
Why the U.S. Spends So Much More Than Other Nations on Health Care - yeukhon
https://www.nytimes.com/2018/01/02/upshot/us-health-care-expensive-country-comparison.html
======
spiderfarmer
I think the US could easily solve this if they wanted to, but from my (Dutch)
point of view:

\- The US is philosophically much more egotistic than other developed
countries

\- Politically the US is the most divided western country with its two party
system

\- Money in politics means it's one of the most corrupt, preventing solutions
that could serve its citizens

\- Conservative media does a very good job at keeping at least 50% of the
country comically uninformed

\- The "American Dream" gives people the impression that working hard solves
everything and that their country is the best in the world period

\- Religion is not focussed on empathy at all anymore, if it ever was

The billionare .0001% will probably do their utmost to keep the status quo, as
evidently, they are the ones that are profiting from the current situation and
they are the ones calling the shots for the next 3 years.

The US is doing very good in a lot of areas, but I think collective egotism is
preventing it from reaching its true potential.

~~~
Joeri
Counterpoint from a fellow european. I found americans to not be more selfish,
but more appreciative of self-reliance. In europe in most countries the
philosophy is that of the nanny state, taking care of its citizens no matter
what got them into a care-needing situation. In much of the US there’s much
more a perception of responsibility for your own success, with negative
individual outcomes being considered a necessary evil linked to personal
freedom.

Looking at the stats clearly the US needs a little more nanny state to
generate better outcomes for the bottom half of the country. But equally
europe needs more appreciation of self-reliance and entrepreneurship to enable
a richer startup culture and let the EU become an economic leader instead of
follower.

~~~
Gustomaximus
Sweden and Norway, both flagship nanny states are extremely entrepreneurial
and not just by volume but success. This goes against the logic you can't have
social support and people reaching for entrepreneurial success.

I think, though know this is anecdotal, US startup success is based largely on
its market size of both consumers and venture capital.

~~~
Jommi
How on earth is Norway entrepreneurial by volume OR success?

~~~
i_call_solo
It's not. They have a lot of oil which allows them to give back to their
citizens.

~~~
wooter
and shit on the environment. this comment thread is full of the exact
condescension that conservatives and libertarians are sick of. People who
uphold the Constitution and the vision of the Founders are comically
uninformed? Stanford's Hoover Institute is comically uninformed? What a joke.

~~~
knieveltech
Given every libertarian/conservative economic theory that's been advanced
since Reagan entered office has been tried and without exception resulted in
increased income inequality and bricking the economy, comically uninformed
seems pretty accurate. Given conservatives collective track record of having
legislation thrown out in court on constitutional grounds claims of upholding
it are likewise clearly unfounded.

~~~
wooter
Totally and utterly false and uninfotmed nonsense. Quite accurate if leftist
policies - the failures of which can be measured and hundreds of millions of
dead bodies and collapsed economies.

Is Peter Thiel comically uninformed?

~~~
knieveltech
Fascinating. So we should ignore Kansas' state economy going belly up due to
grotesque mismanagement by "conservatives" attempting to implement
libertarian-inspired economic policies? What about the sharp (and enduring)
spikes in income inequality and the market crashes provoked by the Reagan and
Bush Jr. regimes? We pretending basic economic indicators are hard to track or
something?

Incidentally, you probably don't want to drag body counts into a conversation
that's teetering on the brink of a larger critique of capitalism. Unless, that
is, you'd like to review deaths world-wide from preventable illness due to
lack of access to healthcare? In the US alone it's estimated to be 45,000
deaths annually. Meanwhile Texas (in all it's staunch conservative glory) has
3rd world infant mortality rates.

Regarding collapsed leftist economies, what percentage of these are
attributable to inherent failures of socialist policy vs simple economic
sabotage and regime tampering by the US and it's allies? Would you like to
review what the CIA has been up to since the 1950's?

Or would you rather simply review the number of times conservative legislators
have run afoul of the constitution just in the last 5 years? We can start with
the electoral maps of North Carolina getting chucked over illegal racist
gerrymandering, and a thick stack of executive orders that have died in a
judge's trash can this year.

------
omarforgotpwd
"The US spends more on healthcare because the prices are higher!"

Um, okay. Duh. A better question to ask would be: Why are prices not falling?
In the "normal" economy, people can't offer any arbitrarily high price they
want: They have to compete with others to offer their good or service at a low
price. The more you raise your price, the more you invite competition and give
them room to run a profitable business.

Anyone who has gone to a doctors office or hospital lately knows why there is
so much overspending in health care: The health care system is the most fucked
up, overcomplicated, ridiculous system you could possibly imagine. You start
out by filling out a big paper form with all your info on it... They use that
to bill your insurance, which then says okay, we're going to pay you half of
what you asked for. What ridiculously perverse incentives. Now the provider
will naturally ask for twice as much, knowing they won't get everything they
bill for.

Health Care will be fixed not by laws or insurance companies, but by technical
innovation and good old fashioned economics. You know, those old ideas Adam
Smith had. If there was serious technical and economic / business model
innovation in the industry (an Apple of health care) prices would go down,
outcomes would improve, etc.

~~~
rectang
> _" The US spends more on healthcare because the prices are higher!"_

> _Um, okay. Duh. A better question to ask would be: Why are prices not
> falling?_

It's an excellent observation, and it begs your excellent question.

Unfortunately, we can't get to an excellent answer. The US is ideologically
incapable of acknowledging that "market failure" exists.

~~~
monkeyprojects
Health care is the absolute prime example of a Veblen good as people are
willing to pay for perceived quality. After all would you prefer the heart
surgeon who charges $5000 or the one who can charge $25000

~~~
epmaybe
Seems like a bad example. All board certified cardiothoracic surgeons have to
report their mortality rates from procedures (there are problems with that,
but one could easily look this up). Not to mention most work for a hospital
and therefore have a fixed salary. On top of this, most healthcare consumers
in America are directed by their insurance provider as to who they can even go
to for these sort of procedures.

~~~
DrScump
Mortality rate is a poor metric.

First, it "penalizes" doctors/hospitals that take on the most severe cases.
There is no objective metric for "we saved X people who would have died at an
average facility." Do you _want_ a metric that would encourage a
doctor/hospital to _deny_ an aggressive procedure for fear of taking a hit in
its mortality metrics?

