first economist takes the $100 and eats a pile of shit.
Walking a little more, the first economist looks at the second and says, "You know, I gave you $100 to eat shit, then you gave me back the same $100 to eat shit. I can't help but feel like we both just ate shit for nothing."
"That's not true," responded the second economist. "We increased the GDP by $200!"
You used a wrong allegory to try to demonstrate a point that noone was making.
Another example of political economy is two different efforts to address climate crisis, with very different outcomes.
During the Obama Admin, the push was for carbon taxes. Wonks loved it. Logical, concise, moral. Complete nonstarter. Because carbon taxes has no built-in constituency that's willing to advocate and defend it.
Whereas in 2020, progressives pushed "green new deal" themed industrial policy and investment strategy. Made most everyone a benefactor. Millions of jobs. 100s of billions of dollars. Much better political economy.
Thankfully the economist bastiat solved this absurdity in 1850.
https://en.m.wikipedia.org/wiki/Parable_of_the_broken_window
you laugh, but this is exactly what the US gov't does, esp. with military budget allocation. Why do you think all sorts of military products are split into different pieces for manufacturing, separated into different states? It certainly doesn't help efficiency.
I'm not saying that healthcare shouldn't be improved via efficiency increases - it needs improving! But let's not kumbaya and ignore the plight of those whose livelihood would be disrupted (and not of their own fault).
Also a marginal Joule that you can demand at will is different from one that you committed to months in advance.
Similarly for data.
Of course, in practice most plans don't reflect this 'essential' complexity, but are full of accidental complexity to confuse people.
Ted Cruz would probably cosign a bill to 'throw all puppies off a mountain' for an all inclusive trip to Tulum
Academically this sounds enlightening, but it only takes one cursory walk around a supermarket in the US to see this is unequivocally false. Healthcare is an externality, not a base of anything. From the average customer to the product in the aisle to the marketing - everything is 100% not a direct cost benefit function in terms of healthcare.
Where I live in Europe, the expectation is that the kids will walk or take the bike to school. 95% of the paths they need to travel is covered by walkways (usually separated from the roads, and in many cases with dedicated bike lanes). Everywhere the kids need to cross, there are crosswalks, and every morning before school a team of parents is organized to safeguard these crosswalks.
Meanwhile, driving is slowed down significantly by the efforts above. The roads are underfunded and lines tend to form around the school (some parents still do drive their kids, up to about half when the weather is really bad). But with parents blocking the crosswalk every time a kid is near, bottlenecks do form. Basically, if you're in a car, you're treated as a 2nd rate citizen. :)
Oh, and I suppose one benefit of all this walking is that hospital bills go down. Mostly because of the exercise, but also to some extent due reduction in air polution (which is helped further by most of the remaining cars being electric, most of which, ironically, are of a certain American brand).
wow, didn't realize so much of EU can afford electric vehicles. They are more expensive over here in the U.S. - especially compared to a decent used car. Is this a function of the cost of fuel being much higher over there? Or are there subsidies for purchasing electric or something else?
I don't live in the EU, though. You need to move a bit further north and west.
And it's not that electric cars are cheaper here than in the US, rather other cars are taxed at +100% or so (more for "luxery" cars), while electric cars have had low to zero taxes.
Also, fuel has an extra tax of about $1/liter ($3.8/gallon) on top of the normal price (and 25% VAT even on that), meaning even before the current boom, fuel was typically priced around $1.5-$/l (around $5-$7/gallon), and has been approaching $2.5-$3/l (up to about $10/gallon) recently.
Another difference compared to the US is that we have about 25% fewer cars per capita here, despite having about 20% higher nominal GDP per capita than the US (purchasing power of households are lower than in the US, due to taxes and tariffs ). Partly because of car-hostile taxes (except for electric cars) and partly because other means of transportation are subsidized. More of the money is put into buses, trains and sidewalks and less into cars, roads and parking lots.
Unfortunately I think your comment is even less enlightening.
I mean, not all healthcare problems are caused by lifestyle. So clearly healthcare is a base layer - there is no situation where it wouldn’t exist.
So I'll break down my reasoning a bit. It requires a full blog post to get out, so please forgive the abridged version.
Healthcare is a catch all for all the other problems of society. The top costly conditions in the US are (in order of this barely sourced article): Mental Disorders, Heart Conditions, Trauma-Related Injuries, Diabetes, Cancer, COPD and Asthma.
Every single one of these is plainly racking up unneeded costs by the daily actions of all of us. My quip on the supermarket was a remark on the total view of health (from mental to reproductive care to basic carcinogens to ...).
How many people are mindlessly scrolling on Instagram while performing another task, how many people smell of cigarettes, the marketing of 'sinful goods' (depending on the state), the near impossibility to avoid added sugar in every packaged foodstuff, the number of 'alcohol noses' you can see down a 50ft isle, the parenting of children, the smell of fossil fuel exhaust from the parking lot, the gait of the elderly, injured, or soon-to-be, the accommodations (or lack thereof) for those in wheelchairs and with living assistance, and still the primary food at checkout - And to include everyone in the conversation: think of the anyone working two jobs and has 0 time to prepare fresh food for themselves or anyone else, the eventual cost is in the habitual behaviors made in the constraints of under-compensated labor.... I could keep going and I've left out other observations contributing to other conditions but I think you understand.
The thing I'm trying to say is that there are interventions all over the place - however, the up-front costs (ignoring all else) of a 'double blind randomized trial' for every single one of them to earn the proper authority to define its relative utility to cost is unrealistic at the moment (also most governments do not allow for risk based price of care) - an economic externality.
