So why is our healthcare twice as expensive as the countries who actually do have socialized health care? When is that competition going to kick in and bring down costs?

https://www.healthsystemtracker.org/chart-collection/health-...

Because Americans don't want to let people who can't pay for emergency care die (which I'd argue is a good thing) but also can't have a serious conversation about how to pay for that.

It’s a false excuse. Plenty of countries that also don’t let poor people die because they cannot afford going to the hospital also spend much, much less per capita. Actually, all of them do, and by far. The US really are an anomaly.

The socialism / capitalism argument is a way entrenched interests rile-up the public and stop productive conversation.

Is it more about emergency care or the fact that we pay more for prescription drugs and expensive procedures?

I like to say that there's blame enough for everyone to share. There's truth to virtually every argument. The entire "system" is so "sloppy" and filled with points where money just leaks out.

The emergency care angle is what drives the socialism / capitalism bickering and that's what I see a the biggest impediment to actually making effective change.

As a paramedic (part-time) and someone who has worked in claims benefit management systems, EMTALA (the rules/laws around emergency stabilizing care) are not what make our healthcare astronomical. It's prescriptions, imaging, and labs. You can easily be charged several thousand dollars for diagnostic imaging. My insurance covers labs 100% but a recent stool sample test charged $780 to see if I had blood in a stool.

Speaking of DI, DI is a money-printing machine, with CT and MRI machines that range from a few hundred thousand to over a million have breakeven points well under two years. And the DI companies work to find and gather physicians who want to start a DI practice. Offer financing, consulting, and then, shockingly, we find that physicians who own a DI practice or a share in one tend to over-refer their patients to imaging.

EMTALA (and the ACA) drives the socialism / capitalism bickering that I think is a primary cause of conversations about reform to run aground.

Because Obamacare legislation ended up as a terrible version of socialism/pork-barrel spending/crony-capitalism in order to get the required support to pass.

The democrats wanted to get subsidized healthcare for low income people and people with existing health issues that would guarantee they would be uneconomical to insure. The healthcare providers, insurance companies and pharma companies wanted to remain viable, profitable businesses.

The compromise was to essentially guarantee profits to healthcare companies by crafting legislation that overcharges young people, healthy people, male people, middle class and affluent people to subsidize costs for other groups, while giving a consistent profit margin regardless of costs to insurance companies.

There is nothing about American healthcare that resembles functioning markets or capitalism. It's a very heavily regulated industry where the government exerts extreme control, while choosing to legislate in a way that maintains a consistent flow of money to influential lobbying groups and political donors.

I'm old enough to remember health care prior to Obamacare, and I can assure you it was broken before too.

Frankly the difference I noticed post Obamacare was a friend of mine was able to get insurance in time to not go bankrupt treating her colon cancer.

I can't get behind the idea that Obamacare is somehow what broke our medical system.

It was actually worse in that you could be denied health insurance. And I know a lot of people who are denied health insurance for very mundane reasons.

Insurance companies had teams of people who, if you made a substantial claim, would look over your application for anything that was amiss. And if they found it, they'd drop you so they wouldn't have to pay.

Your health record became a criminal record. You just hoped there was nothing on it that would prevent you from getting coverage in the future.

Obamacare has some very serious problems, but at least you can't be denied insurance just because you have back pain.

surgeon here. before Obamacare insurance companies denied payments if they deemed the issue pre-existing and were not told about it in the patient's application. I was in private practice for 10 years and now employed surgeon for 12 bc insurance companies notoriously deny payments for no legitimate reason. One time I saw a patient with an inguinal hernia and then fixed it. We were denied payment because my initial consultation said, 'presents with hernia he's had for 2 years, but now increasing in size and causing discomfort'. Their reason for denial was that he only had coverage for a year and had not told them about the hernia. From then on, my notes were very brief. 'Patient presents with symptomatic hernia'

Before Obamacare, some policies had lifetime limits, which could affect expensive treatments like cancer.