Secondly, it ignores ongoing quality of life. A cardiac surgery can have a
later death that does not count in its mortality rate, even if it was due to a
complication caused by, or significantly contributed to, by inferior medicine.

~~~
epmaybe
Oh, I'm in agreement, and should have made my point about this more clear. The
reason I brought it up at all is that there are other external factors that
influence a patients decision, or lack thereof, in choosing a CT surgeon for
their non urgent (or emergency I guess, but there's even less choice there)
procedure.

------
Dowwie
Are you familiar with the path that an American needs to take in order to
become a cardiologist capable of financially supporting a family in a city
where their children can realize their potential? The system that creates an
American cardiologist is designed such that the cardiologist and it's
respective delivery system will charge as much as economically possible for
services. There aren't many cardiologists in the country and that is by
design. A hospital can't even establish itself without the explicit consent of
other hospitals already operating in a region -- healthcare entrepreneurs
require a "certificate of need" issued before they are permitted to open a new
hospital -- and dare not compete. The American Medical Association, medical
schools, lenders, cardiologist fellowship programs, and others play a role in
manufacturing a cardiologist. Everyone is participating in the system as a
profit seeking, economic growth oriented player. Long ago, their objectives
shifted to maximizing shareholder value and honoring fiduciary
responsibilities.

No one has managed to control the cost of care in a system like this.

~~~
maxerickson
CONs aren't required in all states (and none at the federal level since the
1980s).

[http://www.ncsl.org/research/health/con-certificate-of-
need-...](http://www.ncsl.org/research/health/con-certificate-of-need-state-
laws.aspx)

States that don't have them don't have dramatically lower prices.

~~~
rgbrenner
Every state except LA had a CON law.. You can't restrain supply for a couple
of decades, then repeal the law, and immediately say: see, there's no
difference.

We're already seeing a difference in prices after a few years[0].. and it
takes years and hundreds of millions of dollars (up to $1B+) for a hospital to
go from a proposal to operating:

 _CON laws raise overall healthcare spending by 3.1 percent—5.0 percent for
physician care. As for type of provider, while CON has little effect on
Medicaid spend- ing, it increases overall Medicare spending by 6.9 percent._

 _States that repealed CON laws have seen overall healthcare spending reduced
by 0.8 percent per year, leveling out to a 4 percent drop after year five. The
greatest decline in spending is with physicians at 1.4 percent per year,
compared to a drop of 0.3 percent per year in hospital expenditures._

And by constraining supply of beds, hospitals redirected investment into
equipment, increasing per-unit costs of providing care [1,2]. Arguably CON
laws have contributed to unnecessary tests (since hospitals need to use the
equipment they buy to pay for it), and use of more expensive equipment than
necessary.

Of course this isn't the sole problem with our health system... there are many
that contribute to the problem. But CON laws are negative, and are one of the
issues we need to deal with if we want to reduce health costs.

0\. [https://www.mercatus.org/publication/health-spending-
reined-...](https://www.mercatus.org/publication/health-spending-reined-in-
CON-laws)

1\. [https://jhu.pure.elsevier.com/en/publications/impact-of-
stat...](https://jhu.pure.elsevier.com/en/publications/impact-of-state-
certificate-of-need-laws-on-health-care-costs-and-4)

2\. [https://www.mercatus.org/publication/do-certificate-need-
law...](https://www.mercatus.org/publication/do-certificate-need-laws-limit-
spending)

------
nukeop
This is a classic american problem - keep throwing money at something until it
works.

This conundrum plagues their healthcare, their education, their military,
their welfare spending and so on. For example, they spend more on their
military than the next 15 highest spending countries combined, and don't get
proportionally better results. They spend a lot more on education (per
student) than most European countries, but suffer from worse education quality
than some developing nations. There is a fundamental problem with how this
money gets spent, instead of how much of it is available.

~~~
pbreit
I do not understand why insurance companies are not able to or do not wish to
exert downward pressure on prices?

~~~
moduspol
Their margins are limited by law and the people paying (employers) are mostly
price inelastic.

This puts them in a position where they're incentivized for costs to go up,
because 15% of $2000 is more than 15% of $1000. In other industries, you'd see
insurance companies push back because ultimately consumers will push back and
either drop insurance or switch to another provider.

Switching insurance at an employer, though, is a colossal undertaking that is
bound to frustrate employees, so often it isn't done. And until recently,
individuals would be fined for not having insurance, so dropping insurance
wasn't really an option.

If consumers were the ones paying for it, switching weren't a pain to do, and
insurance companies weren't incentivized to maximize costs, that'd go a long
way toward fixing this.

------
tomohawk
It's hard to contain costs when there is no transparency regarding them.

Just try to figure out the price of a medical procedure. The prices of
procedures vary depending on who you are.

Having the need to get a particular type of MRI every few years, I call around
looking for 1) the equipment the facility has to do the MRI, and 2) the cost.
It's hard enough to get #1 (there's a large disparity in quality of MRI based
on equipment). #2 is practically impossible to get, and has no correlation to
the equipment quality.

If providers were required to be fully transparent on pricing, and provide the
same price to all, then you might see cost containment.

------
newprint
As someone who worked for CareFirst, I had a privilege to accidentally
overhear the panel of doctors who work for C.F. deciding if C.F. will cover
procedure for the patient....fuck those guys. Next to the building, there was
a helicopter landing platform for CEO. US insurance system anti-humane.

~~~
prostoalex
How much of that egregiousness has been fixed by ACA’s cap on insurance
company’s profits, in your opinion?

~~~
ggg9990
Wouldn't a profit cap encourage profligate spending on things like corporate
helicopters?

~~~
rbehrends
The ACA requires the somewhat perversely called Medical Loss Ratio (MLR) to be
at least 80% (and 85% for large group plans). The MLR is the percentage of
revenues from insurance premiums that are being used on actual healthcare
benefits (and thus can't go towards profits, hence the name). Corporate
helicopters don't increase the MLR and reduce profits.

~~~
Zak
This is a perverse incentive. If I'm running an insurance company and my goal
is to maximize absolute profit, how do I do that when my profit margin is
capped by law in this manner?

Well, I certainly don't have an incentive to reduce healthcare costs; quite
the opposite. 20% of a larger cost leaves me with more profit, and most of my
customers won't drop my service. It's required by law and subsidized in a lot
of cases.

~~~
rbehrends
This is why there are marketplaces where you have to compete against other
insurers. And companies in particular will evaluate their group plans
critically.

