
Employer health plans are getting pricier and skimpier - hhs
https://www.axios.com/2019-employer-coverage-workers-premiums-deductibles-ea2cbdf3-91bd-4b4d-9611-71fd72b1140c.html
======
comnetxr
Imagine if grocery stores forced us to choose one of a few dozen grocery
"insurance" memberships to buy groceries, and negotiated directly with the
insurers. No prices are labeled in store, they just detect whatever you take
and send you a bill at the end of the month. (Differing brands of the same
food product are not available in store of course.) Individuals are charged
3-100x more per product than negotiated rates, but can't find out until
afterwards. Grocery "insurance" would then become a necessity. People would
trade away disproportionate amounts of their salary to get good grocery
benefits from their employers, i.e. to not get price-gouged by virtue of being
an individual on the market. Stores would run discount programs for the very
poor, which they could point to when people get outraged (as drug companies do
now.) When politicians would threaten the system, grocery stores would fund
ads about the "long lines" and limited food availability that would occur.
Instead laws would get passed reinforcing the system by making sure everyone
gets grocery insurance, as its a necessity (and it would _be_ a necessity).

I'm not saying that health care _could_ be exactly like grocery stores, with
many alternatives, transparent pricing, and customers making the final
decisions, but that it would have to be much _more_ like grocery stores to
call it a free market. What we are working with now is just a system of
pricing cartels supported by fear and lobbying. It needs to go.

~~~
plughs
Then imagine that there are some people who can't afford the food they need in
the grocery store and are going to die.

Alternatives and transparent pricing isn't going to make brain surgery
affordable to the average consumer.

~~~
kuzimoto
According to Wikipedia, there are only .5% of all physicians in the US who can
perform neurosurgery. So it's probably safe to say the demand for brain
surgery is much higher than the supply.

This incentivises people to become doctors that perform such complecated
procedures as it takes a lot of time and a lot of money to be able to do those
things.

If you were to force doctors to perform work on people that can't afford it,
then presumably they will earn less money. If they earn less money, there is
less incentive to do that kind of work as they will pick something easier and
more profitable.

You will end up with fewer people to do brain surgery.

~~~
rubidium
If money were the only incentive to life no one would become a schoool
teacher. Your summary is missing something.

~~~
kuzimoto
That is true, but if you're the type of person that likes to help others it's
much easier to become a teacher than doctor.

Also, if you are a doctor and your primary motivation is helping people,
wouldn't you want to help many people with simple problems, than few people
with highly complex problems (which most likely have a higher risk of
failure)? There is already a shortage of doctors doing the easy stuff.

I just don't see the incentive for doing difficult procedures other than with
money.

~~~
tanr54ok
> Also, if you are a doctor and your primary motivation is helping people,
> wouldn't you want to help many people with simple problems, than few people
> with highly complex problems (which most likely have a higher risk of
> failure)?

Your analysis completely falls flat here. Not all doctors are motivated by the
same things and yet most of them would consider their primary motivation
helping people.

Neurosurgeons are a prime example. They would very much prefer few complex
cases (not everyone gets a brain tumor thankfully) as their way to maximize
benefit rather than manage cholesterol meds for 100s.

Speciality surgeons by their nature are motivated by a certain degree of risk.

The incentive for doing difficult procedures is often because they are
challenging. Compensation for doctors in the US isn’t fully correlated with
difficulty either... with no offense to my dermatology colleagues making more
than most general surgery sub specialists.

~~~
kuzimoto
> Not all doctors are motivated by the same things and yet most of them would
> consider their primary motivation helping people.

That's fair. I probably over-emphasized the money part of it.

> The incentive for doing difficult procedures is often because they are
> challenging.

We can assume that since doctors aren't doing this for free or at least cheap
already, that they require at least some amount of compensation. To return to
my original point, if you force doctors to perform procedures on people that
can't afford them, and the amount they receive is less than they want, then
there be a greater shortage of such doctors.