We celebrated the fact that now medicare can negotiate 10 drug prices. It should negotiate all drugs. The organization that gets the lowest prices is the VA. Congress could easily pass a law saying medicare will only pay that much and it would not cost much to implement.

System is very broken.

The ACA made broad and sweeping changes, but the "shadow" socialist component of the American healthcare "system" goes back to the EMTALA[0].

[0] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...

> There is nothing about American healthcare that resembles functioning markets or capitalism.

This is cope, just like "(socialist catastrophe) wasn't caused by TRUE socialism" is cope.

The mechanism by which capitalism causes concentration of wealth and power, and by which said concentration then creates means, motive, and opportunity for self-dealing is crystal clear.

If it were fully free market, there would be more competition. If it were fully socialized, the government would control prices.

Instead, our system is the worst* of both worlds. The government limits the supply to prevent competition, but allows those they've licensed to charge as much as they want.

*(That is, worst for patients; it's the best for profits)

I don't believe there exists a possible free market for health insurance, just like with flood insurance or earthquake insurance. Adverse selection kills it.

Even if there were no insurance, I don't believe there exists a possible free market for expensive emergency medical procedures either.

Well, we don't have competition because the much-vaunted doctor's union blocked how many doctors we could have so that they could keep doctor pay up. And that's not me attributing purpose. That's them saying why they did it.

Because we don't have death panels like in countries with government-run plans. Your insurance carrier won't deny you a bone marrow transplant because you're 85 (it costs over $1m). Other countries will deny it, because you're 85 and have had a good life.

The UK's death panel is called NICE: https://en.wikipedia.org/wiki/National_Institute_for_Health_...

We should have something similar in the US. 80% of all healthcare spending is consumed by people in the last 3 years of their life.

> Your insurance carrier won't deny you a bone marrow transplant because you're 85 (it costs over $1m).

Your experience with insurance in the US is very different from mine.

My experience is insurance denying my 34 year old sister's MS meditation until she ended up in the ER.

True. I've never had a bad experience with them.

I think it could be cool to have an evidence-based death panel of experts instead of our ad-hoc death panel of one guy (or one LLM!) running through a spreadsheet and clicking "no."

How much time would you spend shopping around while you're bleeding out from a head wound? What would you use for negotiation leverage?

Typically one would not do that. You'd shop around ahead of time, sign up for a plan and then if/when the emergency came it would already be taken care of.

That's what we have now. I hope you're conscious enough to tell the ambulance driver which hospital to drive to.

SF Bay Area south bay -> Good Samaritan (anything but Valley Med)

SF Bay Area peninsula -> Stanford

Austin -> St David's

The American healthcare "system" is dysfunctional because parties who profit from the status quo keep the public bickering about inflammatory issues and distracted from making meaningful change. (My favorite example is "death panels".)

Since the American system doesn't allow people who can't pay for emergency care to die the system ends having a socialist component. Socialism is such a hot-button issue that we can't have mature conversation about funding it. Almost any conversation about it gets caught-up in partisan and "personal responsibility" bickering.

It would be easier if we just let people who can't pay die.

That's repugnant and wrong, but it would certainly make the conversation easier.

It is perfect example of crony-capitalism... Under socialism basic care would come from one pot. And state would tell what everything can costs.

Respectfully save me the Ayn Rand. Some of us live in the real world and not the political utopias of our minds.

I'm going to jump in here and offer up an Ayn Rand because you brought her name up.

Ask anyone who has a dog, preferably a big dog, what it costs for a vet visit.

Better yet, talk to someone who has had a sick dog. Something terminal, or possibly terminal. Costs are wayyy lower. Same x-ray, same imaging, many similar medicines. I've talked with vets, human doctors, and doctors who own dogs. They all come to the same conclusion:

Only ONE key difference - there is no insurance or government regulation involved (obvously stuff like taxes, basic health codes, licensing, but I think you know what I mean).

I'm more than happy to agree with you if you could show me a plausible explanation for this enormous disparity in costs.

Because if I kill your dog I don't get charged with murder.