------
zip1234
Living in the US and having to pay the high deductibles for health care, here
is my idea: \- price transparency - The problem is not easily being able to
shop around for procedures and doctors. It is extremely difficult to know how
much things will cost. If the prices have to be published in some way so the
cost is known up front, the price will go down. Many people's insurance
doesn't start paying until after the deductible. Most people just pay the
price whatever it is because it is impossible to know how much something will
cost until after. Of course, this means that hospitals can charge whatever
they want with no recourse. When insurance companies pay, they fight back and
get lower prices, but people can't do that. Voting with their feet will
increase competition and drive down costs.

~~~
advisedwang
Price transparency doesn't help when you don't realistically have a choice. If
I'm going to ER or taking an ambulance I can't check prices to decide what
hospital to go to. If I'm in hospital and need surgery I can hardly decide to
change hospital because their surgery is cheaper. When my I discover on my
bill that my doc consulted with an expensive expert, it's too late for me to
ask her to use a cheaper one.

Hospital's aren't like grocery stores.

~~~
yeukhon
When it comes to emergency, you probably right we can't shop around. But when
it comes to taking medication, there should be a price. In HK, we can find out
the price of a treatment or a surgery from the hospital's website. Maybe not
the full exact amount, but close enough for someone to know what to expect.
There shouldn't be a "we will take care of the rest of your treatment and send
the bill to you" as in your own story.

~~~
nybble41
Even with regard to emergencies, there is no reason you can't shop around in
advance so that you already know which hospital you want when the emergency
occurs, given that there is more than one in your area.

~~~
yeukhon
I understand your point. but let me refer you to a previous discussion:
[https://news.ycombinator.com/item?id=16007125](https://news.ycombinator.com/item?id=16007125)

In short, if you call 911, the operator will call for an ambulance. You can't
choose. If you have a minor stroke, you can certainly choose to have a friend
to drive you there, or you can call a specific ambulance (I have never done
that before and I am not even sure if that's even possible). But risk is on
you.

I can't go to Mount Sinai West Hospital (midtown in NYC) if I am in Brooklyn
at this moment. You understand emergency means racing with time. I can be
_transferred_ to Mount Sinai West later after I am discharged though. Also, I
believe there is protocol for how far an ambulance is allowed to serve on
active duty, unless another area is requesting additional availability, but
don't quote me on this.

If only we can teleport...

~~~
nybble41
> In short, if you call 911, the operator will call for an ambulance. You
> can't choose.

That is merely a procedural issue. There is certainly no reason why the 911
operator can't honor your request for an ambulance from a specific hospital,
provided that it's within their range. In the absence of a specific request,
the operator has a duty to look out for your interests, which should include
not sending you to a hospital known for over-charging when there are other
reasonable options available. (This is the same logic that says they shouldn't
just send you to the hospital that pays them the most kickbacks.) Their
default balance between cost and care might reasonably differ from yours, but
if you have expressed a preference then they have a responsibility to honor
it.

Of course, not every emergency is quite as time-sensitive as a stroke or heart
attack, and depending on your location, and the locations of the hospitals,
the difference in travel time may not be significant. Even if price is not the
determining factor in the majority of cases, competition over the patients for
whom where it _is_ a factor can help keep costs in check for everyone.

------
treyfitty
I have a friend who worked with the billing system at a major hospital in
Florida. Beyond the obvious practice of providers billing for much more than
the actual cost of service, to maximize insurance reimbursement after rounds
of "negotiations" after each client, there is something more insidious going
on as an industry.

My friend (anecdote, sure, but something like this will never be written in
policy, so I can't cite) said "we were told NOT to send anything to
collections unless the amount was "very high." He was then told that the
hospital was made whole with every insurance reimbursement, and that any
amount "owed" from clients aren't actually a big deal- if they pay it, great,
if not, it's alright. Furthermore, the impetus for not sending to collections
was because there is a certain threshold where if the populous found out about
their many shady billing practices, they would be exposed, and would rather
not deal with that.

I'd like to say that I am surprised nothing has been done about this, but I'm
honestly not surprised because the incentives and economics are there in your
face.

~~~
yeukhon
I am sorry, but I read it three times and I am still unsure how the practice
helps the providers? I was looking for "stealing more from clients", but I
can't deduce any from this anecdote.

------
aaavl2821
Much of the cause of the high cost of care in the US is not social, or
political, or demographic, but economic:

The single biggest line item in the US healthcare budget is hospital care

The price of hospital care (as measured by cost of inpatient bed day, [1]) in
the US is on the order of twice as high as that of France, Germany and the
U.K.

The time period where the cost of US healthcare in OP article separated from
other countries coincides with the increase in hospital consolidation in the
US

Hospital consolidation is demonstrated to lead to increase in price without
commensurate increase in care [2]

There are other factors as well, but this is probably the single biggest cause
of high US healthcare cost, and it's almost never discussed

Good article with historical context here:
[https://www.nationalaffairs.com/publications/detail/the-
peri...](https://www.nationalaffairs.com/publications/detail/the-perils-of-
hospital-consolidation)

1:
[http://www.who.int/choice/country/country_specific/en/](http://www.who.int/choice/country/country_specific/en/)

2: [https://www.rwjf.org/en/library/research/2012/06/the-
impact-...](https://www.rwjf.org/en/library/research/2012/06/the-impact-of-
hospital-consolidation.html)

~~~
BugsJustFindMe
> _The price of hospital care (as measured by cost of inpatient bed day, [1])
> in the US is on the order of twice as high as that of France, Germany and
> the U.K._

And why do you think that is? Everything is political, including economics.

~~~
aaavl2821
the articles i linked suggest it is in part because of hospital / health
system consolidation leading to higher negotiating power. i think that is an
economic factor, although i think i can see where you are coming from

i assume youre suggesting that having a single payer would balance out the
negotiating dynamic? that could certainly be the case. to be pedantic, if the
US does get a single payer system, one could argue that the political act of
creating a single payer system is driven by economic factors (local provider
monopolies increase cost of care, payers adopt high deductible plans in
response, people suffer financially as a result, therefore vote with their
wallets)

i dont think politics supersedes economics or vice versa, theyre very
intertwined

------
narrator
Some guy was telling me how IBM Watson was going to make healthcare more
efficient by helping doctors make smart choices. I replied that that wasn't
going to help profits, so it probably wouldn't be adopted. Hospitals and
insurers really should be merged so the incentives are all properly aligned.
Kaiser Permanente works this way and, IMHO, it's actually not that bad.

~~~
hkmurakami
I always wonder why kp hasn't expanded more.