Couple this externality behavior with a market of near perfect inelasticity for good health (and before someone comments, yes, suicide / assisted euthanasia may not be inelastic in price on this metric) - and you can't say "Healthcare is such a base layer of the economy" - an alternative analysis is "Healthcare is an externality that is priced in a government controlled market"
[Edit] I completely left out the externality of the high reward litigation industry on malpractice and all of the above conditions as evidence of harm - adding pressure on compensation to the highest paid professionals.
One of the nice things about working from home is that it allows people to escape that kind of environment to a point, but it just enables other types of obsessive micromanagement like "Why hasn't your mouse moved for 15 minutes!" or keeping cameras pointed at you all day long.
What we really need is less micromanaging and an expectation that not everyone is going to be at their desk every minute of the day, but that's a very hard sell in some environments.
It definitely isn't, standing puts enormous strains on our bodies. Walking for 6h is much easier and better, but sitting out lying down are much better than just standing.
do you have evidence to support these claims? what makes the US patient population or their expectations or the US taxation system unique in the world?
A part of the latter is based on the actual superiority of the quality of medical care in this country -- due to the high levels of wealth produced by this (mostly market-oriented) economy and advanced medical technology, doctors can in fact perform miracles here that they cannot elsewhere.
How is it superior? Sure, some countries fare worse. But folks aren't getting the healthcare they need because of cost, and the results aren't exactly the best in the world. I'm not convinced that "culturally" folks have high expectations either, and sure, you might want to change your lifestyle to lose weight - but at the same time, you might just need medical oversight to do so. Not to mention that a bunch of things medicine helps are not things that lifestyle just fixes.
It sounds like your point is that wider delivery of healthcare would be superior overall. That's fine, but I contend that the best way to achieve that is by increasing the supply of healthcare providers, instead of applying a price ceiling, which leads to shortages (as seen elsewhere on this thread[0]) and quality deterioration.
This is a big thing. I'm in the UK, where healthcare is very socialised, but I very much appreciate the fact that the US invests in making and productionising the next generation of healthcare, which we can then buy in bulk at a discount.
I've been hospitalized in four different countries. The least sane was America. The sanest was a private hospital in England, but the public hospital in England was fine too. My home country of Canada is sane, reliable, and reliably slow and mediocre bordering on subpar. Cyprus lacked toilet seats, but at least the food was fantastic.
America's healthcare system is bananas. Even trying to come up with a metaphor here is difficult. It's $5k a day stays with Wonderbread, tuna, and bad not-actually-mayo-mayo for lunch. It's well groomed, well respected, monied indentured second and third opinion servants. It's Moloch's own mediation on Moloch[0] sold on the discount rack of the bookstore pharmacy downstairs.
You can think Americans are different. They are not. They move to Canada all the time and we service their bum knees just fine.
You can think Americans do all the medical research in the world. They don't. Plenty comes out of Europe, China, and elsewhere.
You can think your tax code is unique. Ok this one I kinda agree with. It's almost as bananas as your medical system. But it doesn't change the fact that Americans put up with absolute bananaspants insanity for a healthcare system when they're perfectly capable of funding their libraries and roads.
China beats you on scale. And so on.
The basic fact is that Americans have what is essentially a psychopathic medical system at the best of times. One can negotiate with a psychopath, but Kafka returns your offer with a can of stale soup and doesn't even laugh.
[0] https://slatestarcodex.com/2014/07/30/meditations-on-moloch/
https://en.wikipedia.org/wiki/List_of_countries_by_research_...
At the end of the day, though, this is a distraction from the core argument. A valid defence of US healthcare policy is not "but we're good at research." Imagine if China was trying to defend their overbudget and under-effective military by talking up how much they've done for global aeronautical research.
Grandma lost her house because she got kidney stones, but, butterfingers, at least we research stuff! Oh and often times our pharma kills more people than it saves and true justice is never metered out ala opioid epidemic.
Keep shouting #1, #1, #1 until you believe it.
If it's that big of a deal for you, work to fix it and you can come on here with your credentials and blah blah instead of whining about people who have experience in what they're talking about :)
Where bankruptcy becomes an issue is when a medical condition leaves someone unable to work for months. With no income they can burn through savings and credit quickly. Then when they file for bankruptcy of course they have some medical debts, but those medical debts are typically not the primary cause of the bankruptcy and even if the medical debts were eliminated they would still be insolvent.
But a medical condition that means you can’t work is the #1 cause of medical bankruptcy in Canada.
This isn't necessarily a great metric, because almost all countries have better outcomes and all countries have lower per capita cost, whether their systems are public, private, or mixed. The US spends more public funds on healthcare than countries with universal socialized health care systems. The fact that we're also personally bankrupted after spending the same tax proportion on healthcare is just a bonus.
It's not specifically private healthcare or insurance that's the problem, it's the specific corruption of the people who own the healthcare industry and their legislators.
The US federal govt spends >8% of GDP on healthcare, with the current system of all of our insurance and payments and everything that we have to pay in addition, totaling nearly 20% of GDP: https://www.crfb.org/papers/american-health-care-health-spen...
The UK spent 9.6% of GDP on healthcare in that same year (2017) for their publicly-funded full healthcare system: https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...
That has to be related to the fact that American drugs are sold to a lesser price abroad than at home, right?
In Quebec, cancer treatment is free. Given that even late-stage cancer patients live much longer nowadays, and those treatments are probably expensive as heck, I wonder how we can afford it.
There is quite a bit of variety across Europe - U.K. is 100% government run, France is a public/private mix, Germany is similar to Obamacare in some ways, others are single payer, apparently some are private, also. But I've read that they all have cost controls.