Not at all the same thing.

But the Koch's want people to believe libertarianism is a kinder version of hate that believes in weed and unlimited freedom to rake in cash.

I'm in agreement that healthcare is sorely lacking many individualist incentives, including market ones [0], but can we not pigeonhole anything we don't like as "socialism" ? It just makes for a terrible time talking past one another.

[0] hint: receiving bills for charges you never assented to is not a foundation of a working market, and should obviously be illegal.

It’s been a long time since I’ve seen someone say something this wrong on HN. Calling the American health care system socialist in any way is laughable.

That's just a reflection of how thick the wool over your eyes.

Ah yes, of course, https://bitworking.org/news/2008/01/the-free-market-fairy/

He's right, though.

I moved to Canada recently and caught a flu that I didn't take care of and, in turn, developed into pneumonia. It took me FIVE days to be able sit down with a doctor and get an antibiotic prescribed even thought it was more than evident I needed immediate care. I could have died if I waited another day. But was it free? ... ehrm ... yeah.

In Mexico, doctors are as free market as it can get, downsides and upsides of that considered; with cash in hand you can get any kind of attention you need in the exact moment you need it. And it's not even that expensive, after converting MXN <-> USD. I could've dropped by with any of the 1,000s doctors that are available, many of which don't even require appointments. I would've got the attention I needed and the antibiotic prescription in 2-3 hours. That would had cost me ~60 USD.

> MEXICO CITY (AP) — Mexico’s president said Friday the country’s minimum wage will rise by 20% in 2024, to the equivalent of about $14.25 per day.

> About one-third of Mexico’s registered workers report earning the minimum wage, which will amount to about $1.75 per hour starting Jan. 1.

$60 is 4 days wages for 1/3 of workers in Mexico. It's the equivalent of $820 for someone making 75k per year in the US. So it's the same as any other free-market healthcare system: easy access for the wealthy at the exclusion of the poor.

https://apnews.com/article/mexico-minimum-wage-increase-peso...

Your reasoning is flawed as $75k/year is WAY above the minimum wage in the US. Adjusting for that, it comes to about ~$160.

I'm not saying it's fair, I'm saying it's cheap, compared to the US as that is implied by the context of this conversation.

When you buy a $1 dollar shirt from Malaysia, is it cheap? Yes. Is it fair? Who knows.

It's the same thing.

Also, doctors in Mexico make way more than minimum wage, it's not unusual for some of them to have incomes around 200k-300k USD/year, plus read about RESICO and your jaw will drop to the floor. The average person in the US would kill to have the income and purchasing power doctors have in Mexico.

"Canadian healthcare wait times" are mostly a myth invented by the American healthcare lobby [1]. Canadian cities are dotted with walk-in clinics you can go to and see a doctor same day. Or worst case scenario you would go to a hospital ER. Neither of these options will cost you any money and you will get same-day treatment and care. If you made an appointment with a GP then yeah you would wait, since those visits are typically for non-medical emergencies. :)

[1]: https://www.washingtonpost.com/outlook/2020/08/06/health-ins...

Hey, I'm not a "myth invented by the American healthcare lobby", wtf.

I went through that ordeal ~4 months ago, me, personally, I didn't read it on a magazine or whatever.

Germany has socialized healthcare and you can just go to your doctor without an appointment in acute cases like yours. Saying that ~60 USD is not that expensive comes from a privileged position where 60 USD doesn't hurt you.

Tell me you don't know anything about healthcare without telling me you don't know anything about healthcare.

I have a partner who's a nurse practitioner in primary care and I just want to emphasize how hellish it is for people on the inside as well. The economic model of running a healthcare business is entirely based on their ability to bill for provider time. Healthcare providers have very high costs to match their very high fees and also pay a bunch of people to 'help' providers see more patients. A big part of this mix is also that it is not enough to provide healthcare - you are actually paid for providing documentation that you carried out the specific care that you "should have done" given the case notes. Ensuring you properly annotate the files of patients (for the benefit of generating the right charge codes! Nothing to do with patient care) is another burden that's required to sustainably provide care. As a result the costs "per provider" are much higher than the provider themselves - you also need medical assistants who do every piece of work the provider isn't legally required to do, billing staff to properly bill that work, admin staff to manage their schedule in detail, etc.