~~~
DrScump
They've been doing a _huge_ amount of infill in Northern California, replacing
whole facilities with brand-new complexes in existing core patient areas. (One
example is their Santa Clara facility, which replaced a predecessor less than
a mile away with one maybe _5 times_ its size.)

It must be an _insane_ amount of capital expenditure.

~~~
hkmurakami
just passed by the SC facility (the one on Homestead?) and it did indeed look
massive.

Great to hear that they are expanding in their core practice and geographies.
Hope they continue to do well.

~~~
DrScump
That new residential neighborhood on Kiely Boulevard across the street from
Central Park is where the prior Kaiser medical center was, going back to at
least the 1960s.

------
zhyder
Lack of price transparency feels like a big part of the problem here. It's
nearly impossible for a consumer to shop around based on price, allowing
prices to go up freely.

I'm actually surprised healthcare providers can legally be as opaque as they
are: how is it okay to charge arbitrary amounts after the fact and require the
consumer to pay? Even car mechanics make upfront estimates and get them signed
by the consumer, because otherwise the consumer might refuse to pay. Why
doesn't the same happen in healthcare for at least non-emergency procedures?

~~~
sethammons
I see a retina specialist twice a year. I recently changed to a high
deductible plan with an HSA. I called to see what the cost of my appointment
would be. They could not or would not tell me. Incall three separate times,
talking to different people and different departments. I went in and continued
asking the front desk. "It depends on the services you end up getting." Ok,
sure, but for a standard appointment, what then? "I can't say." Listen lady,
I'm looking for a ball park. $50? $100? $1000? $5000? "Oh, I can't imagine it
will be that much." Which one? "We will have to just bill you after." So
absolutely frustrating. It ended up being like $150. Without price
transparency like a public menu, we won't get better.

~~~
kthejoker2
Had the same experience with my son's ear infection on a holiday weekend.
Received a bill for $900. I refused to pay it, I wrote them and said I had
asked to receive an itemized list of charges for a typical ear infection and
had been refused and that if these prices were known at the time of the
service I wouldn't've undertaken the service.

So of course they came down to $450 without even batting an eye. Complete
madness. I've still never paid it, with no apparent consequences.

------
meri_dian
Doctors, surgeons, nurses, lab techs, hospital bureaucracy and staff, etc....

All of these people need to get paid, and in the US they get paid very well.

High health care costs are not a mystery or a conspiracy. There are just many
people in the industry that make a lot of money, and they charge high fees to
maintain their incomes.

~~~
hackeraccount
That's such a simple thing and yet no one seems to acknowledge it. Look at
Obamacare, it's going to lower health care costs. How? Savings! What does that
mean? Everyone you don't like won't make as much money. All the people you
like will keep getting paid. I understand we all hate health insurance and
pharmaceutical CEO's but taking them out back and shooting them will save less
then is commonly understood. The same goes for money wasted on advertising.

Saving money on health care is (to repeat an oft told joke) like going to
heaven. Everyone (Republicans and Democrats both) wants to do it but no one
wants to die.

------
snarfy
There is no competition. The day there is competition is the day you walk in
to your doctor's office and the prices are posted above the reception desk
like a restaurant menu. $50 general visit, $75 for a broken arm, $100 treat
common infection, etc. You don't see prices because you don't pay. Insurance
pays. If you are ever without insurance and have to pay, they always have
different, lower rates. Doctor's scamming insurance companies, insurance
companies scamming the government, the government scamming all its citizens.

~~~
peacetreefrog
This is the root cause, the fact people don't pay for their own healthcare and
there's no competition. Then we layer on this huge complicated system to try
to contain costs other ways.

------
thomastjeffery
Now can we have a "Why the U.S. Spends More than the Next _Eight_ countries
_combined_ , and 63.7% More than The Entire Rest of The World on Defense"?

[https://en.wikipedia.org/wiki/List_of_countries_by_military_...](https://en.wikipedia.org/wiki/List_of_countries_by_military_expenditures)

    
    
        ---
    

Oh wait, we spend _even more_ now:

[http://clerk.house.gov/evs/2017/roll378.xml](http://clerk.house.gov/evs/2017/roll378.xml)

~~~
lmm
The US gets that much more military for its money. Look at the diagram on the
bottom of
[https://www.globalsecurity.org/military/world/carriers.htm](https://www.globalsecurity.org/military/world/carriers.htm)
. Or remember that the US Air Force is the world's biggest air force, the US
Navy is the world's second-biggest air force, and the US Marines are the
world's third-biggest air force.

There's space for people to disagree on whether what we get out of the
military is worth what we spend on it, but there's no mystery about where the
money's going.

~~~
thomastjeffery
I grew up on a US Army base.

Believe me: There is _plenty_ of mystery, and _plenty_ more obvious waste. The
most obvious is called "use or lose".

Why in the hell do we need it?

China has a _billion_ more people, borders Russia, North Korea, Afghanistan,
and Pakistan, yet spends less than a quarter as much as the US on defense,
even by the most liberal estimates.

I can see arguing the merit of spending more than every country on Earth. I
would still disagree, but it would definitely be a discussion.

However, the US contributes more than a third (closer to 1/2 now) of defense
spending for _the entire goddamn world._

It disgusts me that my country takes so much money from its citizens, and
throws it at all into a machine of death, whilst simultaneously blaming its
egregious debt on Social Security.

~~~
lmm
> China has a billion more people, borders Russia, North Korea, Afghanistan,
> and Pakistan, yet spends less than a quarter as much as the US on defense,
> even by the most liberal estimates.

Sure. But it has no (conventional) power projection capacity, whereas the US
has been engaged in two simultaneous occupations of outright hostile foreign
countries literally on the other side of the world for a decade, at the same
time as deploying troops to defend dozens of friendly nations all around the
world, enforcing freedom of the seas again all around the world... . The front
line of a US-China conflict would likely be Taiwan, that's what spending 4x as
much is buying us. Again, we can argue over whether that's something we should
be spending money on, but on the whole (of course there is some level of
waste, as there is in all large organizations) we're getting what we're paying
for.

~~~
thomastjeffery
> the US has been engaged in two simultaneous occupations of outright hostile
> foreign countries literally on the other side of the world for a decade

And spying on the entire world, including its own citizens, etc.

