My apologies, it might have been more accurate to say "in the US and similarly uncivilized countries".

That was my though as well before even reading the comments.

I suppose I should admit as an European that confidence in your own superiority is not solely and American trait.

The US is far wealthier though, like just compare the developer salaries for a start.

What's a $250k payroll worth if that's also what you have to pay for the average hospital visit? I'd stick to my €100k and not have my life ruined just because I broke my leg or my kid is born with a heart disease.

If you make 250k you can afford fantastic insurance and you'll still have a lot more left over.

It's significantly better to be a high earner in the US than almost anywhere else in Europe (in terms of capital)

Ok, sounds cool. I'm in. Where do I book the insurance for getting shot?

I definitely didn't expect this in a HN thread

I didn't expect to lose a cousin on a business trip to the US (Michigan) 6 years ago either. Life is full of surprises.

I'm sincerely sorry for your loss, but moving the goalpost doesn't help the discussion. Again, nothing to take away from how dreadful what you lived through is.

Condolences appreciated.

> doesn't help the discussion

That's exactly my point. The discussion started to derail into "Who has more money?" like that's the ultimate metric. This just makes me sad but is pretty representative for the stereotypical US mindset. My point is there is a lot more to life than money.

At no point did I claim it was the ultimate metric and instead clarified that I was talking purely in terms of capital

Life insurance is available- as is emergency healthcare riders.

Americans won’t admit it publicly but a big part of living in America is knowing what parts of America you shouldn’t go. And if you do have to go to or through those areas, you start to understand why so many people drive urban assault vehicles.

And what about sending 2-3 kids to some good universities, how much do you need to save in cash? 1 million?

A bit more, I would say count 100k/year/kid.

And that outside of your own retirement.

I’m currently on a US salary that is very generous. I don’t spend a dime extra because of those. It’s kinda terrifying I don’t know how they do it.

If you think this is good oh boy do I have news for you. You don't need to "afford" fantastic insurance, healthcare is essential and needs to be free for everyone, which it is here. I have complete freedom of choice across 27 countries, no strings attached, completely free of cost. So do people poorer than me.

Just ran some arbitrary numbers. Someone earning $190k in mid Ohio would have take home of around $140k, between state/federal. That's before any other retirement savings or anything else. A 'fantastic' insurance plan from blue cross anthem will be around $2400/month for a family of 3. With a 'modest' deductible of $4k. $2400*12=I around $29k. This person is having to spend ~ 21% of 'take home' just on medical insurance. Assuming working independently, some of that is deductible, and one might argue how much left over is "a lot" or not. There's still food, shelter, utilities, transportation, education, etc. they need to account for, as well as saving for the future.

Actually, looking at it, if the person is 'independent', they'd pay another ~$10k or so on FICA, or have some LLC structure set up. Or they might be lucky enough to have an employer who pays for some/most of this 'fantastic' insurance... until they don't.

Perhaps in terms of raw dollars, there's some advantage, but there's an pervasive threat of "what if" scenarios that is hard to shake for a lot of folks.

But if you are earning that you are likely working for a large corporation where your actual out of pocket expenses are much closer to something like $1000/month for that family (varies by situation). Far better scenario then a much lower European salary (probably closer to $80,000) with higher taxes and the same (at best) quality care.

If you are working independently yea it may be more expensive, but (unfortunately) so few people work independently so it’s an edge case not really that valuable here. Though worth noting providing a way to untie healthcare from employers and still make it affordable so that you can more easily start a company is a good idea.

It’s really difficult to do good analysis here. If you were in Ohio making $190,000 your family is automatically in the top 10% or so. If you worked remote you could buy a house outside of a major city for your salary equivalent, or in a city like Columbus for 2x your salary with some fantastic public schools.

Also a nitpick while I think you get much more efficient and cheaper healthcare with the government running it, at the end of the day it’s never free so you have to actually compare taxes to premiums to get a fair assessment of cost.

> untie healthcare from employers

This 1000 times. I don't think we'll see a meaningful change in my lifetime, but it's an existential burden that we, collectively, have had for generations. So much so, really, that hundreds of millions of people seemingly can not envision meaningful change.

The constant "just get a great job with great benefits!" refrain irks me to no end, and demonstrates a privilege that people often deny exists. Even if/when I can get that "great job with great benefits", I still only have it at the pleasure of the employer. I grow old? You're gone. Employer makes bad decisions? They "take responsibility" by letting me go.

The notion of having access to health care, regardless of my employment status, should be such a basic thing to grasp. If I'm unemployed for a year or so (illness, family issues, whatever), having to upend specific doctors/medicines/hospitals/treatments because "insurance change" is life altering for many. Seen it myself in dozens of personal connections over the years. Want to change jobs? Whether abusive working conditions or just need to be with family? "Can't do it... I need my health care... the only doctors that take my health care are in this area...". Or... "I won't have health insurance for 6 months if I take that new job".