The lack of regard for patient schedules is a direct result of how insanely packed the schedules of providers are. Fifteen minutes per patient is luxurious and my partner spends a lot of time after work entering notes for patients she saw that day (she "works" 32 hours / 4 days a week, which is really closer to 40-45 all told). My understanding is that the clinic does not have a high profit margin (serving medical / medicare patients + high overall costs), so every patient counts, and the admin staff will add people w/o permission. It's common for her to find patients scheduled over her breaks or for her to be scheduled after she should have left the building. Burnout has always been bad but it's reaching epidemic levels now in the wake of covid, which further restricts the supply of healthcare and makes people wait longer to be seen.

Somehow, US healthcare is ~ 2-3x expensive as equivalents in other wealthy countries, which get better outcomes. Who is collecting this extra money? It's not the medical professionals, you say (and I believe).

It's partially medical professionals! My partner is better paid than she would be in, say, Canada. US medical worker pay absolutely contributes to our costs - I just meant to point out it's not the only factor and that those jobs, though well paid, can be taxing for the people in them on a day-by-day basis.

I think people tend to get stuck on the ridiculous charges/billing and don't often get to the point where they appreciate just how bad the provided healthcare is, and how much it utterly destroys patient agency by replacing it with bureaucracy. The provider/"insurer" dynamic is really the deep set home of the rot. As a table stakes reform, health "insurance" companies need to be prevented from managing healthcare and relegated to purely financial payers, but doing so would put so many low-level bureaucrats out of work it's politically untenable.

For a recent event, I got a whole nurse calling me from the "insurance" company, out of the blue, seemingly just to chat about the medical situation and how things are going. I haven't figured out what her KPIs are, but I doubt she remains so friendly when you bump up against them! And she obviously represents a severe misallocation of labor - the industry would be better off if someone with her education (and likely experience) was actually providing healthcare.

> - the industry would be better off if someone with her education (and likely experience) was actually providing healthcare.

Worse the odds are good she was hired to help the insurance company prevent people from getting healthcare.

No, the worst part is dying of a painful terminal illness while being sued into bankruptcy in your dying days having to fight to keep minimal possessions because the hospitals and doctors want money.

None of that stuff would be possible without government. It's a statism run amok.

It's the same story every time. Something works relatively OK (US health care before 20 century big-gov), huge changes to incentive structure and overheads are introduced by statists ignoring higher order effects, everything goes downhill, statists blame capitalism.

Let me legally not have insurance, pay anyone in cash for my health care (no licensens and government enforced monopolies), and buy any medicine I'd like and opt out of this madness completely and let's compare with real capitalism.

It's always been legal not to have insurance (though there was a brief period where externalizing costs that way was taxed). You can pay cash for health care as you like now with any provider who cares to negotiate with you on a cash basis. There's even a variety of non-MD providers whose licensure ranges from more accessible through informal to non-existent should you object to credentials as distorting.

If you try doing health care this way for long enough, you might even discover which incentives are poorly aligned without collective policy of some kind, but who knows, maybe not.

We can surely fix this mess via same invisible hand that sent people down the horses aisle in the farm goods warehouses to use deworming medicine as a preventative antiviral.

It's really not, it's a frankenstein of a system with capitalist and socialist traits. If it were capitalism run amok, a consumer would be able to figure out the price of something as though it were a cup of coffee. Pricing is completely opaque and provides nearly zero demand for providers to compete.

It's not socialist (Medicaid/Medicare notwithstanding). But, it's definitely not "ECON-101 free-market capitalism" either. Lots of regulatory capture from both medical and insurance providers. Plus a bunch of self-inflicted dysfunction because we keep electing ding-dongs into Congress.