> Compensation for doctors in the US isn’t fully correlated with difficulty
> either... with no offense to my dermatology colleagues making more than most
> general surgery sub specialists.

Not directly anyway, it's probably more supply/demand. Low supply of
neurosurgeon means high cost. Whether that's from artificially suppressing the
supply of these doctors or because it's very challenging is up for debate.

I'd guess dermatologists make so much because people are more willing to spend
money on that sort of work.

------
eric_b
The problem is that there is not a _single_ reason that healthcare is so
expensive. Even if you list the top 15 reasons, you still have to apply the "5
whys" to each of them to find root causes and possible solutions.

\- Doctor's are paid too much... why? \- Well they need to be paid a lot
because medical school debt is 250k or more... why? \- Medical schools/the AMA
are artificially limiting the number of students and residents for their own
ends (keeping wages and scarcity high) so they need to charge a lot... why? \-
I honestly don't know.

But the current political climate in the US is incapable of dealing with any
kind of multifaceted problem.

One thing that will not make healthcare less expensive is "Medicare For All".
It will just shift the bill to different people. Now, you can argue it's the
morally correct course of action, or those people who will be forced to foot
the bill (upper middle class taxpayers) are more capable of doing so, but you
cannot credibly claim with a straight face that it will make anything cheaper.
In fact, the opposite will occur.

(I don't want to hear one thing about negotiating power. That is a debunked
line of reasoning. Medicare/Medicaid cover more people than many single payer
systems in other countries, and their costs are still outrageous)

~~~
mullen
> One thing that will not make healthcare less expensive is "Medicare For
> All". It will just shift the bill to different people. Now, you can argue
> it's the morally correct course of action, or those people who will be
> forced to foot the bill (upper middle class taxpayers) are more capable of
> doing so, but you cannot credibly claim with a straight face that it will
> make anything cheaper. In fact, the opposite will occur.

Having every person under the same plan that has the negotiating power of
327.2 million people will definitely drive costs down. Don't want to pay what
the government says it is going to pay? Good luck finding customers then,
because the government is bargaining on behalf of all of the customers in the
US.

People who say this stuff are the same people who proclaim there is no
solution to a problem that the only occurs in the US. Literally, every
Industrial Nation has addressed this problem for much lower costs with better
out comes.

~~~
simonsarris
> Having every person under the same plan that has the negotiating power of
> 327.2 million people will definitely drive costs down.

Why do you think this would be true? Why do you think the bargaining power
would work the way you think it would?

If you were correct, then cop cars must be fairly cheap compared to normal
cars. Is this the case?

What about other goods? Laptops? Cruise missiles? etc.

Actually is it true for _any_ good which the US Gov is the _sole_ buyer? Can
you think of even a single good where your supposition is true?

~~~
romwell
Perhaps this is a good reason:

>Literally, every Industrial Nation has addressed this problem for much lower
costs with better out comes.

~~~
simonsarris
But why those nations have lower costs isn't so simple. If you remove all
profit and admin overhead from the US system, its _still_ something like
$5000/person more expensive than other countries (I think that that was vs
Canada).

A large component of healthcare cost in the US is simply healthcare use. We
are deeply, deeply unhealthy with 75% overweight rates and absurd levels of
pre/diabetes, which are the largest comorbidities of all, and comorbidities of
each other. Costs will never be comparable until overweight/obesity rates and
usage are comparable too. They are not.

