As someone in the UK with income in the top 1%, I have never bothered with private insurance because I genuinely don't feel I need it. I occasionally pay for private GP services, and I've paid for some private services for my son, but for the most part the NHS works. It has waiting times for non-essential things, and if you don't want that, you can pay for insurance that gets you seen faster and it costs a pittance. But if you need treatment, you get it. Overall, paying cash for healthcare here is also so much cheaper that for Americans, for elective procedures with short-ish recovery, flying to London can be a cost-effective option compared to US hospitals.

I'm sure that if you're rich enough, you have fantastic care available in the US, but from what I've seen of prices for pretty basic stuff, I'm not so convinced most of the top 20% in the US have healthcare I'd consider tolerable.

As soon as you need treatment beyond standard GP/prescriptions, like checks/analyses or specialised consultation/treatment then private insurance comes very handy to get good care quickly.

Waiting times are not only for non-essential things. The only thing with no waiting time is A&E if you are in immediate danger of death.

The NHS is some "safety net" that does the bare minimum at this point, or no longer anything at all (eg. dentistry).

Interestingly, nowadays if you have a good job and private insurance in China you get better routine checks than in Europe/UK. Even Chinese hospitals are extremely thorough and quick compared to British ones (at least the main Chinese cities)

I have had extensive rounds of tests for various things with the NHS over the last several years, and never had a problem sufficient to feel private insurance, even as cheap as it is in the UK, to be worth it. I don't doubt it's worth it for some, but there's a reason - and while costs will stop some, costs does not explain nearly all of it, given how cheap it is - that only about 10% of the UK population has private insurance, even with the underfunding of the NHS in recent years (e.g. 20%-30% lower healthcare spend for capita PPP adjusted than comparable economies does have an effect).

There's an inflection point, sure, where you start spending enough privately that the insurance is worth it, but so many of these things are so cheap here anyway that the gap from between where it starts to pay off until you're ill enough to get reasonably fast treatment with the NHS is quite narrow.

Sometimes people think it is wider than it really is because people want and push for treatments that are not medically indicated. E.g. patients pushing for pointless MRIs is common enough that same-day MRIs is a huge industry here even though they only make an impact on outcomes for very specific symptoms.

Private care is still affordable so I can understand that you feel that private insurance is not worth it, but you were also very lucky with your NHS experience.

For instance the UK have very bad outcomes for cancer because things tend to be caught late and treatment delayed thereafter. Frankly, for anything potentially serious or time-sensitive I would go straight private (and in fact the NHS tells you to do that when they ask you if you have private insurance).

The NHS has much bigger problems than funding. Even the new, left-wing government has indicated that they won't increase funding without reforms.

> The NHS has much bigger problems than funding. Even the new, left-wing government has indicated that they won't increase funding without reforms.

It's always very convenient to starve something of funding for years when you want to insist something needs to be reformed before you can spend as much as it costs to provide service at an adequate quality.

Reform or no reform, outcomes won't improve without increasing the funding, as no other system in a comparable country manages to deliver more at the NHS cost level.

The point is that throwing ever more money at a bottomless pit isn't a solution. Hence there must be changes, not just more money.

Another issue is that the NHS is a religion. It is blasphemous to suggest departing from free-of-charge delivery or private involvement (although that's already what we have). Even suggesting "reform" is badly received.

The reason is that private intervention is tricky. The US has a fully private healthcare system, and as you can see from this post, it's shit.

I'm from the US so excuse any oversimplifications, but over the past couple decades I've noticed a trend of US-ification in British politics. I would be careful with looking to greener pastures.

The thing is that right next to the UK is France, which I know.

The French system is based on a mandatory health insurance, now with mandatory private health insurance in addition to that.

GPs and most health professionals are private practices that set up shop like a, say, lawyer would and there is big private sector involvement up to hospital level.

I think there are many similar examples throughout the world.

This is partly why I find this focus on the US system in the UK puzzling. My best guess is that it is used as a scarecrow by those opposed to any changes to the NHS.

As someone in the same income range, and many friends in comparable spot, I have to say that NHS is sometimes ok.

Here's an NHS case.

Case 1. My friend's wife had her body going numb, like, completely senseless. They didn't have a private insurance back then. It was maddening hard to get past the GP. And then there were numerous tests, and queues, and... She had a viral brain infection that was, luckily, easy to fix. Could go horribly wrong should they wait for a couple more months.

The problem is that GPs are afraid to assign tests other than the most simple blood tests (unless it's an obviously broken bone).