There's 1000 different examples I could find why "employer/insurance" connection is bad, and very few I can think of that are good for all parties, yet, we continue in this mess.

> but (unfortunately) so few people work independently so it’s an edge case not really that valuable here.

I know a growing number of folks doing this, and many more who would love to, but ... "health insurance" keeps them tied to "employers".

argh...

Great post and I do apologize if I came off as 'not caring' about people working independently it's just if we do broad characterizations we have to compare broadly and so few work independently.

Maybe an idea there to start an independent business owners healthcare association or something that redistributes profits via lower premiums or something? How the hell do you start something like that?

FWIW, there are orgs that do that, but they almost always end up being somewhat regional, and... it ends up being a lot of work. FreelancersUnion, in New York, I believe did/does something like that. Some chambers of commerce and similar groups do too, but... it doesn't really end up changing much of the price at all, especially since ACA. (oh, misread, I initially read that as simply just offering a buyers group to get 'group' rates).

You've generally always been able to buy health insurance independently. I started... 14(?) years ago. The ACA, well-intentioned, was hobbled from day one, and my $220/month high deductible plan has morphed in to a $1300/month plan which is still high deductible ($14k/year), has fewer options, and ... well... some pregnancy services will be covered (cis male here). You want a 'low' deductible? You're looking at probably $2k or more for 2 adults. And yes, I know health insurance has an age component - I'm years older than I was then too. $3k/year in exchange for taking on some risk (higher deductible) makes some sense. But base price of $15k/year in health insurance, plus another $14k/year in deductibles means this is essentially catastrophic only, but not really priced as such).

It's all region-based, and even where I'm at, I get measurably fewer options because I live 2 miles over a county line, and 'no one' insures out here. It got worse for several years - I know in NC, there are ~100 counties, and I believe there were more than 30 at one point who had only one insurer even selling health insurance in those counties.

Also.. FWIW, I didn't take it as you didn't care, but yes, freelance workers are generally overlooked, even as the ranks grow. They just tend to be growing on the lower-end of the spectrum - rideshare drivers, door dash delivery, etc. Much easier to just ignore growing segments of society while we pride ourselves on our ability to "get a better job with great benefits!". I'm not in a position of having to choose food over medication, but having to decide between medication or surgery today over funding retirement savings? I've been there, as have some friends of mine. Yes, it comes across as a bit privileged, but privileges are all relative.

Better how? It is probably better if you do not intend to have children or ever need medical care. People saying that taxes in the US are much lower than Europe, as a person who lived in London, San Francisco and NYC I’d like to disagree.

The tax rate for my income bracket in the UK is 45%, and while federal income tax is 39.6% I still have to pay state and city taxes on top of that which works out to be about the same.

However I get free medical care in the UK, affordable college tuition (10x less than the US at least), maternity leave, great public transit, I could go on. What does the same amount of taxes paid get me in the US? I’m not complaining about having to pay taxes, but sure would be nice to get something back that isn’t military.

> The tax rate for my income bracket in the UK is 45%, and while federal income tax is 39.6% I still have to pay state and city taxes on top of that which works out to be about the same.

This statement is meaningless without specifying the brackets or providing an effective tax rate for a certain amount of income.

Oh, spare me the semantics, the difference is still single digit % of the total income.

How would a reader know that? And how can that be true when the brackets are so different? UK does not even look like it has single vs married distinctions, not to mention the myriad deductions in the US, and the drastically different taxes in various locales (I pay $30k+ less per year by living 10 miles across the state/city border).

https://www.nerdwallet.com/article/taxes/federal-income-tax-...

https://www.gov.uk/income-tax-rates

The 45% income tax rate is for 150k GBP, which is $167k. The top bracket for US federal income tax starts at $578k/$693k at a 37% tax rate.

I was providing my personal anecdotal experience of having the basically the same net income in 3 places. 37% federal tax also does not account for 6.8% state tax and the 3.8% NYC tax which I know does not apply to all of the US, but then we get into the territory where we have to address that I will probably not have same income in bumblefuck alabama anyway.

People here are talking like the difference between US taxes and EU taxes is 20% or more, when in reality it’s maybe 5%

The difference in tax burden is give here: https://data.oecd.org/tax/tax-revenue.htm . It varies quite a bit by country, but the contrast with France/Nordics is particularly large

I’m not sure how income tax % to GDP is relevant here, but perhaps I am looking at a wrong thing, it’s quite painful on mobile

UPD: looked at the tax wedge, the US vs UK looks pretty similar to me- which supports my point. Germany looks a lot higher, but they have 100% free tuition and I am not familiar with the rest of the benefits germans get.

A single digit % of total income may not be a big deal in European salary terms, but when you make US salaries it's significant. That's your first mistake.