High prices in the US are very unfortunately largely explained by usage, and
no amount of profit-reducing or cost cutting will work unless you are cutting
usage itself:

[https://randomcriticalanalysis.com/2016/09/25/high-us-
health...](https://randomcriticalanalysis.com/2016/09/25/high-us-health-care-
spending-is-quite-well-explained-by-its-high-material-standard-of-living/)

~~~
philjohn
In the UK the NHS negotiates prices for drugs. NICE have to approve all drugs
and if a drug is too expensive, the manufacturer either has to lower the price
so that the benefit outweighs the cost, or they lose a large market.

This is why hand waving away "bargaining power" ignores one of the sources of
high costs.

The other is that our doctors are mostly either employed by the NHS, or
employed by a private provider who is paid by the NHS ... yes, there are
doctors who do private only work, but they are fairly small in number.

Perhaps our student loans system also helps - fees are £9k a year, but you
start paying them back at 9% of income over £25k ... so it's essentially a
graduate tax and they are fully written off after a set number of years if you
don't pay them off.

~~~
rayiner
The difference in drug spending between countries amounts to a small fraction
of overall healthcare spending. $1200 a year in the US versus $900 in
Switzerland or $800 in Germany, Canada, and Japan.

~~~
jacobush
It's incidental what the numbers are. Given how effed the US system is, I
would fully expect that $1200 being spent on the entirely wrong things, like a
few super expensive drugs, and a lot of antibiotics which should have been
dirt cheap getting a ridiculous markup, or on Oxycontin.

------
tempsy
Yep, and what people don't always realize is that because employer health
plans get more expensive every year for employers, it negatively impacts wage
growth. You are paying for it even if you don't necessarily feel it.

~~~
basseq
This is really important. Pulled from the underlying study[1], employers cover
82%/70% (individual/family) of the cost of healthcare. Those numbers are down
just slightly from 86%/73% in 2019.

Or, put another way, employers have borne 69%/80% of the cost of healthcare
increases. You complain because your individual plan has gone up by $986 in 20
years? Your employer's cost has gone up _$4,005_. Oh, and that's _with_
cutting the underlying coverage ("skimpier").

It negatively impacts wage growth because that extra $4k is a bottom-line
_benefit_ (or cost of employment, if you want to think about it that way).

Finally, note the disparity between individual and family plans. Employers are
offering 2.5x more benefit—nearly $9,000 more—to workers with families.

\-----

[1] [http://files.kff.org/attachment/Report-Employer-Health-
Benef...](http://files.kff.org/attachment/Report-Employer-Health-Benefits-
Annual-Survey-2019)

Fig. 1.10 shows premiums increasing from $2,196/$5,791 in 2019 to
$7,188/$20,576. (Note also that 72% of that is attributed to premium increases
vs. inflation and worker earnings, per Fig. 1.14.) Fig 6.1 shows % of premium
paid by workers going from 14%/27% to 18%/30%.

~~~
kevindong
> Finally, note the disparity between individual and family plans. Employers
> are offering 2.5x more benefit—nearly $9,000 more—to workers with families.

Interestingly, my employer discloses the full premium that they pay to the
health insurer every year. As an employee without a partner/dependents (I just
graduated college/started my career), my employer spends ~$17k/year less on my
health/dental/vision benefits than employees with a partner/dependents.

That effective pay difference makes me mildly salty.

~~~
basseq
It's an interesting topic, particularly as it relates to employers being
women/family-friendly. How do you feel about parental leave, for instance?

Of course, this is a benefit that's within your control: just get a
partner/dependent! And the flip side is that even individual employees might
value knowing that the company "has your back" as your family situation
changes.

Or, more bluntly, your company _has_ to offer disparate benefits, because
other employers do, and no employee with a family would work for your company
otherwise.

Of course, all this masks the REAL problem that employers and healthcare are
so intertwined. Even this article puts some of the blame on employers, when
really it's the healthcare companies and the overall rising cost of care.

------
nickgrosvenor
This is absolutely the biggest story in America, and most people aren't
talking about it.

An entire generation is draining their savings to keep up with premium costs.

Not to mention the millions of people locked into careers they would otherwise
get out of, if not for the health coverage.