Case 2. My wife fainted in the middle of a family dinner. It looked serious, and I recognized the sympthoms thanks to dr. ChatGPT. Our car was at service that day. I was trying to get an ambulance but calling all the publicly available NHS numbers but all we got were endless questioneers. We had to force the situation by taking a taxi right to the hospital door. She had an urgent surgery the same evening, quite serious.

Again, there's just TOO MUCH backpressure from NHS at the entrance. Once you get past these filters, it actually it decent.

OTOH, with my highest tier private insurance I had an MRI scans, kidney checks, blood tests all done within a week or two, mostly because of how I had to coordinate things between various private clinics. Not fast, sure, but acceptable.

How much do you pay for your private insurance?

Wasn't me, it's a corporate perk

On the other hand doctors on the US prescribe far too many tests. These tests are generally set to have a 5% false positive rate so if you prescribe 14 tests you’re more likely than not to get a false positive. From talking to doctors it seems extremely common for something like that to happen and it’s always a headache when it does.

"all the publicly available NHS numbers"? The number you should call if it looks serious is 999 (or 112; same thing). If they don't send an ambulance, then sure, that's a problem (and one worth filing a complaint about), but the times I've called 999 the reaction has been immediate.

As for tests, one of the reasons they "are afraid" has nothing to do with being afraid, but what is medically indicated. A lot of private services will do everything "just in case", the NHS won't. That means you often get people wondering why they've not been sent to an MRI for example (as one of the most common examples), because it's only actually affecting outcomes for a very small set of diagnoses. But some GPs certainly do get it wrong, and people need to be more aggressive about changing GPs if they feel they're not being heard.

Yes, I know, 999 was what we called.

So how it works, unfortunately, is that GPs get a lot of pressure to not do things "just in case". But "just in case" is the only way you can notice things that are wrong on a deeper level.

What, for example, is "back pain"? In 90% of the cases this can be fixed by, say, 10 sessions with a physio. But sometimes it can mean something serious, like a spinal disk injury.

Or sleepiness. 98% of that can be fixed with lifestyle and diet changes. But sometimes this can a sympthom of something scary.

Or my wife's example: didn't feel quite right for 3-4 weeks then fainted. Turned out to be serious. The full GP discussion would have taken weeks.

Or my friend's example: increasing numbness, nothing serious at first. Major brain infection. The GP actively tried to downplay things.

I don't know if there is a solution to this. Right now it feels that without chatgpt-assisted self-diagnoses and being aggressive with getting over the GP wall the system tries to avoid helping out.

Also: an unironic 1%-er income in France is like literally the bottom of the barrel Bay Area salary. If you're at or above the median America is great, outside of some very high cost of living cities.

Really teachers and baristas and builders get paid more than 99% of people in France

Or are you just talking specific tech jobs.

According to this article (https://www.lemonde.fr/en/france/article/2022/06/03/france-h...), top 1% earner in France in 2021 was 7180€ monthly, so ~8000$.

And what is 8k/month in terms of US percentile?

Family income: 60 Individual: 75

https://dqydj.com/income-percentile-calculator/

Yeah, I've always found the "meme" of the 1% kind of amusing.

The 95th percentile US taxpayer earns as much as the 99th percentile Brit. Huge, huge difference.

The the UK is quite "unequal pay" as far as Europe goes.

Adding some numbers to this thread. 99th percentile yearly income is:

- USA: $819k (2021)

- UK: £187k = $247k (2024)

- FR: €111k = $123k (2023)

If you're a billionaire or close to it, the US healthcare system is fantastic, unless of course you're traveling in one of the "medical deserts" and have an acute emergency.

If you’re a billionaire EVERYTHING is fantastic.

You'd still stuck with the built environment as it is, just as everybody else.

A billion is just three Manhattan skyscrapers, so it can't change a city. Depending on where you live, you might well experience the exhaust, dust and noise of these environments, no matter how luxurious your individual dwelling.

Not necessarily: if you're famous, you might have a hard time going out in public.

I think that's more a problem with being famous: the top of the Wikipedia list* as I write this is "Bernard Arnault & family", who I've never heard of and therefore couldn't spot in a lineup much less a crowd.

But I did double-take when walking past Russell T Davis (or a lookalike) in Sheffield a decade and a half ago, and Richard Osman in Cambridge train station some other time.

* https://en.wikipedia.org/wiki/The_World's_Billionaires

That's why I said "if". Some billionaires are not well-known publicly, and then there's Elon Musk or Bill Gates.

Indeed, though I think he likes it that way, and that it's a choice.