This is not true.
Private healthcare is alive and well in the UK in the supply of both privately and publicly-commissioned healthcare.
Wikipedia said 8% of health care in England is private, mostly specialist, often through employer provided plans meant to augment NHS. The other 92% of health care is directly supplied by NHS [0]. So they appear to be a mix of public and private, like many other systems.
I know I'm a broken record on this but people who say this are simply wrong.
1) There is not one NHS for the UK. Health is devolved and there are totally separate systems for NI, Scotland, Wales, and England.
2) Speaking only for England, it's not "run by the government". The NHS in England is run by NHS England and Improvement. The people who work for NHSE/I are not civil servants, they do not work for the government.
It is more similar to the US system than a system like the UK or Canada.
Singapore controls prices through collective bargaining at the national level and unlike the US practically every purchase in its hospitals has to go through registration with the HSA (the country's relevant regulatory agency). You essentially cannot purchase any major equipment without running it by the national government. That's one of the reasons why the country has a very transparent pricing system.
It's not only savings accounts but also a very tight control over costs and acquisitions that keeps the price low, that's completely missing in the American system which just keeps growing.
And getting HSA approval doesn’t have anything to do with price - that regulatory. Even the FDA has to approve anything used in the US.
It is true you can’t purchase at the hospital level without some agreement on price, but the hospitals often do their own tenders, which are confidential prices. It’s not done at the national level for everything.
And yes, prices are tightening but companies are already deciding to just not market in Singapore if prices get too low.
Check out Germany, I think it was AZ that decided to just not launch a drug there at all because the price was too low.
yea because they have healthy population, its not because of some smart govt policy( if only it was that easy).
singapore obesity rate = 10%
usa obesity rate = 42 %
usa obesity healthcare spend = 90%
The costs for obese folk are on average 90%-100% higher than for non-obese folk, but that's not 90% of total spending. (See e.g. https://pubmed.ncbi.nlm.nih.gov/33470881/)
Total cost approaches 20% of spending: https://www.hsph.harvard.edu/obesity-prevention-source/obesi...
https://www.nhlbi.nih.gov/health/metabolic-syndrome
metabolic disease = all things that can be fixed by lifestyle modifications ( unless you are too far gone, ie).
see my reply here: https://news.ycombinator.com/item?id=32744868
For example, there are a lot of people on psychiatric medications that can cause metabolic syndrome as a primary side effect.
Would be interesting to know how often.
Because obesity also drives down lifespan, and age has a huge impact on healthcare expenditures.
I can’t imagine any downside of trying to prioritize lowering obesity.
Obesity is a serious public health problem but we won't fix it by calling people stupid or charging them extra.
There are too many stakeholders with too many backgrounds and conditions for anything like your proposed system to work. Everyone would be angry.
And this genetic mutation somehow happened in the last 50-100 years or so? Obese people have always existed. Obese poor people are fairly new. The root cause is diet, not genetics.
Read "a contamination theory of the obesity epidemic" to see how incorrect your assumptions are.
Gut flora, in turn, play a significant role in hormone and appetite.
The interactions are complex, but genetics contributes to obesity.
Yes, precisely. Keep chopping down at these factors until all that's practically left is private healthcare -- that's a feature not a bug. It's enough that I have to pay the bill to scrape the blood off the street when a motorcycle is crashed, not interested in paying someone elses motorcycle related health premiums on top of that (I've gotten enough motorcycle injuries while carrying my own private healthcare :) )
>This is one of the moral hazards of a socialized medical system.
As you say with public healthcare the effect (you say temptation) is to socialize your health related losses while privatizing the gains you reap.
> socialize your health related losses while privatizing the gains you reap.
Those famous health care gains.
Driving cars would be minor and apply to almost everyone, so it would mostly cancel out and be negligible. Really it would be a slight discount for taking transit, and that seems... fine to me.
And those other ones aren't even notable risk factors.
Yeah, so almost everyone.
> Driving is one of the most dangerous things humans do. The argument that all health care should be private– the perspective this comment addressed– would not make such a consolation simply because it's common.
Car deaths are about 1% of deaths. Heart disease and cancer are each around 15x as likely.
Even if it's high on the danger scale, I don't think it would be a very big factor in health care costs.
CDC: Motor vehicle crashes are a leading cause of death in the U.S.1, with over 100 people dying every day. 2 More than 2.5 million drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle traffic crashes in 2015.1 The economic impact is also notable: for crashes that occurred in 2017, the cost of medical care and productivity losses associated with occupant injuries and deaths from motor vehicle traffic crashes exceeded $75 Billion."
American Society of Civil Engineers infrastructure report card says only 45% of the US population has no access to public transit.
Motor vehicle crashes are slightly outside the top ten causes of death. Those 100+ deaths are coming out of about 9300 total deaths.
> The economic impact is also notable: for crashes that occurred in 2017, the cost of medical care and productivity losses associated with occupant injuries and deaths from motor vehicle traffic crashes exceeded $75 Billion.
Productivity losses are outside the scope of medical costs, but even if we include those dollars that's $75B out of $4100B in health care spending.
So I stand by my statement that it's a pretty small impact.
> American Society of Civil Engineers infrastructure report card says only 45% of the US population has no access to public transit.
And most of the other 55% still need cars.
You said "good subway systems and a walkable infrastructure" and that's what I responded to. We can go ahead and remove the word "subway", but the fraction of people with access to good public transit systems is pretty small.
You use a lot of energy? You pay for the damage to the world.