This situation is probably going to lead to unbelievable outcomes.

~~~
MuffinFlavored
> An entire generation is draining their savings to keep up with premium
> costs.

Knock on wood but, myself and pretty much everybody I know has insurance
covered ~75% through our full time employers. I think my portion of my
insurance is about... $100/mo? I've never had to use it way/shape/form in the
past... 5-10 years.

Isn't the truth that the most unhealthy people are what drives health care
costs?

It'd be interesting to see a visual of who uses their insurance and how much
of it they use. Let's not forget that lack of exercise, obesity, and heart
disease are rampant in America.

~~~
geddy
Yeah, I really wonder where that $10,000/person figure comes from when you
remove obesity and smoking related illnesses, so, the two highest and most
preventable causes of death in this country.

I always believed you should be able to qualify for lower costs (or be charged
higher) depending on how you take care of yourself. Annual physical fitness
test. I'm a little sick and tired of paying high premiums for people to have
healthcare that don't take care of themselves.

~~~
geggam
Many of us who won the genetic lottery are sick of paying for those who didn't

Where do you draw this line ?

If someone cannot afford to eat or live a healthy lifestyle do you kick them
while they are down ?

~~~
MuffinFlavored
The brotherhood of "we can all band together to pay for each other" falls
apart when the line to McDonald's is wrapped around the corner in my eyes.

If you take in over 3,500 calories a day of pizza, soda, cheeseburgers, or
candy then follow it up with little to no exercise/movement, you are
contributing to the "health insurance crisis".

------
badrequest
The sooner we can completely divorce healthcare from employment, the better.

~~~
throwaway_law
I hear this statement all the time...but what does it mean?

If employers didn't provide health insurance to employees wouldn't we just
wind up with 40% of the insured uninsured? Its not like Corporate America is
going to make up the difference and start paying cash to compensate for the
lost benefit, at least thats what happened as pensions got stripped away from
the workplace. Even if the employer's did make up the cash difference, its not
like that will bring pricing down, individuals can't negotiate individual
insurance rates, pools of employees can negotiate group rates, so if anything
costs would probably go up.

How will this help: 1) insured more people; or 2) bring costs down?

~~~
throwaway66920
Getting insurance as an individual is expensive because you’re not part of a
group plan. With a group plan the insurance company has some reason to believe
you’re not collectively a bunch of dying people committing moral hazard,
you’re just one of a generally similar looking company workforce.

If employers stopped providing it, I think it is presumed that the mentality
towards individual plans would change

~~~
2sk21
Well, one way of looking at it is that the general population is the biggest
group possible :-)

~~~
throwaway66920
Sort of. This is true if everyone is required to participate in the system.
And there’s only one provider. If you imagine there being a cheap plan and an
expensive plan, you would probably expect that the expensive plan is a way
better return on the dollar because there are fewer poor people on it weighing
it down (because poor people are likely to have more health issues).

True meaning it averages out to a reasonably healthy person _

~~~
throwaway_law
>you would probably expect that the expensive plan is a way better return on
the dollar because there are fewer poor people on it weighing it down

It is unfortunately true in the US (probably everywhere) there is worse
health/higher incidences of chronic conditions in the poor (mostly because all
chronic conditions are diet related). However, in the US the biggest weight
would be the elderly who have chronic conditions at a higher rate than any
other demographic (generally due to a lifetime of poor diet combined with
irregular care over their life to treat the conditions until they are
Medicare), but thats the irony these are the people already covered by
Government healthcare (and they seem fairly happy with it. Its time to extend
it to everyone.

------
nkurz
It seems like a strange omission for this article not to mention that the
reason health insurance is so expensive in the US is that health expenditures
are so high. The US spends more than $10,000 per year per person on health
care[1], more than any other country. Clearly, on average, premiums clearly
must be higher than the amount paid out on behalf of the customer.

If you want lower premiums, you somehow need to lower the amount spent on
health care. The problem is that, perversely, health insurance companies are
incentivized to spend _more_ on health care rather than less. By law, they
must spend at least 80% of the money collected as premiums on health care
costs[2]. The more they pay, the larger the 20% they are allowed to keep.

So if you want to reduce the cost of health insurance in the US, you need to
reduce the cost of health care. If you want to reduce the cost of health care,
you somehow need to change the incentives so that the big players benefit when
the cost of health care goes down rather than up. Failing that, you need to
change the system so those big players are no longer in control.

[1] [https://www.healthsystemtracker.org/chart-
collection/health-...](https://www.healthsystemtracker.org/chart-
collection/health-spending-u-s-compare-countries/)

[2] [https://www.healthcare.gov/health-care-law-
protections/rate-...](https://www.healthcare.gov/health-care-law-
protections/rate-review/)