Even if you believe the US should play world police, and demand a group of
people with a totally different culture and history pay by it's rules, there
are _plenty_ of _significant_ areas where we are _clearly_ wasting
_significant_ amounts of tax dollars, all under the umbrella of "defense".
Instead, Congress overwhelmingly decided, after Trump asked for a $20 billion
increase, to have a $100 billion increase.

> We're getting what we're paying for

I don't buy that. We are paying an unfathomable about * 5.

There is extremely significant and obvious waste. Even what is not "waste"
does not clearly help taxpayers in any way. Very significant portions are
clearly to the detriment of taxpayers.

------
lsc
The thing I keep wanting to bring up:

>Higher prices aren’t all bad for consumers. They probably lead to some
increased innovation, which confers benefits to patients globally. Though it’s
reasonable to push back on high health care prices, there may be a limit to
how far we should.

Fundamentally speaking, much like education, while I agree that healthcare is
unaffordable to many, I point out that this is different from being too
expensive. I think the idea that we are spending too much of our wealth on
education and healthcare is... wrong.

I mean, sure, there are limits on what we want to spend, as a society, on
healthcare, and yes, I personally think that a lot of the public money being
spent on healthcare (and I think a lot of public money _should_ be spent on
healthcare) should be spent on research that benefits all, but overall? as a
society? I don't think spending 17% of our GDP on healthcare is a problem
(assuming we're receiving good benefits from that, which I think we are)

And yeah, maybe there needs to be 'community college' equivalent of
healthcare; a system where anyone can show up and get care that is good but
not the best for next to nothing. And yes, we do need more and better-funded
research for the public good. I certainly don't have a problem with private
industry researching new drugs for us, but we have to understand that their
incentives are... different, and that there's a place for public-funded work
for the public-interest.

~~~
intopieces
> I think the idea that we are spending too much of our wealth on education
> and healthcare is... wrong.[...]I don't think spending 17% of our GDP on
> healthcare is a problem (assuming we're receiving good benefits from that,
> which I think we are)

You're missing a dimension to both of these numbers: Outcome. The U.S. spends
more on healthcare than any other country — but not with better health
outcomes [0].

"The US stands out as an outlier: it spends far more on health than any other
country, yet the life expectancy of the American population is not longer, but
actually shorter than in other countries that spend far less." [1]

[0][http://beta.latimes.com/nation/la-na-healthcare-
comparison-2...](http://beta.latimes.com/nation/la-na-healthcare-
comparison-20170715-htmlstory.html)

[1][https://ourworldindata.org/the-link-between-life-
expectancy-...](https://ourworldindata.org/the-link-between-life-expectancy-
and-health-spending-us-focus)

~~~
lsc
One explanation of the difference in outcomes, especially your "Number of
deaths per 100,000 from preventable diseases or complications had adequate
healthcare been available, in 2013" statistic has mostly to do with
accessibility. Lack of access. That, and a cultural avoidance of seeking help,
but I bet it's mostly the lack of access.

If you have bad insurance? there's huge variance in what a procedure will
cost, and in my experience, hospitals aren't setup to deal with the "how much
is this going to cost me?" question.

The ACA may have helped with this. With my yearly out of pocket limits, I have
some peace of mind that it won't, at least, go over that.

Personally, I think we can continue to compare this to the education system,
we need something like 'community colleges' \- Sure, you need paperwork and to
go through a bunch of hoops if you want to go to Stanford- and you get a
better product than at the community college, if you can make it, but anyone
can walk into the community college and get half a pretty decent education
that is almost completely paid for by the government. I think we need
something similar in medicine... a place anyone can walk in where they know
they can get care that meets minimal government standards that is next to
free.

But... my point is just that making the whole system cheaper is not the best
way to solve that. We don't want to replace Stanford with the University of
Phoenix.

To continue my analogy, the private sector does beautifully at the high end,
in both schooling and medicine. To bring back the University of Phoenix
example, at the low end? I would much rather have the low end government
product than the low end private sector product.

~~~
intopieces
It's precisely about lack of access, hence the conclusion of the quote: "..
had adequate healthcare been available." There is a cultural avoidance of
seeking help because the help will bankrupt you. Because it's too expensive.

Making it cheaper = better access = better health outcomes. How do we know?
Every other industrialized nation does it better than we do for cheaper.

~~~
lsc
>Making it cheaper = better access = better health outcomes. How do we know?
Every other industrialized nation does it better than we do for cheaper.

My understanding was that the nations that have better outcomes for the poor
tax people and use that money to pay for government supervised medical care,
and that it's the government paying for and supervising the care that leads to
better access.

Private sector solutions, as I said before, seem to work extraordinarily well
for the rich, both in medicine and education. If Stanford will let me in, sign
me up. But, when I am shopping on the low end? I want some government
intervention. Cheap private sector medicine, I suspect, would look a lot like
cheap private sector education... ITT tech, Corinthian Colleges, or at best,
the university of phoenix.

------
neilwilson
It spends so much more on healthcare because of its obsession with possessive
individualism and the ridiculous notion that a government of the people is out
to get them.

It'll change one the USA resembles India and China leads the world.

~~~
rhaps0dy
"It'll change one" -> "it'll change once"

It took me 15+ seconds to make this correction and parse the last sentence,
here's it so that you don't have to spend them.

------
rdlecler1
You have huge variation in the life expectancy between rich and poor
individuals in the US. Here you have a lot of poor people with no healthcare
and then you have more affluent people who may be spending hundreds of
thousands of dollars a year on healthcare. If I have a few million dollars
saved and I can spend a couple hundred thousand to live a few more years
there’s a good chance that I’ll take that option. This system is not intended
to provide the greatest benefit to the most people but rather to provide the
greatest benefit to those people who can afford it. Coming from Canada and
seeing the quality/detail of care you get with private insurance here is
astounding. There is certainly a lot of fat in the US system but it’s also
incredibly comprehensive if you’re fortunate enough to have good insurance.

------
dmitri1981
It's simple economics: third party payment. Patients want as much care as
possible, doctors are incentivised to provide it and insurance companies pay
for it. Until that changes healthcare costs will not decrease

~~~
hackeraccount
I used to think that. My only argument of skepticism is sort of weird. Animal
health care costs. Apparently the cost of vets is going up just as fast as
that of humans. And in that case it's mainly first party payment. It could be
that the two have no connection but for me, it raises doubts.