That might be a good idea after we make sure that every single person has equal access to healthy foods and equal ability to afford healthier options. Maybe we could also ban companies from adding HFCS to everything, ban advertising of any unhealthy foods, fine people for not wearing masks or vaccinating their babies, and police what people are allowed to have in their refrigerators so we can punish anyone who has too many unhealthy foods in their home!
Or... maybe we can let doctors and scientists figure out what the best ways to combat the obesity problem are and try to find ways to help people instead of punishing them while in the meantime making sure everyone has access to the care that they need. If we had universal healthcare the costs for your family would the same as everyone else no matter if you or the next person drinks, or smokes, or likes rock climbing, or plays sports, or drives more than x number of miles in a year, or has more than x number of sexual partners, or doesn't exercise at least x number of hours a day and nobody would have to go around spying on everybody to make sure they aren't doing anything that might raise someone else's costs "or else".
yes it is, because the health population itself is supported by strong intervention. Singapore banned the advertisements of sugary drinks years ago, Singapore strictly regulates the number of vehicle licenses in the country encouraging public transport and walking, it forces citizens to allocate money for healthcare to private savings funds which incentives reducing your own healthcare costs, and so on.
The reason American's are obese isn't a miracle or because Americans are stupider, it's because Americans refuse to take collective action when it comes to the health of the nation.
You need this with lots of stuff. “Vice” states are adjacent to more prudish states. Think New Hampshire, Delaware, Pennsylvania, South Carolina.
In the case of healthcare, states tend to push costs to somewhere else. As in send the sick person to NYC.
Granted, not the total amount spent, but city states do have some advantages on things like this.
Also FWIW France and Switzerland both have universal healthcare, under different systems where France splits payments 3 ways and covers more with the govt[1], and Switzerland seems to have a system like the ACA in the US where it's compulsory, but they also set caps on the deductibles and maximum price.
[1]: https://en.wikipedia.org/wiki/Health_care_in_France
[2]: https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
Also "socialization" is very different from "nationalization". The general trend you're talking about is more to do with the fact that having society subsidize healthcare for the poor can lead to better outcomes. As it relates to who actually does the insuring, underwriting, and payment (public vs private), one isn't necessarily better than the other; each has its trade-offs. It's just that the US (in particular) has chosen the worst of both worlds.
I work in this industry, and from where I sit, the closest thing we have to a clean A/B test that controls for all of those confounding variables is actually being run in the US right now, with Medicare. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare.
- 48% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly that the CBO projects that by 2023, the majority of beneficiaries with choose the private over the public option. The CBO further projects this proportion to increase to 61%(!!) by 2032. (https://www.kff.org/medicare/issue-brief/medicare-advantage-...)
- For most beneficiaries, Medicare Advantage costs about 40% less than Original Medicare and are, on average, of higher quality than Original Medicare (https://healthpayerintelligence.com/news/medicare-advantage-...)
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan (https://www.commonwealthfund.org/publications/issue-briefs/2...)
So no, you cannot look the cost difference between the US and other countries and simply conclude that it's because of private insurance, because the actual data tells a different story. And "universal healthcare" is not the same as "public" healthcare. It might help to think about it this way: universal access to food can be achieved without nationalizing the food industry, or the food payment industry.
For example I just got a 900€ dentist bill recently. By default the sécurité sociale would just reimburse 300€ of it, for the essential care as well as a standard deductible on dental crowns. With my current mutuelle there's only 3€ left for me to pay.
> Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. (emphasis added)
Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.
Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.
> that must follow rules set by Medicare. (emphasis added)
Yeah, I'm not sure that anyone seriously believes that insurance companies should operate in a 100% unregulated fashion. Even the US's food industry (which is predominately privatized) is regulated in some capacity. The argument is whether regulated private insurance can deliver good outcomes. That is very much the case, as evidenced by Switzerland, the Netherlands, and Medicare Advantage.
> Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.
First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.
To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices.
This cocktail of regulations does not exist for Medicare Advantage insurers — even though they are still regulated in different ways. That's a very important distinction. Currently, Medicare Advantage insurers are allowed to return 50 percent to 70 percent of any cost savings to beneficiaries in the form of reduced premiums or expanded benefits — whereas with employer-sponsored insurance, even if such cost savings existed, they would accrue to employers (unbeknownst to worker beneficiaries) — and that's assuming there are cost savings for employers; there aren't, due to the aforementioned regulatory concoction. A big part of why Medicare Advantage actually works really well is because it's effectively a basic income for health insurance, it's just that individuals are empowered to use those dollars to buy whichever healthcare plan meets their needs (including a public option), as opposed to being forced to choose among a small selection of plans curated by an employer.
> Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.
Medicare Advantage plans can both be HMOs as well as PPOs (https://www.medicare.gov/types-of-medicare-health-plans/pref...), it's just that there happen to be many MA plans that are HMOs. HMOs can have very good outcomes with significant cost savings (think of the pre-2010 UK NHS as a public HMO), but can also have bad outcomes if managed poorly (think of the 2022 NHS or US's VA as poorly managed public HMOs). With Medicare Advantage, seniors have the option to choose.
I don’t really understand why anybody would be against introducing this in the US.
> A dead simple “this is how much you’re allowed to charge”.
This has its own set of unintended consequences, including physician rationing (it's a huge crisis of the NHS right now), and a reduction of investment in new medical research. There are many good reasons to be against introducing this in the US.