~~~
claudeganon
Only the latter option is a feasible solution. If you look at countries with
mixed systems (like South Africa), a great deal of the cost savings disappear.
Tim Faust has a great new book that breaks this down. Also, recommend his
interview on the Death Panel podcast.

[https://www.mhpbooks.com/books/health-justice-
now/](https://www.mhpbooks.com/books/health-justice-now/)

[https://deathpanelpodcast.com/2019/02/02/all-care-for-all-
pe...](https://deathpanelpodcast.com/2019/02/02/all-care-for-all-people-w-tim-
faust/)

------
d1zzy
I would love if everyone that seems to be in support of a single player system
would make a mental note right now that they were in support of it, and then
years later after the US moves to such a system (seems pretty likely?) they
review how much it helped.

I grew up in a single payer system and I'm theoretically in support of it for
the many reasons people already listed in the comments (larger negotiation
position, spreading the risk to more people, because it's humane, because it
removes an incentive to stay in the wrong job, etc). But while I agree with
those arguments I also have a strong conviction that if such a system were to
be adopted in the US, it will NOT result in better care and more efficient and
overall reduce the costs in the system. Not without many other changes in
other laws and even cultural changes. Just because something works in Germany
for example it doesn't mean it will work in the US, there are different
demographics, different mentality, different service expectations, different
tax system and a largely different legal and law system. Not to mention we
were just discussing a few days back about the increasing national debt and
this needs to be done without increasing the deficit.

~~~
GordonS
I'm in the UK, and have unfortunately had all too much experience of the
health care system here.

My view is that it's optimised for the majority, and for the "easy" things.
For example, all the NHS endocrinologists I've seen have only really known
about diabetes, the dieticians I've seen only really know about weight loss,
the pain specialists I've seen have a narrow and fixed list of mess they
prescribe, and the neurologists I've seen only really knew about... well, not
much TBH. I can only guess it's because they're over-stretched and simply
don't have time, but it's also been my experience that consultant's knowledge
is way behind the times; almost like they haven't read a paper since they left
medical school. Oh, and waiting list times are often ridiculous.

The NHS fails many, but I know helps far more than it fails, and if you have
the money you have the option of private medical insurance or self-funding
private medical care.

I'd still take our "sort of works for most people" system over that of the USA
any day.

------
arbuge
I see alot of the proposed solutions to the US healthcare system boil down to
some form of "Medicare for all". I think a single payer system would be great
and I am all for it.

That said, I doubt it would solve all the problems in the US healthcare system
at this point. It seems to me the biggest one is that providers, i.e. doctors,
hospitals and drug companies all bill way too much. I think it is just
politically less palatable though to go after doctors than after a big
anonymous insurance company.

I do remember when I had an appendix operation a few years ago and was billed
$50,000 for it, including some gems such as $4,400/night just for the hospital
room and $50 for 2 tylenol that the Walgreens down the road would sell you for
$5 a 24-pack.

I know several doctor acquaintances making >$1m and even $2m a year - I know
they get together regularly where they actually discuss techniques to bill
their patients the most money. One dermatologist discovered that removing 2
skin lesions on the same day was a bad idea - he got paid about 50% less for
the 2nd one that way. Sending the patient home and telling him to come back
next week for the 2nd one would however double the bill. So that's what he
does! More patient inconvenience and added expense - but who cares?