Also, lol at UK public transit. Horrifically expensive - probably more than a single digit % of total income if you actually have to commute anywhere on a regular basis.

I work as an engineer in America and yea.. that’s totally not how the math works. Healthcare expenses are largely covered along with the much higher pay and lower taxes. I think my out of pocket cost last year was negative after hsa contributions from the company.

Yeah but what happens if you lose your job and get really sick? Or what happens if you get really sick and lose your job?

In the US, that sounds like a need to either ruin your finances/live/pension/etc. In most places of Europe, not so much.

If you're productive and then get sick and get fired for being sick, by the time you die of lack of access to healthcare you had become poor. So you see, nothing bad happens to the good useful people!

You have cobra coverage until you go get another job, which is something you absolutely have to do regardless. If you have an hsa, you’ll still have a bunch of money in there, too.

At the end of the day, the revealed preference is that many EU+CA developers move to the US for the salary, and extremely few US developers move to the EU. Draw your own conclusions.

An EU eng knows that if shit hits the fan, she can go back to Europe and have live well. So why not earn some extra cash in the US.

An American doesn't have that privilege.

I’ll give you an example.

The delta in wages from my home country to the US, after taxes, could pay for private insurance for 5 families.

This is just ignorant. Nobody with a $250k salary at a tech company in the US is paying any meaningful amount to health care. It is covered by insurance that their work provides.

I often describe the US as the richest (and most well armed) underdeveloped country.

It's unfair, as all short takes are, and it saddens me to see my friends who live there, who are at no fault for the mess they are in, suffer. I fear the coming mid-terms will only make things worse.

Extra-urban (outside of the big cities) Texas feels increasingly feudal every time I visit; maybe it’s because I’ve spent an increasing amount of my life in comparatively egalitarian Germany so it’s easier to see than when I was embedded in it.

Yeah, but SF is swamped with homeless ppl. Yay for all those devs earning a lot while living in dystopia. If I can earn less but be confident that I won't go broke because of an unfortunate events. And that the system is humane, and tries to find a balance between capitalism and humanism, I'll take that any day.

US wealth is a joke.

I love when Europeans repeat Fox News talking points. Really shows how "progressive" they really are.

Have you been to SF? I spent a bunch of time there for five years between 2013 and 2018 and the homeless problem got worse every time I visited. It's really bad, and I live in a place that has lots of homeless people.

More importantly the US has far more inequality.

Developers are already very well off no matter what country they live in, and I'd wager that "normal" people in the US are not far wealthier than people in Nordic countries for instance.

Adding a little love to the world every day, huh?

The cruelty is the point here in the good ole US of A.

Op is saying that making healthcare dependent on employment is the mark of an uncivilized country. It's not a blanket dismissal of other countries.

But US is pretty much a third world country when it comes to social safety net

The US safety net, in terms of spending, is as expansive or more expansive than the rest of the world. For example, the U.S. spends $748 billion on Medicaid, health care for the poor, which is matched by state governments. Obamacare subsidies are another $160 billion a year. The fact is the terrible U.S. government administration of these programs and the regulatory capture of the health care system by doctors, pharma, and hospitals are the core issues, but liberals whistle past these real issues and wonder why we don't have European comforts and outcomes per dollar.

Just to be clear, you’re not implying that, just because the US spends more on healthcare than other countries, that means it’s any good right?

Coz like… it’s not hard to spend trillions of dollars when you charge $5000 for a tablet you can buy in Australia for like… $20.

I don't think that was the point that they are trying to make.

A lot of people hold the belief Healthcare in the US is bad because it callously refuses to spend money on people. This is not the case.

When you remember that those funds were largely deducted from someone's paycheck, it has a real impact on those workers and it's important not to dismiss all the hard work that did go into supplying those funds.

That's not to say that there are major structural issues with how Healthcare is regulated in the US, primarily related to how those funds are spent

I don’t know how “spending more money for less benefits” is better than “callously refusing to spend any money”? If your country has good intentions or bad it makes very little difference when u’re dying from treatable cancer because u can’t afford the care. Or when u have to go back to work immediately after giving birth. Honestly, my mother lives in Russia, which is by no means an example of a country with a good social net, she was mortified when I told her about US labor laws. It’s true u net more cash in the US, but u also have only urself to rely on if anything bad happens, and people are really bad at financial planning for any and all unfortunate circumstances

>I don’t know how “spending more money for less benefits” is better than “callously refusing to spend any money”?

I don't know if it is better, but it is certainly a different problem, which matters if anyone is interested in understanding or fixing it.

I think it is important to understand the problem specifically there are a lot of patients dying of treatable cancer who would benefit from a health care system that functions better.