Switzerland does not have price controls on medicines, treatments, etc. and the reason why it is so often cited is because it enjoys a comparable level of healthcare innovation to the US while still ensuring universal access (through its ACA-like subsidies). It also costs a lot per capita (among the highest in the OECD), but it actually gets what it pays for (https://pubmed.ncbi.nlm.nih.gov/26766626/) (https://www.theweek.in/news/world/2022/05/07/7-reasons-why-s...)
In fact, of the countries that usually make up the global leaders in health/medical innovators, all but 1 (the UK) engage in price controls (https://immigrantinvest.com/insider/the-best-healthcare-coun...), and the UK's NHS is suffering from a rationing crisis, and (ironically) a cost crisis.
The UK's difficulty lie in their leadership and political issues and in the economic consequences of Brexit. I'm not sure it's the best example for your argument.
Where you're correct is that the difficulty lies in leadership's inability to actually change the prices to attract the supply necessary to reflect the increase in demand — and that's because the Single Provider system is tied to politics rather than market forces. The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary. In contrast, the private sector can (and will) increase prices to overcome demand — we see this happening in Switzerland (https://pubmed.ncbi.nlm.nih.gov/26766626/).
> The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times
So where we may agree to disagree is that the NHS's woes are in fact a very strong example of the greater argument, on net.
And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.
Yeah that's completely untrue; the list prices that insurers pay for GPs are heavily inflated by the market distortions introduced by the Federal government. I don't know if you read any of what I've written up-thread, but I'll paste the relevant parts here for your benefit:
"First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.
To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices."
Put simply, the US healthcare industry is not subject to traditional market forces.
> The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
It's quite clear that the reason the government is not doing this is because it would further exacerbate the staffing shortage and lead to even higher wait times. That's not a political problem, that's a hard economics problem.
> It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.
There is a key governance difference between making the decision to lift distortionary regulations once & up-front so as to unblock efficient resources allocation vs actively having to continuously adjust resource allocation. With the former, you just have to trust that the "good governance" happens once, whereas with the latter, you have to trust that "good governance" happens forever (politics notwithstanding). The Swiss chose the former, whereas the UK struggles with the latter. Domestically in the US, Medicare Advantage is a proven model — and the governance prescription here is to have the entire private insurance industry look more like Medicare Advantage.
I'm going to call you on this point, because what you're hinting at, whether you realize it or not, is that employers need to step up their medical care spend management game, which if implemented, looks damn near dystopian. As someone that works in insuretech, the number of times I've raised concerns about revealing too much about the shape of medical spend to employers is scary to quantify, because once you start going down that road, it isn't that far to "huh, 20% of our workforce is 80% of spend" hrrrm...
We do not want to be going down the road where employers are singled out as the appropriate optimizers there.
What I'm suggesting is that the proven private sector model is one where employers are simply not involved, not a part of the equation. Private insurance purchased on the individual market. That's exactly how it works in Switzerland, the Netherlands, and also how it works in Medicare Advantage (seniors directly buy their insurance plans using dollars they theoretically set aside over the course of their lifetime through Medicare FICA taxes).
The most practical way to get there, in America, would be to either enact Medicare Advantage For All, or to tweak the employer mandate to only include ICHRAs rather than group health insurance. ICHRAs are employer-sponsored funds (in lieu of employer sponsored insurance) that the employee-beneficiary uses to buy health insurance on the individual market.
Indeed. It's basically the convenient bogeyman for opponents of the current government.
>The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary.
Private Eye on "24 Hours to Save the NHS <https://twitter.com/KulganofCrydee/status/833654730849136641>
For example, if someone makes a pill that cost $1 million to live one more day, they can sell it, but most national health services won't buy it.
In the US, the national health services and insurance companies are mandated to buy it, and a byzantine system of price controls ensure we only pay 900k.
This is of course already happening since, most of the world has price controls. The US market is probably financing most of the world's medical research, and if we stop paying so much, it may shrink a lot.
One of our largest problems right now is that our system is failing and can’t keep up.
The solutions being rolled out by the provinces to fix the huge backlog of people waiting for care is to privatize more of the service delivery (while keeping single payer).
You said private healthcare/insurance were to blame. Switzerland has private health insurance.
Universal healthcare is a separate goal post. For what it’s worth, I’m unclear its comprehensive iteration is compatible with America’s immigration model. (It absolutely is for life-saving measures.)
> You said private healthcare/insurance were to blame. Switzerland has private health insurance.
Private business in all western countries operates within the regulations and laws that cover them. The health insurance industry in Switzerland operates under a very different set of regulations and laws than the same industry in the USA. If you want to blame the OP for not being more explicit - "private healthcare/insurance and the regulatory framework are to blame" - then fine, but ... this is actually the crux of the issue.
I'm not sure it is. Universal healthcare is orthogonal to private health insurance. That's the lesson of Switzerland's example. I don't believe this is commonly known or accepted in American politics. Instead, any attempt at reform is pitched and vilified as an attempt to end private health insurance and healthcare.
However, "private health insurance" is not, in and of itself, really "a thing". Only "private health insurance plus a regulatory structure for it". It is in this department that the US falls over so badly, while, for example, Switzerland gets it (mostly) right.
Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.
So does the US: https://www.healthcare.gov/glossary/minimum-essential-covera...
> there are treatments and operations (e.g. congenital defects and invalidity-related) that are directly billed to the public social insurance (funded by salary deductions) to help health insurances reduce their risk.
> Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.
You're mistaken, Switzerland has no centralized social insurance — it is fully privatized (for real medicine as well as alternative medicine), and is decentralized among its Cantons. It's just that the private Swiss insurers tend to be non-profits (same holds true for the US, e.g. Blue Cross, Kaiser, etc) and the for-profit insurers' profits are heavily capped/regulated (same holds true for the US).