~~~
grecy
Everything in American society is done the way it is done because it's making
someone very, very rich.

Healthcare. Education. Defence. Incarceration. Taxes. Bank Transfers. Telco.
Roads. Infrastructure.

Patient convenience, Overall society happiness - whatever you want to talk
about. It's a money machine. And the money is more important than the people.

------
KoftaBob
This is why I feel the "most Americans like their health insurance" cliche is
complete garbage.

~~~
taurath
Nobody does. The real translation is old people don’t want to change doctors.

~~~
hfern
It's worth pointing out that for the vast majority of people doctors !=
insurance. The payer is not the provider.

The refrain of "people like their health insurance" deliberately conflates the
two. People like their doctors, not their insurance. Doctors accept multiple
insurance companies.

~~~
mieseratte
> Doctors accept multiple insurance companies.

Some do, but not all. One of my providers takes exactly one insurer, which I
do not have, so pay out-of-pocket.

Luckily most insurance companies allow you to submit receipts to receive
credit towards your deductible.

------
payne92
I just got my renewal quote: $2,372/month for a family of 4 is going to
$2,883/month. That's a ~20% increase, to $34,595 PER YEAR.

(And this is while benefits continue to be cut back: $150/month for many
prescriptions, etc.)

As others have written, there's no _single_ reason. But, I think there's a
major unintended structural problem: under US law, insurance companies are
required to pay a high percentage (like ~90%) of their premiums out to service
providers. The intent is to cut administrative overhead.

The effect: it's very hard for an insurance company to invest in technology or
administrative improvements. So, the status quo persists.

WORSE, the admin overhead is pushed onto the providers, so the overhead cost
gets hidden. It's not uncommon for a family medicine general practitioner to
have a back office of _3-5 people_ dealing with billing and insurance
paperwork.

~~~
Gibbon1
> WORSE, the admin overhead is pushed onto the providers, so the overhead cost
> gets hidden. It's not uncommon for a family medicine general practitioner to
> have a back office of 3-5 people dealing with billing and insurance
> paperwork.

My old doctor from when I was a baby till he retired had a practice with three
to four other doctors. They had a nurse and one of the doctors wives did all
the office work, billing, and answering phones. Current doctors practice has
two doctors, four nurses, and eight office staff.

Old doctors office could would take x-rays and set a simple fracture. Or
stitch up a simple cut. New doctor won't do any of that.

------
weeksie
Insurance companies need to be expropriated. The entire thing needs a
restructure from the ground up, there are too many critical path issues that
will keep things expensive if we try to have two systems at once (medicare for
all + private)

the US should get real medicare, then move to a public/private system where
you get base coverage through medicare and pay extra for fancy coverage.

~~~
geggam
Simply removing insurance and letting the free market adjust would fix the
issue.

When I was a kid no one worried about hospital bankrupting the family. Now
anything larger than a paper cut has the chance to bankrupt most families.

Combine that with the accident rate in cars you have an almost certain chance
for a large percentage of the US to be bankrupt

~~~
weeksie
Free markets don't work with the information asymmetries involved in
healthcare.

~~~
geggam
Odd how it worked before insurance took over the healthcare system.

Care to share what you see would be different ?

~~~
zanny
50 years of medical innovation leading to the propagation of procedures,
medicines, and equipment costing upwards of tens of millions of dollars to
procure and maintain.

 _Nobody_ is equipped to try to make an informed purchasing decision on if
they want the $50k or $100k option to try to save their life while bleeding
out of a gurney after getting hit by a car.

------
tempsy
I think another thing about employer-based healthcare that few think about is
that if you work for a large company then it is almost certainly self-insured,
meaning that you or your employer is paying premiums into a fund that it is
managing itself.