There are 2781 billioners in the world (according to first search result).

I'm fairly sure most of those can go out for dinner or drinks and no one would know who they were.

Hire your own public and make them act normal when you’re around.

The US health care system is partly socialized. Health care is provided for the unemployed or low income and the employed are covered as employers are required to provide health coverage. The odd ones out are typically small business owners who don't insure themselves and choose to take on the risk of potentially large medical bills.

In all cases treatment is required by law, regardless of payment.

>In all cases treatment is required by law, regardless of payment.

No, it's not. This is a myth. The only thing that's required is to stabilize the patient. If you need surgery to repair your shattered leg bone so you don't get an infection and need an amputation, you're not going to get that surgery without payment. But once you get a bad infection and need the leg amputated so you don't die, they'll do that for free.

I'm not sure where this is happening, and I'm not saying you're wrong, but where I live, doctors are paid salary and they care for patients, so from my perspective what you're referring to sounds like a myth. My friends, who are doctors, operate all the time on people who have no identification and they do their absolute best. And there is no monetary incentive to do otherwise and they would quit and find a different hospital if there were. Anecdotal? Maybe. I'm open to hear from a doctor that says otherwise.

As best I can tell, the medical community and education system would reject a doctor in the US from licensure for any other attitude towards health care.

Doctors have absolutely nothing to do with who gets care and who doesn't: that's controlled by hospital administration and other hospital staff. The doctors are just employees. When was the last time you saw a doctor in the ER reception room talking to new arrivals and deciding if they need to see a doctor or not?

I'd love to go to a hospital where the administration determines if my health condition is emergency or not. That's a cash in hand settlement case.

Please show me a hospital where actual doctors are manning the ER intake desks and triaging patients instead of actually working with patients in exam rooms.

I didn't say that. But at the very least a nurse or PA will take your vitals while you wait for the doctor. And the doctor will determine when you are low risk enough to be discharged. They aren't taking your vitals in the lobby anywhere I've seen, unless that's where you collapse.

The whole conversation here is about Americans not getting life-saving healthcare, and you haven't refuted my claim. If you need chemotherapy for cancer, for instance, you're not going to get that in an ER. If you need bone reconstruction, you're not going to get that in an ER either. These are things that are done by appointment after consultation with specialists. They're not immediate life-threatening emergencies (you're not going to die in an hour without chemo), so the hospital has no responsibility to provide these treatments to you without regard for payment. Their only obligation is to stabilize you so you can see a specialist later.

[delayed]

Just wanted to post back to share that I researched such incidences and except for a few cases where the hospital was sued and lost and doctors fired, I didn't find any examples of this as an accepted or legally viable practice. If you have some examples to share, I'll be interested.

> In all cases treatment is required by law, regardless of payment.

Screening for and stabilization of emergency medical conditions is required at all emergency departments by law, regardless of ability to pay, but that's much more limited than "in all cases, treatment is required by law, regardless of payment", and even then, hospitals skirt the rules.

And how does this differ from care elsewhere?

To contrast, my sister lives in Europe and needs shoulder surgery and unless she pays for a private treatment (by the same doctor) she will not be treated for 12 months. Guess what I paid for. Is that any better?

It's a patchwork, with a lot of holes for people to fall through:

* Hospitals must treat or stabilize regardless of payment, but only for emergencies - they just have to try to keep you from dying on the spot

* The ACA (or Medicaid) subsidizes insurance for the unemployed, if your household income for the calendar year is low enough

* Employers are required to offer coverage to their employees, provided they work more than 30 hours a week at that company and it has at least 50 full time employees (this extends to dependent children but not spouses or other dependents)

This is better than nothing, don't get me wrong, but it could be a lot better still. We have the technology.

Not true except for immediate emergency care.

Many employers do not provide coverage. They skirt the law by employing people part-time (Walmart, Amazon) or as gig workers.

Even if the law reads as you claim that doesn’t mean you can get care in the US.

And that's different from other countries how? I can walk into a hospital in any country in Europe as a non-citizen and request non emergency care and receive it?

>Many employers do not provide coverage

For under 50 employees, making less than 50k, Healthcare.gov covers those cases. You can visit there now to confirm my claim.

And yes, it means you can get care in the US. I brought my Euro girlfriend here and she got care under a bullshit name. And they treated her, the same as any other patient. And she never paid anything. It was non emergency and we went to an emergency room anyway.

Do you have a counter example? If so please share.

Counter examples that don’t involve fraud, as you describe? Yes, many, but I don’t see any reason to try to refute the nonsense you posted.