I don't know if you legitimately do not know that.
I did not talk about federal/cantonal to avoid writing a thesis in a comment. I never said it was centralized.
Salary deductions pay for subsidies to lower income beneficiaries to purchase the same private health insurance (KV) as everyone else. This is more or less identical to the US's ACA, and in fact the ACA was modeled after the Swiss healthcare system.
The one big difference between the US's ACA and the Swiss healthcare system is that the ACA also included an employer mandate and stimulated a regime in which the majority of working-age adults receive their private health insurance from their employers as opposed to the individual market, which is not how the Swiss KV works.
I am not conflating anything, you have a superficial understanding that makes you think it is privatized. If you dig into the spending public & private and the actual details you would see that Switzerland is not privatized as people generally think.
Even the US uses Medicare for certain congenital diseases as well (as well as end-stage renal disease).
The Swiss private KV system accounts for the vast majority of health expenditure, even more so than the US where half of health expenditure is nationalized in Medicare and Medicaid.
The intention of my comments was to make clear that in that regard, Switzerland is not an efficient free market private insurance paradise. There are lots of nuances to it, and the private insurance system in fact brings in inefficiencies, namely, a very complex and costly cost itemization and enormous amounts of paperwork and stress for doctors, customers, employers, and the insurances (for example, if there is an accident in a public place involving a car, there are at least one or two days worth of people's times just filling in forms)
In Switzerland (and also the Netherlands), the vast majority of this is covered by private health insurance, not via any sort of public health insurance. That's what sets Switzerland and the Netherlands apart from other peer developed countries, and they have results to show for it.
Regarding rare conditions, we agree — even the US has a public healthcare system alongside which covers rare conditions (e.g. end stage renal disease). US's Medicare Advantage system of private individual health insurance for senior citizens (with Original Medicare as a public option) is also a proven model with results to show for it. The CBO expects that by 2032, 61% of health insurance expenditure for senior citizens will be by the private sector (https://www.kff.org/medicare/issue-brief/medicare-advantage-...).
https://www.cbpp.org/research/social-security/ssi-a-lifeline...
You also haven't given even a hint of proof for this alleged trend.
Maybe there is a trend, but let's look at some serious data before we just assume it's an obvious fact.
In an analysis we published in 2011, the ratio of social service spending to medical care spending was significantly associated with better health outcomes across 34 OECD (Organization for Economic Cooperation and Development) countries between 2000 and 2005.
and
When comparing state-to-state spending between 2000 and 2009, those states with higher ratios of social service spending to health care spending had better outcomes on average.
[1] https://qualitysafety.bmj.com/content/20/10/826.abstract
[2] https://www.rwjf.org/en/blog/2016/08/how_social_spending.htm...
[3] http://content.healthaffairs.org/content/35/5/760.abstract
Last time I checked, Canada, for example, spent 1/3rd less than the USA and Canadians lived a few years longer.
IIRC, of the "universal coverage" systems, Switzerland's ACA-like system had the highest per capita, but still less than USA's system.
Much has changed these last few years. eg Our life expectancy in the USA has fallen.
You’re far better to look at things like “survival after cancer diagnosis” where the US has some of the world’s best outcomes.
https://www.healio.com/news/hematology-oncology/20180131/us-...
Only if we assume public health is unrelated to individual health.
Using life expectancy to judge the quality of a healthcare system or quality of public health efforts is like judging car quality by how nice the body work is. It's a component, but a relatively minor one in overall quality.
https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
Western Europe does better, Eastern Europe does worse. Pretty much as one would expect.
--
Your prior "5 year cancer survival rate" was pretty random. The cherry picking of one favorable stat while ignoring the mountain of counterfactuals.
I was confused.
Then I spotted this.
https://www.aei.org/carpe-diem/us-vs-europe-life-expectancy-...
Aha. Just another "libertarian" talking point. Good grief.
First I argued that life expectancy isn't a good measure because of lifestyle, then you say "public health should address those", then I argued Europe does worse than the US on several public health metrics like smoking rates and alcohol consumption, then you go back to life expectancy.
I have no idea the point your making because you're failing to actually provide counterfactuals.
A much bigger factor is GDP per person.
I think of it as: The more material wealth you have, the better your life is, and you get less risk of bad health.
> Looking for evidence to the contrary
There was no evidence behind your claim either. 90% of US healthcare costs go to managing ( not treating ) obesity/metabolic disease . Yes 90% [1].
Which country with similar metabolic disease rate has better outcomes with less costs?
"90% of the nation's $4.1 trillion in annual health care expenditures go to people with chronic and mental health conditions"
Obesity is $173 billion, diabetes $327 billion.
We could certainly do much better, but blaming health care cost on metabolic diseases is disingenuous. Diabetes cost is roughly the same percentage of total expenditure as it is in other industrialized nations. (I didn't check obesity)
It stands to reason that really, the problem is the size of the pie, not the size of the slice.
> We could certainly do much better, but blaming health care cost on metabolic diseases is disingenuous.
How so? Only recommendation for all these chronic conditions is 'diet and exercise' is it not ?
Obesity isn't the only one. I am not obese , not even close, but I have hyperlipidemia. I am managing it with 'diet and exercise' after initially being put on statins. Same with hypertension, heart disease ect. All of these are metabolic diseases. Sure, I'll give you 'mental health conditions' may not be a lifestyle disease ( Even those are being now linked to diet ) .
And it's not just mental health issues (~25% of all chronic health issues), it's also respiratory issues (~10%).