How crazy is it to think that not only does Apple or Ford or Trader Joe's need
to manage it's own business but that it is also hiring actuaries/insurance
specialists/consultants etc to manage a complex insurance program for all of
its workers? I'm not sure many people that work at large companies realize
that their employer knows every diagnosis, procedure, and prescription you've
ever picked up, and actively trying to incentivize you to use as little
healthcare as possible.

~~~
mieseratte
> I'm not sure many people that work at large companies realize that their
> employer knows every diagnosis, procedure, and prescription you've ever
> picked up, and actively trying to incentivize you to use as little
> healthcare as possible.

I work for such a company, and it's great. I pay about $30 per month for a
plan with a tiny deductible ($2,500), and they offer great wellness perks like
weekly classes (yoga, kick-boxing) in-office, partner with a local CSA that
does a bi-weekly produce truck out in the parking lot. They do encourage folks
to get yearly wellness screenings, and basic dental cleanings by increasing
your plan by about $2 per week if you don't.

This is a single, no dependents rate. I believe the comprehensive plan, with
families runs about $70 per month.

As it were, the plan is employer funded but we have some type of partnership
with a major provider for administration so the employer itself isn't hiring
actuaries / specialists / consultants. Perhaps your personal experiences
differ here?

~~~
tempsy
I don’t understand your comment. If the company is large it is likely self-
funded, so it is taking on the risk, whether they are doing it in house or
hiring a benefits consultant to do it for them.

I didn’t say anything about the quality of a self-funded plan, simply just
pointing out that a self-funded plans means your relationship with your
company is not merely just a worker but you morph into this insurance risk
that they now have to actively manage. I am pointing out how strange it is to
ask a company to have to do that, which is unlike any other country in the
world.

~~~
mieseratte
> I don’t understand your comment. If the company is large it is likely self-
> funded, so it is taking on the risk, whether they are doing it in house or
> hiring a benefits consultant to do it for them.

Because they partner with a larger provider for the doctor / hospital /
pharmacy networks and specialist support. This is a very common pattern
insofar as I'm aware.

Has your experience differed?

~~~
tempsy
The network of providers available to you is a separate issue from whether
your company manages the risk or an insurance company does. Didn’t mention
anything about provider networks.

~~~
mieseratte
> The network of providers available to you is a separate issue from whether
> your company manages the risk or an insurance company does

What I'm saying is, my company manages the risk. We partner with a larger
insurer company that provides A) network B) specialists for the roles you've
claimed a company would normally hire. Because of this we don't have inside
actuaries and specialists and such. As a result, there is no inside man
looking at my claims.

I will ask for for a third time, have you experience that differs here?

~~~
tempsy
What you’ve described is the self-insurance model for large companies. That
doesn’t conflict with any of my earlier comments. Companies can decide whether
they want to administer it internally or use a consultant.

You seem to believe that just because a company uses a consultant that no one
in HR or Finance or management would be privy to viewing your claims history
via the consultant? Not sure what would lead you to believe that. Just because
your company is outsourcing the task doesn’t mean it is shielded from the
data.

------
knob
Sharing this idea in order to gather critique. The cost of healthcare in the
USA is insane. Could we look for insight into the US Military? Example: This
morning, a coworker told me she's going to have an operation on her back. The
"cost of the tray" (I have no idea what this is) is $14,000. She has to pay
$8,000 up-front two days before the operation, and the remainder will be
financed over two years.

To me, it's insane to think the US Military pays $14,000 for this same
operation in US Veterans' hospitals. Why don't we look into the military to
see how they're doing it?

Or am I completely off-base here? Thoughts?

~~~
notTyler
The insurance companies are for profit corporations who pay politicians so
they can keep taking your money when you're healthy and cutting you when
you're not. The army is not, as far as I know, a for profit enterprise.

~~~
chooseaname
This is the one and true answer with regards to insurance companies.