The point is that hospitals in the US indeed treat anyone with or without ID. Emergency or not.

I'm not sure what point you were making, or refuting, but I didn't catch it.

You got lucky. US hospitals routinely turn people away for non-emergency conditions. That probably happens everywhere but I was only responding about US medical care.

https://journalofethics.ama-assn.org/article/obligation-prov...

What you linked to is a legal description and critique. While it represents the legal imperative, it's not representative, I don't think, of actual medical care.

It wouldn't make sense to risk your license or insurability. It's a bad business decision both for the doctor and for the hospital to send you home without care and discover later that a more serious condition was underlying the symptoms presented as non-emergent. It makes sense to at least check, and in so doing, treat. And if treating to provide the best care possible to avoid liability.

If you have examples of hospitals doing otherwise as a matter of practice I'll be interested to understand how that business model is possible.

As far as I've researched, I've only found cases where the hospital was sued and lost. Doctors fired or jailed. Etc.

The situation is that by requiring emergency care (which is subjective) the law creates enough risk that the de facto mode of operation is to treat all cases where risk is a factor, which is very nearly all cases.

Millions of Americans without medical insurance cannot get routine care. That can happen for a variety of reasons, but one of those reasons comes down to hospitals and clinics refusing to give non-emergency care for free. I don’t need to provide anecdotes for an endemic problem that gets studied at the federal policy level.

Personally I have experienced wait times approaching infinity, the hospital not denying care, but not providing it either, because people with insurance or cash get to the front of the queue unless an indigent person bleeds out in the ER.

If you go to an ER and need diagnostic tests for a real but non-emergency condition you will likely get referred to a diagnostic clinic, a place that only does tests and does not provide medical care, and that’s where your journey will end if you don’t have insurance or cash up front.

Try to get prenatal care in the US without insurance or cash. Possible to find programs for low-income uninsured people in some cities, but not everywhere by any stretch, and getting worse every year.

Talk to homeless people and advocates about people who cannot get treatment or medications because they have no insurance or money. Hospitals won’t dispense things like insulin until you go into shock in the ER, assuming you can get to one.

In my state the wait is under 8 minutes for ER care. So, I can't relate.

Yes, you're required to fill out forms and participate in the system. And therein lies the rub. The people that don't have care are those who are not capable of filling out and keeping up with all the forms. Or are otherwise unwilling to do so. And that's exactly how it goes in Europe too. You don't just get to walk into any hospital with no ID and no registration (aka insurance) and get non emergency care. That's pretty comparable. And even with their "free" care they still have to pay for private treatment from the same doctor anyway so they won't have to wait a year for non emergency surgery.

At worst you can say our forms are longer, and more complicated. But you can't say it's not socialized. If you fill out all the forms you get the same care at the same price as Europe (if you count taxation) and at least in my state, there's no line for the hospital and I can see a doctor in a few days, usually, for specialty stuff.

And objectively, we have more broke people entering this country and still living long enough that our life expectancy is on par with countries that have a tenth of the immigration rate and a lesser poverty rate. So medically speaking, we're pretty miraculous, all things considered. So says the data.

> In my state the wait is under 8 minutes for ER care. So, I can't relate.

That statement doesn't match actual data about ER wait times, for example [1], [2], [3]. It seems anecdotal (one lucky visit) at best, and just made up at worst. As the father of three with multiple ER visits of varying severity in my own set of anecdotes, 8 minutes seems extremely unlikely unless you required resuscitation, or the ER had no other patients.

While a hospital employee (health care professional) may talk to you within a few minutes to ascertain your condition and severity, and insurance/payment method, that doesn't equal time to get care, nor does it mean you will leave the ER with satisfactory treatment, referral to a clinic, or medications.

Without getting into the possible reasons, health care in the US consistently (during most of my lifetime anyway) ranks very high for cost, very high for corruption and profiteering, and increasingly worse in terms of outcomes. And the US has a large and growing population of uninsured and underinsured citizens, even compared to other countries with similar demographics and immigration (Canada, Australia).

> our life expectancy is on par with countries that have a tenth of the immigration rate and a lesser poverty rate

Actually the US ranks rather poorly in terms of life expectancy, even compared to countries with similar immigration rates and poverty [4]. You can slice the numbers all kinds of ways, and interpret them according to your own biases, of course. But given that the USA stands as the richest country and the biggest spender on health care per capita, by wide margins, one has to wonder why it ranks below, for example, Thailand and Panama on at least some measures of medical outcomes and life expectancy.