Sure it is necessary to understand the problem to fix it, I am not denying that. Sure, “refusing to pay” vs “paying a lot and accomplishing fuck all” are different problems. But the context of this discussion is “can US healthcare system be objectively called third-world-like” which it can. Whether it is bad because of X or Y reasons is not relevant and comments like the one I responded to, come off as trying to diminish how dire the situation really is.

Didn't seem like they were trying to diminish anything. The specifically called out how terrible the administration of the health programs are.

There are significant differences when it comes to expectations on a fix. If the problem is just refusal to spend, the policy problem is easily improved with easy to write legislation: 'medicare will now cover everyone over 55'. The US healthcare system is far more difficult to improve than that, as just asking the government to cover more bills at the prices companies and the public pay would be hard to sustain. Changes to make costs more in line with European countries would have extreme opposition from some people: Every dollar of waste is someone else's income, and in general those are also American voters. This doesn't make American healthcare any better, but it means that it takes extreme efforts to make it better, even a little bit. So it's at least not a matter of malice.

As for labor laws, the US does far better than it seems. Easy to fire also means easy to hire too, as the risk taken by the employer is also far lower. And the stronger the protections, the higher the slack, showing in unemployment. Very few European countries have the unemployment rates of the US, and the ones that do get there via a lot of temporary work, which has about as many protections as US work. And even with those protections, you still see Spain and Greece at well over 10% unemployment, while the US is under 4.

I think there are some "simple" fixes that would go a long way to improving the healthcare system.

The easiest is basing Medicare spending on patient benefit in terms off quality adjusted life years.

I think it is a common misunderstanding that European countries maintain lower costs via price caps. In actuality, most don't limit the sale price, but control how much they are willing to pay for a drug, device, or procedure. This means that a product has to be substantially better to command a substantially higher price. More treatment with slightly worse products means much more benefit overall. Similarly, it puts some downward pressure on the price of new products because they have to compete with cheaper but less effective ones.

Using spain and greece for comparison sure seems like cherrypicking your data.

Also it has been proven many times by many people that if US were to transition to single payer insurance system, it would actually decrease the spending. No one claims it is easy, but there is absolutely no reason for the US insurance system to exist under single payer, that would be just setting piles of cash on fire.

I would quibble with the word proven here. There are compelling arguments with good data. single-payer could be better or worse depending on actual implementation and coverage.

It's also worth noting that many countries with single pair still have a supplemental insurance market for premium coverage not included.

We don’t have European comforts because we pay for our own national defense. We also pay for Europe’s defense.

We should work out a deal where we continue to provide their security, and they provide our healthcare. Even Stevens.

American healthcare is not underfunded due to defence spending. American healthcare is very well funded. It's just horribly inefficient and perverse.

The USA pays for a lot of offense too. The USA also pays a lot for healthcare in general so lack of funds isn’t the issue.

It never seizes to amaze me the simplicity with which the Americans view the world :)

There's literally a war in Europe right now because Europeans underfunded defense. Luckily, America will save you again :)

Big numbers are just big numbers, per capita and outcomes is where it's at.

Having said that, the US healthcare system is very efficient at extracting profit.

An interesting rebuttal to the usual complaints about the US healthcare system (no idea how factual it actually is, but it passes my basic sniff tests, but it is a subject I am unfamiliar with):

https://randomcriticalanalysis.com/why-conventional-wisdom-o...

That said: tying insurance to employment is evil. I’m a New Zealander and our healthcare system certainly has its problems too.

> but liberals whistle past these real issues and wonder why we don't have European comforts and outcomes per dollar.

The US should grow up and stop it with these bicameral partisan pissing matches.

Both the US centre right and alt-right parties are equally responsible for putting US citizens taxes directly in the grubby hands of middlemen who fail to deliver outcomes.

The biggest problem with us Healthcare spending is how the money is allocated and spent. A lunch pin in the high cost is that the government has no concern for the cost to benefit of treatments and largely props up the price of the market. This is a bipartisan problem. If the government set reimbursement for treatments based on patient benefit, it would go a long way to reducing the cost in the US.

I think people from actual third world countries would love to be in the US instead of back home.

Trust me, the unemployed life in third world countries, and even in second world countries, is far more brutal than the unemployed life in the US, especially for unemployed big-tech workers who can find a new job anytime.

  > unemployed life in third world countries, and even in second world countries, is far more brutal than the unemployed life in the US

maybe so, but we should look at the trend not just one sample group at one point in time... for a long time it can be argued that the u.s is riding along as fast as it can to catch up to "the 3rd world" in that regard....

No need to be politically correct. This is the default dogma across both the 'garden' of the West and the 'less-civilized' world too (almost uniformly across Asia (regardless of their 'honorary' inclusion in the 'civilized' category; Middle East etc.).

The only reason Europeans (and Americans are Europeans), keep up the pretense is only in order to further the universalization of Anglo-American culture.