Honestly my current theory about health care costs is that they're high - and
are inflating - because people like health care. There's a basket of potential
goods and people really like that particular item. To get it they spend what
they have and then pressure politicians to get them ways to spend money they
don't have. They complain more and so the politicians find ways to hide the
costs from them.

~~~
peacetreefrog
I agree with you, as people get richer they spend more on health, for
themselves and their pets.

But just because vet costs are _increasing_ at a similar rate (or more) than
human costs doesn't mean the third party vs first party thing isn't the issue.
Absolute overall human health care costs are still way higher then vet costs
for similar services(1), despite the rates of increase the past few years.

Also, anecdotally, some vets are going the other way. There's a vet near my
house, for example, that just started weekend + holiday hours with rates the
same as to their normal ones. We hadn't even gone their before, but when my
dog woke up last Easter with some eye problem, we called around, found them,
and got some ointment that helped. The other two options would have been: wait
a day, or go into an emergency clinic that's k's of dollars. If we had pet
insurance I'm sure we just would have gone in without thinking.

1: [http://parkhillvet.com/2012/09/comparing-costs-of-human-
vs-p...](http://parkhillvet.com/2012/09/comparing-costs-of-human-vs-pet-
health-care/)

------
dandare
Could this problem be attacked by a goodwill billionaire with a long-term
plan? Open several private medical schools that will offer "free" med
education in exchange for multi-year contracts. Open many small copycat
clinics. Manufacture your own generics if possible, import whatever is
cheapest, focus on things you can do cheap, be transparent about pricing,
build awareness and brand.

McDonaldize/Amazonize American healthcare.

------
hellofunk
Something I've always heard but not mentioned in this article is that America
is a very litigious culture, everyone sues everyone for nearly any reason,
which is uncommon in most parts of the world, and doctors must have lots of
malpractice insurance to guard against this; and when doctors pay a lot for
insurance, they must increase their prices to help cover that, and the wheel
spins that way.

------
bob_theslob646
A lot of these comments due a great job of hitting the nail on the head on
most issues, but I have not seen someone talk about the fact that the United
States believes in _treating_ versus _prevention and or curing_.

~~~
wu-ikkyu
>he sacrifices his health in order to make money. Then he sacrifices money to
recuperate his health. And then he is so anxious about the future that he does
not enjoy the present; the result being that he does not live in the present
or the future; he lives as if he is never going to die, and then dies having
never really lived.

-Dalai Lama

------
jernfrost
Part of the reason it is more expensive in the US is because medical school is
very costly in the US. This increases the financial risk of those aquiring a
medical degree. Higher risks usually demands higher profits in the market.

Hence free university education could be a factor in reducing US health care
costs.

Fundamentally you see how the free market approach to everything drives up
costs everywhere.

Or more specifically drives up costs in industries/services which don’t
naturally have functioning markets.

Free market approaches to health care found in Europe or Asia that works tend
to be strongly regulated. E.g. max prices for procedures

~~~
xyzzyz
Part, but definitely not the main reason. If the doctors worked for free, US
would still be more expensive than Germany or Japan.

~~~
epmaybe
Agreed. There are around 80,000 medical students in any given year in the US.
Assume that all of them pay $50,000 per year in tuition. That's maybe $4b per
year. The costs of health insurance, diagnostic testing, pharmaceuticals, etc
more than eclipse that number.

~~~
bkmartin
And the bigger problem is that there is profiteering at every step of the
way... Medical Insurance, devices, private testing labs, hospitals, doctors,
pharma...it all adds up. As someone else said, it's a free market without a
real market for competition... I don't remember where I heard it, so citation
needed, but the number that sticks on my head is that we spend 25% on
administration alone. Lots of billing companies exist just to handle the
complicated mess we have created... More profits in the system.

------
bawana
Bertolini the CEO of Aetna walked away with a $500 million parting gift.
Courtesy of your healthcare premiums. There's the fox guarding the henhouse
off to a new henhouse. STOP THIS OBSCENITY of administrators paying themselves
so much to work in a risk free environment. When they run red ink, the
government bails them out. Taxpayers again - shafted from both ends. We should
find this guy and put him in a stock, the kind the puritans used, not the Wall
Street kind,

------
juhanima
The math in the article is not quite right. Growth from 1.2 trillion to 2.1
trillion in 17 years (1996-2013) only amounts to 3.3% annual growth, which is
not that far away from the 2.4% of the overall economic growth.

The U.S. does spend more per capita than any other country, with Switzerland,
Luxembourg and Norway being the runners up.

[https://www.npr.org/sections/goatsandsoda/2017/04/20/5247741...](https://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-
country-spends-the-most-and-least-on-health-care-per-person)

I think that statistics gives a hint: the richer the country, the more it can
afford to spend. Also the mostly private health care sector in the U.S.
doesn't have similar incentives to cap their spending at a certain point as
their publicly funded counterparts in Europe. There must be a lot of cases
where a rich person buys expensive treatments for a terminal illness that
would be deemed hopeless and left untreated elsewhere, and that has to show in
the statistics somehow. I don't consider this a big flaw in the U.S. system.

~~~
Broken_Hippo
_There must be a lot of cases where a rich person buys expensive treatments
for a terminal illness that would be deemed hopeless and left untreated
elsewhere, and that has to show in the statistics somehow. I don 't consider
this a big flaw in the U.S. system._

Probably not a _lot_ , since most people aren't rich. But more to the point:
That stuff happens other places as well. I'm in Norway, and there is a private
healthcare system. Most of the time, I hear it being used for shortened
waiting times or more luxury in the hospital, but I'm pretty sure rich folks
can go to other lengths - on their own dime. This doesn't affect the state
much because it isn't their freaking money.

 _Also the mostly private health care sector in the U.S. doesn 't have similar
incentives to cap their spending at a certain point as their publicly funded
counterparts in Europe._

I think this is correct, but I think the fragmentation is what causes it. The
fragmentation means there is no incentive to combine resources to make things
cheaper and easier. Where I live in Norway, people can have - free - up to 6
nurse visits a day. Even if you live on an island or are spending your summer
in a remote cabin. All because overall, the outcomes are good. People live
longer, happier lives the longer they can be at home and it is cheaper than
sending the same people to a nursing home.

~~~
vidarh
Actually in Norway there is relatively little you can do _in_ Norway, as
private providers are highly restricted in what services they can legally
provide in areas that are covered by public healthcare, in part because it's
long been seen as immoral to let people buy preference to what is effectively
a limited resource as long as the number of doctors available is limited (and
the answer is not to drastically increase the pool of doctors either, as the
problem there is training - you don't have enough heart transplant cases, say,
to train a much larger pool of transplant surgeons). I believe the
restrictions are lighter than they were, but it's still far more regulated
than most places.

But of course rich people can easily fly to get private treatment abroad.

Healthcare in Norway is close to US costs mostly for other reasons: A much
flatter salary curve means the services that are typically cheap elsewhere,
like e.g. cleaning staff, is much closer to the cost of higher level staff,
driving up overall staff costs significantly; this also drives up costs of
goods and services bought externally by the healthcare system. The population
density is also extremely low - less than half the US, and the US is extremely
low too - and that affects cost to e.g have good hospital coverage and
emergency services. Providing service _at all_ in some places is an ongoing
challenge, with the Northern regions finding it hard to hire and retain staff
despite the tax breaks (for the non-Norwegians: people in the Northernmost
regions gets various tax breaks and other benefits such as student debt write-
downs to get people to stay/move there)