As you seem to allude to, the truly indigent and uninsured may receive some minimal care faster, and for free, compared to the working class or middle class people who appear to have the means to pay. Hospitals and the US health care system at large factor treating the uninsured as a cost of business, passed on to those who can pay-- similar to how Americans who pay for car insurance subsidize those who don't. As a middle-class person with some form of insurance (often useless or inadequate, but that's a different topic) I know my first interaction at a hospital or emergency room will amount to establishing how I will pay, the wallet-dectomy.

America also leads the world in medical debt [5], the aftermath of inadequate insurance and inflated costs for treatment and medications. Medical debt usually ranks at the top of the list of reasons for personal bankruptcy in the US.

[1] https://worldpopulationreview.com/state-rankings/er-wait-tim...

[2] https://www.beckershospitalreview.com/rankings-and-ratings/e...

[3] https://www.statista.com/statistics/1475298/average-wait-tim...

[4] https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

[5] https://en.wikipedia.org/wiki/Medical_debt

I wouldn't trust those sources. Google funded sources (Wikipedia) and other major political lobby participants shouldn't guide a well formed stance on any topic. Statista's Wikipedia page itself demands for its own deletion due to being a poor and unverifiable source of data.

Outside my window is a line of billboards with digital displays that show the ER wait time at the hospitals beneath them (there are 7 within a 5 mile radius). I can see them without having to actually go to the ER. Maybe I could post a photograph for you somewhere. When I go (I've been over 47 times in my life, or at least that's what I have records for) in this state I've never waited more than 30 minutes, and there's rarely more than 4 or 5 people in the lobby. If you are really having a hard time getting care for your children that's a good reason to move to another state.

All that being said, I can agree with you in some cases. In Los Angeles I waited far longer and I don't blame people living there for believing it's bad everywhere. But in fact, it's common here to have no wait at all. The last time I took my elderly mother in for care (three times in the last week) the wait was for the front counter clerk to get back from the bathroom. The lobby was completely empty of patients. Her circulatory system was imaged. We were in and out within 2 hours.

Most of the hospitals here are owned by an insurance provider, and maybe that helps. I'm not sure, really.

>Actually the US ranks rather poorly in terms of life expectancy

Again, check that you are using reliable sources for your claims. Life expectancy is right around 80 in most civilized countries and the US is right there with Europe.

Keep in mind that large corporations don't like paying for their employees' health care and they don't want you to like the health care system that they are forced to pay for. They want you to get online and rally efforts to vote against it so that it will be as bad as it is in Europe.

I live in both places, and I can say with confidence, you will absolutely pay more (in taxes) for health care in Europe, and the wait for care is often so long that you'll pay for private care anyway. Same doctors, you just skip the long wait if you pay. I'm literally paying for it today for a family member.

I'm not saying the US is perfect, I'm just saying that it's partly socialized, and that if you fill out the forms you can get care, same as in Europe, and at least in some states, it's better.

The overarching reality is that even socialized care requires filling out forms and registering in some system. And the rich still get to go to the front of the line. It's no different in Europe.

Possibly true, though too many separate studies and surveys show the inadequacies of American healthcare for me to dismiss them all.

When I last lived in the USA my ACA premium (self-employed, two adults) started at $1,150/mo with $12,000 combined annual deductible, plus a co-pay. I struggled to find doctors who would accept the insurance, and in the US you need a primary care physician to refer to specialists, get diagnostics, etc. After two years of that my premium got raised to $1,450/mo with $14k deductible — prohibitive for me and I will guess most middle-class people. Quality of care fairly poor — doctors and labs missed a critical cardiac condition twice.

I live in Thailand now, where I can walk in to a hospital without a referral, get the tests I need immediately, and pay out of pocket because prices come to 1/5th or less than US prices. Thai hospitals found two urgent conditions missed in the US. I have a catastrophic policy that costs $210/mo for me and my wife, with $500/yr deductible. In a poor developing country that, incidentally, has a lot of immigrants, legal and illegal.

Thailand has socialized health care for citizens. Very cheap but not the best quality of care. If you remove automobile and motorbike collisions (bad in Thailand) the medical outcomes and life expectancies match the US, on average.

Your mileage varies. In the US you can get treatment for some things in the ER. You cannot walk in and get a colonoscopy, or cardiac imaging, which may not seem urgent in the moment but can save your life nevertheless. I prefer not to wait for the heart attack or tumor I may survive if I can get to an ER in time. My father had the same largely genetic conditions and died without insurance, unable to get diagnostic care where he lived.