When you have the state as a single payer then all those expenses just vanishes.

The difference is that in these systems the government has some stake — whether it’s providing the public insurance fund, or owning the company itself — so that the government is financially incentivized to reduce costs.

In the US case everything is private so all parties are incentivized to increase costs as much as possible.

We really should to copy the Bismarck model. Public owned “public fund”, heavily regulated private insurance and care.

Wrong.

"I̶n̶ 2̶0̶2̶3̶ a̶l̶o̶n̶e̶, t̶h̶e̶ f̶o̶u̶r̶ b̶i̶g̶g̶e̶s̶t̶ i̶n̶s̶u̶r̶a̶n̶c̶e̶ c̶o̶m̶p̶a̶n̶i̶e̶s̶ i̶n̶ t̶h̶e̶ U̶.S̶. p̶a̶i̶d̶ a̶ t̶o̶t̶a̶l̶ o̶f̶ $̶3̶.7̶ b̶i̶l̶l̶i̶o̶n̶ t̶o̶ g̶e̶t̶ t̶h̶e̶i̶r̶ n̶a̶m̶e̶s̶ o̶n̶ y̶o̶u̶r̶ s̶c̶r̶e̶e̶n̶s̶" [1] (EDIT: It's less than $30bn [3].) out of $1.5 trillion of premiums collected [2].

[1] https://www.bankrate.com/insurance/car/insurance-advertising...

[2] https://www.cms.gov/files/document/highlights.pdf

[3] https://www.emarketer.com/content/us-healthcare-pharma-ad-sp...

2. I misspoke and meant "marketing" broadly, not ads in particular. This all fits under administrative overhead which is one of the major sources of inefficiency between private health plans in the US compared to Medicare/Medicaid.

Do you have a figure for this?

They are both insurance programs.

Aside from variations in fraud detection efforts (which Medicare/Medicaid should do more of), what justifies such a gap?

It's various methods by which they grow and retain market share, which Medicare/Medicaid don't need to do.

This doesn't say the difference is in marketing.

I have no idea what the actual solution should be, though.

I don't know. I remember reading an MIT PhD thesis describing how Kaiser Permanente does autism diagnosis [0] – and comparing it to my personal experience of the same topic in Australia, it seemed significantly more rigorous – e.g. specialist centres that only do autism diagnosis, using the multidisciplinary team diagnosis model instead of the single clinician diagnosis model, use of research reliable examiners for ADOS (the training and validation process required to use ADOS in research settings is much more intensive than that required to use it clinically), etc. Now, the thesis does acknowledge that Kaiser is somewhat of an outlier in this regard compared to the US average (plus it is 10 years old so now so I don't know how things have evolved since), but I still get the impression that this highly rigorous approach to autism diagnosis is much more of a thing in the US than in Australia – and if that's true of autism, maybe it is true of other conditions as well.

[0] https://dspace.mit.edu/handle/1721.1/90070 – the first half of the thesis uses the pseudonym "Allied Health", but I know from other sources that "Allied"=Kaiser; the second half discusses Kaiser without any pseudonym

If you live in an area served by Kaiser and don’t have a very specific health reason to choose a different provider, I highly recommend them. They might not be able to treat that rare and aggressive cancer as well as the Mayo Clinic, but because it’s whole-life care, you’re more likely to find the cancer early.

Edit: Question. Can Mayo expand to cover everyone in Florida? Or is their advantage in hiring the best of the best? What makes their model better than Kaiser?

I have my doubts. Over the last 50 years the ratio of US per capita health care costs and European per capita health care costs (or per capita health care costs for most of the rest of first world countries) has stayed about the same.

In other words, health care costs have risen at about the same rate throughout the first world over the last 50 years. So if in 1970 the US was paying say 3x per capita what some other country paid the US would still now be paying about 3x what they are now paying. Both would be paying maybe 35x now than they were in 1970.

Over that same time both US and European obesity rates went up, but they went up way more in the US. If obesity was a major factor driving health care costs then I'd expect US health care costs to be rising significantly faster than European health care costs.

A number of gene therapies are to expensive for any public health system, so are only available in the us.

Needles to say they're experimental and carry lots of weight in a effectiveness vs cost analysis.

I had almost identical cases of cellulitis, one in the US and one in the UK. In the UK, I opted for private hospitalization in one of the fancier hospitals in London. The care was noticeably superior in the UK hospital. The attending doctor was available for a case summary on a few minutes notice, the sterilization and cleaning of the room was vastly better and the nursing staff could recite my case notes and recent test results and vitals at any time. None of these applied for the US hospital.

The bill in the UK was about half what it was in the US and the walk-in price in the US if I hadn't had local insurance would have been nearly double the price I did pay.

The kicker was that the UK hospital was run by HCA, an American corporation.