~~~
Broken_Hippo
Thanks for the information. Most of what I know about the private system here
(Norway) is from language & civics classes - though I hear rumors of tourism
as you've mentioned.

------
MintPattern
> There are ways to combat high health care prices. One is an all-payer
> system, like that seen in Maryland. This regulates prices so that all
> insurers and public programs pay the same amount. A single-payer system
> could also regulate prices. If attempted nationally, or even in a state,
> either of these would be met with resistance from all those who directly
> benefit from high prices, including physicians, hospitals, pharmaceutical
> companies — and pretty much every other provider of health care in the
> United States.

And then end up like Venezuela has after implementing price controls? How
about you let intelligent macroeconomics majors who have spent years in
college studying exactly the ideal solution to this predicament give
thoughtful and effective solutions. I understand the writer was likely good
intentioned, but:

1) The road to hell is paved with good intentions.

2) For every complex problem there is an answer that is clear, simple, and
wrong.

While some liberal arts majors have their own theories and hunches to inject
on how our world economy should run, a well-studied economist would give the
best answer for providing a solution that establishes the perfect price-point
between satisfying as much of the medical demand as possible while having a
never-extinguished supply of medical care.

A little history: During the great depression, the US implemented price
controls on wages; capping the wages. So companies started adding in health
coverage in with the job as a perk instead. The great depression was extended
and the health insurance in our country has been forever screwed up by that
event.

Btw, I'm not pro government or anti-government, left or right. I'm pro-lets-
get-the-facts-straight-before-we-jump-to-conclusions-that-affect-the-whole-
country. Admitting that you don't know the answer to something goes a long
ways.

------
ensiferum
Because it's a business designed to make maximum profit?

------
qwertyml
Because of the fraudulent agents in the insurance, healthcare and government.
And the innocent american citizens who nod yes for every crap policy and rule
that is thrown at them. Isn't it obvious?

Same medical service costs 10 times less in other countries for same or better
quality. Because they have kept the service of a price 1$ as 100$.

We need some disruptor to simply crush the insurance industry.

If you don't take insurance you may become medical bankrupt if somewhere you
screw up your health.

They started with 1 $ few decades back and slowly increased and since world
has majority of un smart people people collectively couldn't find a just
system.

And everyone and every future generation has to pay the price for the mistakes
previous generations made.

Its just is hell guys.

------
motiw
Simply because it is acceptable to maximize profit from people fears and
misery, coupled with shameless politicians that support/bend to the will of
the health care mafia with a regulation environment that diffuse any incentive
to lower cost

------
fallingfrog
"Because it's more expensive" seems like a non-answer to me. Why is it more
expensive, and who's getting the money, and what rules are allowing this to
take place, and who made those rules? That's what we need to know.

------
mtgx
It's not that Americans spend the most, either, but also the fact that unlike
other governments, the U.S. government has little incentive to fix national
healthcare crisis, especially when Big Pharma benefits from those crisis and
lobbyists against the fixes.

In countries where the government foots the bill for healthcare, and
healthcare is obviously a big portion of their expenses, the government will
usually scramble to do everything it can to improve the population's general
health. That includes trying to limit pollution, better regulating the "food"
that comes on the market, and so on.

~~~
nybble41
> In countries where the government foots the bill for healthcare, and
> healthcare is obviously a big portion of their expenses, the government will
> usually scramble to do everything it can to improve the population's general
> health.

That is actually one of the bigger problems with the single-payer system. Your
health is fundamentally related to everything you do, and consequently giving
the government an interest in your health opens the doors to monitoring and
controlling every aspect of your life in the name of regulating health care
costs. In forfeiting the liberty to do things which may negatively impact your
health then you become not a free individual, but more akin to the
government's pet, your every action subject to their approval.

------
dynofuz
the problem is that the people telling you what to do (the healthcare
providers / docs) are getting paid to provide services to you. additionally,
insurers are not smart enough to communicate the costs and benefits to
patients appropriately.

we need a decoupling of the guide (maybe insurers that are actually good) that
tells patients what to do next for optimal care and the org that provides the
care. that way providers (docs) dont have an incentive to say do more if more
isnt helpful

------
EGreg
It's a simple reason: Monopsony

Power of collective bargaining drives the price down.

The AMA and other collectivizations of providers drive the price up (cartels).
That's why becoming a doctor in the USA is such a long and hard ordeal,
relative to other countries. And also why litigation is so high.

Oh and of course... THE PATENT SYSTEM causes the USA to pay for most of the
innovation that scientists in the redt of the world are prevented from
building upon with open source.

~~~
geebee
It's fascinating, and kind of horrifying too. I've of course been a patient,
and I saw the initial bill for a neck injury that led to no treatment other
than Tylenol - $16,000. My HMO paid about half that, I believe. I was not on
the hook for the difference. This is negotiated by contract between the HMO
and the hospital. The high bill is the beginning of negotiations between two
large and powerful organizations.

Here's the thing - lacking access to good health care in the US is even worse
than not being able to pay the bill. It means you get stuck with the higher
bill, and no pre-negotiated contract or negotiators to knock it down. I've
talked to people who work at hospitals, and they say their billing department
may knock it down a bit, but it means that the person not represented by an
HMO or similar gets hit not with an $8,000 bill but one much closer to
$16,000.

I know I'm supposed to hate my HMO and everything, and they can be irritating,
but there's no way I'd want to experience the US medical system as an
"independent".