Then add to that the fact that many metabolic diseases have long lists of causes that amount to "not really sure". Atherosclerosis? Can be caused by physical activity. Hypertension? Being older than 65 is a cause.
What the Rand paper does say is "90% of all health care cost is incurred by people with at least one chronic condition". Not metabolic diseases. What it also doesn't say is that the entire 90% are attributable to chronic diseases. (It's sort of akin to claiming that 10% of all healthcare costs are incurred by people named John, Robert, or James. True, but certainly not causal)
Again, I'm not saying that chronic diseases aren't contributing a huge cost burden. I am saying that they're far from the only cause of the cost burden, and that blaming it on metabolic diseases is highly misleading even if you just focus on chronic diseases.
What else is there though? I consulted many physicians for my hyperlipidemia and all of them suggested 'diet and exercise' as the only solution. It is the only thing that worked for me.
yes 'not all' high cholesterol can be managed by lifestyle modifications( eg: your genetics might predispose you to high cholesterol. Do you know how much of healthcare spend goes to to the exceptions you are talking about. I certainly couldn't find any data about this, not sure why.
> Hypertension? Being older than 65 is a cause.
Yes we don't know the cause but we do know the fix even if you are over 65.
AHA recommendation
https://www.heart.org/en/health-topics/high-blood-pressure/c...
If "diet and exercise" were the only thing physicians did to treat these diseases, have you tried to think about the internal consistency of your "and at the same time, this is 90% of healthcare costs" argument?
Have you, even for a moment, considered your own statement that your doctor prescribed you statins? Did this not lead you, for a brief nanosecond, to ponder that "maybe other people get treatment beyond diet and exercise too"?
Also, did it occur to you your nows on argument 3? "It's obesity". "It's metabolic diseases". "Actually, I'd like to argue there's no treatment outside of diet and exercise".
Maybe you need to ponder about the difference between treatment and management, or ask your doctor about it next time. All this was clearly explained to me by doctor when I was started on statins and that only way to treat the disease itself is through lifestyle modifications. Unfortunately, There is a whole swath of idiots on internet who think they know better than doctors and experts.
If you walk into the doctor's office underweight and concerned about an issue you're having, the doctor doesn't put you on a strict fettuccine Alfredo and hamburger diet before treating you.
If you're overweight and concerned about an issue, you're far more likely to be told to lose weight and ignored.
You'll be tested for thyroid dysfunction, for diabetes, for hypertension, for all sorts of stuff that won't be on your radar until a blood test turns up "abnormal" results once. Then you'll get pills, all the pills you care to eat and remember, there is no road map for getting off those pills, you'll just get larger doses and more frequent as your problems worsen (because you're not addressing root causes, just being medicated for "treatable" issues which correspond to existing pharmaceuticals.)
yes we don't measure this and is impossible to measure.
Also anybody legally employed must have insurance (of varying quality).
It's also hard to explain that US patients pay a multiple of the drug price people in other parts of the world pay for the something.
The problem is that if the US wastes 10% of GDP on health care inefficiencies this creates a huge lobby that will fight tooth and mail to keep that money.
What we all forget is that nobody is actually paying the US healthcare invoices.
Roughly two options... 1. You have insurance and they negotiated a different (much lower) rate or 2. you don't have insurance and can't pay the amount on the invoice.
In option 2 you either declare bankruptcy and they get nothing or they sell the claim for something like 20% of the invoice to a collections agency.
Also: if you make a certain amount of money and they hit you with a 100k bill you can't just declare bankruptcy. The court won't allow you to do it because you make too much money.
Isn't this always the case? My understanding was that bankruptcy is for when you don't have enough income to pay bills, so if you have a bill for any amount but are able to pay it then you wouldn't be allowed to declare bankruptcy
I work in the industry as well and it’s one of the few reports that actually breaks down the spending in a logical way.
They basically adjust US spending by GDP (high GDP countries spend more generally) then compare each category to the OECD average (also adjust by GDP), on a price and volume measure.
The answer is - yes, higher price are a factor, but volume is also a major factor. In hospital spending is actually in line with other countries. Drugs costs more but it doesn’t contribute that much to total spending. In terms of durables (equipment) the US spends less.
The biggest driver? Out patient procedures. Not just price, but Americans get way more out patient procedures done compared to other countries and it accounts for like half of the “excess spend” of the US compared to other countries.
We might be able to eke out some minor improvements by tweaking the payment model and eliminating some waste. Those things are worth doing, but they won't fix the fundamental problem. The US won't get healthcare spending down to Japan's levels until Americans start acting like Japanese.
There are some other key factors as well. A large fraction of healthcare spending goes toward treating elderly patients with serious chronic conditions in their last few years of life. Some countries explicitly deny care to such patients because they don't think it's justified on a QALY basis, but Americans seem uncomfortable with rationing on that basis.
And some aspects of the US healthcare system are top notch. For many types of cancers we have the world's best 5-year survival rates. There is a thriving medical tourism business where patients from countries with socialized medicine such as Canada come here to receive rapid treatment instead of waiting for years for something like a hip replacement.
That we spend more per capita for approximately the same level of care as most other first world countries is certainly annoying. But sometimes I think we are too focused on that and not putting enough effort into trying to stop the cost from increasing.
I think increasing costs are a more serious problem because the problem of spending so much more than the others is a US problem. That suggests it is just something we are doing wrong, and by making our system more like some of those others we can fix it.
The problem of rising costs also plagues those other countries, and to about the same extent as it does the US. That suggests it is a much harder problem to solve.
Here are some examples of rising costs per capita.
How much costs per capita went up from 2000 to 2018: US 2.3x, Germany 2.1x, France 1.8x, Canada 2.0x, Italy 1.7x, Japan 2.6x, and UK 2.6x.
Costs per capita in 1980, 1990, 2000, 2010, and 2020 divided by 1970 costs:
1980 1990 2000 2010 2020
US 3.2 8.2 13.9 24.1 36.3
UK 3.1 6.3 15.3 27.8 40.5
FR 3.4 7.6 14.9 21.1 28.5
1980 1990 2000 2010 2020
US 3.2 2.6 1.7 1.7 1.5
UK 3.1 2.0 2.4 1.8 1.5
FR 3.4 2.2 2.0 1.4 1.4
If "latest data available" is checked, uncheck it to unlock the slider that lets you look at historical data back to 1970.
In 1970 US health care spending was $327.0/per capita. France was $192.1, and UK was $124.0. That's 1.7x France and 2.6x UK for the US.
In 2020 it was $11859 for the US, $5468 for France, and $5019 for the UK. That puts 2020 US spending at 2.2x France and 2.4x UK.
From 1970 to 2020 US went up 36x, France 28x, and UK 40x.
It looks like much of the first world has a serious rising health spending problem, with costs rising roughly the same over time everywhere. The US was more expensive long ago, and since the rising costs have been roughly the same the US has stayed more expensive by about the same ratio.
If we could get our spending down to match the rest of the first world, without reducing the level of care, that would be great.
BTW, it is similar if we go by percent of GDP instead of per capita.
US was spending 6.2% of GDP on health in 1970, France 5.2%, and UK 4.0%.
In 2020 that was 18.8% of GDP for the US, 12.2% France, and 12.0% UK.
On-shoring that research also seems to be an advantage -Looking at the astounding amount of research that poured into covid post 2020 would show that we have a huge dormant muscle that can be flexed in unison during an emergency.
https://www.ahip.org/news/articles/new-study-in-the-midst-of...
Generally in business marketing budgets should generate more sales than they cost (in ideal case), so big budgets doesn’t mean that they’re “wasting” that money that could go elsewhere. If the sale wouldn’t happen without an ad, then that’s a necessary ad.
I think that's the core issue here, healthcare and pharmaceuticals have basically inelastic demand. The US is one of only two countries where it's even legal for pharma companies to advertise directly to consumers.
I know in practice they can create demand for products, but that doesn't necessarily seem like a good thing, so I think you could argue that it's still a waste of money even if it does create profit for the company.
I don't think that money is necessarily a waste if it goes back into the economy one way or another. There are very few things that are actually a waste, one example is probably flying first class or private jet. If you literally burn money then it's clearly a waste. A part of me thinks the huge cost of healthcare is contributing to more R&D by the big pharma and possibly the reason we're seeing RDNA breakthroughs. Yes a lot of that money also ends up in the pocket of people running the show, but they most likely then invest it with a Blackrock which in turn pushes the money back into the economy in form of private equity, VC funds, etc. For the record I don't like the high healthcare prices and wish US was more similar to other countries in this regard.
In comparison to France, Germany, Belgium, the Netherlands, etc I would disagree.
So maybe thats where the extra cost goes? To drive research, and support the infrastructure that creates good to better health outcomes on average vs the rest of the world.
Saying something is a failure just because it costs so much is only looking at one side of the coin.
In particular life expectancy is very low by developed world standards and deaths from preventable causes are very high.
I don’t doubt that the US has world leading hospitals but the population level outcomes delivered are poor by developed world standards.
The US is a net exporter of healthcare services but mostly to developing countries and the numbers involved are tiny (https://www.usitc.gov/publications/332/executive_briefings/c...)
The idea that people who want any sort of complex procedure travel to the US is pure fantasy.
As for the COVID-19 vaccines. The first approved vaccine was the “Pfizer” vaccine developed by BioNTech in Germany (https://en.m.wikipedia.org/wiki/Pfizer–BioNTech_COVID-19_vac...).
This isn't true, the US didn't make the first vaccines, it was created by a German company that partnered with Pfizer for trials/production/distribution[0]. People more often travel outside the US for care, we actually have the second highest amount of people leaving their home country for medical care[1], with the top destinations being in South America [1a].
> creates good to better health outcomes on average vs the rest of the world
This would be nice if true, but we spend more and still have worse outcomes in almost every area[2]. The only things I could actually find that are better here is post-op sepsis and 30-day heart attack survival, but in just about every other area it's more dangerous to get care in the US.
[0]: https://en.wikipedia.org/wiki/History_of_COVID-19_vaccine_de...
[1]: https://www.health-tourism.com/medical-tourism/statistics/
[1a]: https://amjmed.org/medical-tourists-incoming-and-outgoing/
[2]: https://www.healthsystemtracker.org/chart-collection/quality...
Of course the biggest issue of all time is that germs are evolving to survive our antibacterial soap, we may need to develop a large variety of antibiotics.
You're conflating 'capitalism' with 'free market'. You can have either without the other and OP was calling out 'capitalism' specifically.
Of course the US market is highly regulated and so the market is not free to lower prices. Of course the AMA is a racket. Of course needs of certificate are abhorrent.
Given the customer non—coerced access to his preferred provider, and not taking his money and slapping a bunch of regulations on him will of course lower prices and give him better care.
I don’t see why the other side can’t see it.
Also wondering what you think a solution is - single-payer for better and simpler price negotiations, or some other approach?
My main concern is if we're spending 20% of GDP on something other countries accomplish with 10%, then that's a huge waste, especially in a country with a larger total GDP pool.