As you said, you're already dealing with a Monopsony. It's worse, because you
don't know what they're charging, whether it's important, whether it should be
done, none of it. And it is run by something closely resembling a cartel, the
AMA and hospitals simply do not operate in anything remotely resembling a free
market. I guess my HMO is my government backed cartel. I pay through the nose
for the insurance (well, my employer "pays" some of it, but it's all through
the employer, so what does it matter the portion that is added to and then
deducted from my actual paycheck vs the part that never makes it to my
paycheck and is paid on my behalf?). But as a result, I have a powerful cartel
on my "side".

When I describe the AMA as a cartel, people often think this means I oppose
occupational licensing entirely. No, not necessarily. That's an interesting
discussion, but there is _plenty_ of room to criticize the AMA (and other
professional and trade licensing bodies). while supporting some limited form
of occupational licensing (actually, you could support substantial licensing
and still be appalled with the AMA and ABA).

------
mwilliaams
I think a lot of it is due to America being so litigious. Doctors and
hospitals are afraid of being sued, so they need lots of insurance to protect
them, and they order lots of arguably unnecessary tests to cover all their
bases. This drives up costs for consumers.

------
baybal2
My guess:

People with some money will pay through expensive insurance, and everybody
else can't pay at all.

This way, pharma and hospitals have near 0 incentive to focus on people with
anything less than mid to high tier insurance plans.

And everything else results from that, like regulatory capture by insurance
companies and everybody teaming up with them.

Even without draconian restrictions on generic drugs, labour mobility in
medical professions, and needlessly elevated standards of care in hospitals
for many conditions, medical treatment in US will still be out of reach of
majority, and the market will still be skewed towards high tier insurance plan
holders.

A more radical, slash and burn reforms will be required by US to reach
countries with private, but affordable to masses healthcare.

I can draw a parallel with restaurant or affordable clothing markets in my
home country - Russia.

In the centre of Moscow, you have countless fancy restaurants that are nearly
always empty. Those ones have $30 average price for a basic meal.

At around 10 km away from the Kremlin, you begin to see rare soup kitchens
serving <$1 meals with 100+ people line ups during lunch hours accommodating
everybody with less than $2k USD of monthly income.

See, if a fancy restaurant will serve even two customers per hour, it will get
more money than a soup kitchen.

The same situation, if not worse goes for affordable apparel. Most people
can't afford anything more than an "Abibas" tracksuit for $2, yet you
genuinely can't find anything that cheap in Moscow's urban core. Putin ordered
the only public market in Moscow serving the masses to be crushed, and its
owner prosecuted in a show trial, just out of resent for its existence showing
the extend of poverty in the country.

------
crimsonalucard
>Why the U.S. Spends So Much More Than Other Nations on Health Care

The conclusion of the article: Because prices are higher.

Seriously?

------
avoutthere
Government setting rates for medicare/medicaid reimbursement is what has
driven up prices. One of the brilliant aspects of market economics is that, if
allowed to operate freely, the market would establish price points for all
levels of service. Government involvement is preventing the market from
functioning as it should.

------
MarlonPro
..And US is not more healthy than the other advanced nations.

------
LoSboccacc
that's what subsidies to a private sector do, duh

------
pishpash
tl;dr: US spends so much more than other nations because US hospitals (and by
extension, doctors, which NYT is too chicken to say out loud), keep increasing
prices for the same care.

There is nothing here about insurance companies. It's lack of competition on
the supply side.

~~~
tomjakubowski
There's no competition at all on the supply side in Canada or Taiwan. Why are
their health care costs microscopic compared to the US?

~~~
pishpash
Because a large single payer fixes prices for most people.

~~~
tobylane
Most? Could you specify how someone loses out?

~~~
nybble41
Shortages, as with any price ceiling—when someone is willing and able to pay
more but there is none available at the fixed price.

------
partycoder
The US jumped the shark in 1971. A comeback is very unlikely.

After WW2, the US established a system that was used extensively for its own
economic advantage: Bretton Woods.

Many countries could use dollars as their reserve currency, and those dollars
could be redeemed for gold.

The US abused this system by printing more dollars than what it had in gold,
giving rise to the concept of "exorbitant privilege" (virtually unlimited
money with no chance of accountability).

This started some sort of bank run and since the US did not have enough gold,
Nixon suspended the convertibility of dollars into gold. After that, dollars
were allowed to float, and if it wasn't for exclusive deals (e.g: oil), it
would have a much lower value.

Now spending on healthcare, education, infrastructure, science, space
exploration: all gone.

------
laci27
It doesn't spend it on 'other nations'.. it spends the money on US
billionaires. 'Other Nations' is just a facade, as it's much easier to loose
track of a few billions here and there in a god forsaken country, than it is
in the middle of NY. The military industrial complex costs a lost, but a BIG
chunk of that money goes to US billionaires. The US population (aka military
people) only get their wages paid, everything else is paid directly to Y and Z
billionaire's tank/gun/warship/plane/drone/software/encrypted computer/add
stuff to this list manufacturer. And these manufacturers buy a lot of
politicians' vote to keep the war machine going.

..the same with pharma...

~~~
ptaipale
Looks like you had so much to say about billionaires that you didn't have time
to read the headline.

It doesn't say anything about spending _on_ other nations. The U.S. spends
more on health care _of its own citizens_ than other nations do. The system is
clearly not very efficient, at least in terms of what it offers to poorer
citizens, although at the top end, results are excellent and the U.S. still is
in the front lines in research and technological progress of medicine.

~~~
xzel
Depends on what you take the word efficient to mean, even at the top end I
don't find medical care very efficient. Basic procedures can be very expensive
for my insurance company. I'll define efficient here as results to cost. In
the US, there are groups at every level between patient, doctor, insurance and
big pharma where often their goal is to create inefficiencies because the less
efficient the treatment, the more money make. Look at something like insurance
billing codes; I have a friend who's entire business is telling Dr's which
codes to book procedures under so they make more money from insurance. His
company is make 10s of million a year. There is stuff like that at every
level.

~~~
ajdlinux
GP didn't say the top end was efficient, just that their results were
excellent.

~~~
ptaipale
Yes, that was my point.

And I might add that the inefficiency (in terms of national health outcomes
vs. national public and private spending) is partially the reason, or
explanation, that U.S. is the forefront of medical technology. The U.S. spends
on things that develop technology but do not contribute much to national
health.

Things like transplants, or cures for rare diseases, are generally not
important for national health outcomes, but U.S. does a lot of work on these.
You achieve low child mortality by forcing relatively simple things done for
every child and family, even those who are not very receptive to care. U.S.
does not do that as much as many other countries with lower spending but
better national health outcomes.