------
patrickmay
Healthcare is expensive and getting more so because of over reliance on
insurance and government imposed restrictions on supply. See "Overcharged" for
a detailed summary of the issues: [https://www.amazon.com/Overcharged-
Americans-Much-Health-Car...](https://www.amazon.com/Overcharged-Americans-
Much-Health-Care/dp/1944424768)

------
coldcode
In no other country is your healthcare tied to your employment but the US.
Germany has had a national healthcare system since around 1880 (after the
country was unified, based on what Krupp did for their employees). Why is the
US the outlier (also in cost per capita)?

~~~
pkaye
During World War II wages were frozen to focus on the war efforts so employers
used ancillary benefits to attract workers. Then things carried on from there.
[https://www.nytimes.com/2017/09/05/upshot/the-real-reason-
th...](https://www.nytimes.com/2017/09/05/upshot/the-real-reason-the-us-has-
employer-sponsored-health-insurance.html)

------
opportune
Even at famously generous employers they will try very hard to push you
towards high deductible plans by giving you 1-2 thousand extra dollars per
year in your HSA. Of course the high deductible plans discourage you from
seeking care so it saves your employer peanuts it can add to its war chest in
Ireland

Some of this probably has its roots in the ACA adding extra taxes onto
“Cadillac insurance plans” though which I didn’t even learn about until
recently. Yes, apparently you may need to pay extra taxes for extra good
insurance

~~~
cullenking
I manage a health plan for our smallish business of 19 employees. We offer
"pretty good" health insurance, meaning, we pay around $600 per employee per
month for health and dental. It gets worse every year. I am considering moving
toward a HSA based plan, because upon analysis, it's actually probably better
for everyone involved. The max out of pocket per year is the same, but instead
of a $1000 deductible you have a $5k deductible. This works for our business
(and I am assuming a bunch of other tech businesses) because our employees are
generally young and in good health. It's a cheaper plan, the worst case
scenario for an employee is the same, and I can give raises for the difference
in price, and once every few years someone will need more than a $1k
deductible, but the raise from the last couple years greatly exceeds the one
time cost.

Anyway, just trying to frame my logic here, because I don't consider myself an
evil employer trying to skimp on health insurance for my employees (which many
I consider friends), but an employer that has to approve health plan changes
annually which each increase cost by a considerable amount. If this trend
continues, each employee will cost $900 a month within 5 years, and the
coverage will be half as good. That's $5k a year per employee that I could put
into their salaries, while not screwing anyone over on the worst case
scenario.

~~~
opportune
From my perspective, I am unlikely to hit the out of pocket maximum but quite
likely to spend more than $1k/year. All the high deductible does is discourage
you from seeking care for things before they become serious. Not sure how it
worked from the employer’s end, but $5k/year will get taxed at roughly 50%
before I see it so it’s not clear whether that will be greater than my out of
pocket costs

~~~
whitehouse3
The missing link here is premium savings. HDHP plans exchange higher
deductibles for a nontrivial premium discount. Insurance companies like to
assure employers that employees will bank this discount into a tax-advantaged
HSA. So the theory goes, a reasonably healthy subscriber will have sufficient
savings to meet their deductible.

This falls apart in practice when employees, who are already spread thin
financially, elect an HDHP but can't or won't set aside cash to cover
expenses.

------
kxrm
There aren't many industries where price shopping is as hard as healthcare.
When you remove the cost of a good so far from the actual beneficiary costs
become incredibly hard to control.

Not many here will remember when the insurance markets started in the US, but
the original deal was that people pool their resources and get a discount vs
street rates. However now that everyone is pooled, what possible metric can
you use to determine if you are actually getting a good deal?

Sure, we hear stories of outrageous bills that are sent to patients that their
health insurance "covers". However, the reality is the insurance company
expects a discount which has caused an opposite effect to uninsured patients.
Costs go up so that the "deal" the insurance company gets looks good. All the
stories about $20 pill of Advil, is all pointing to the leverage hospitals and
doctors used to fight cost cutting at insurance providers.

I think there are only two ways to resolve this at this point. Build a free
market solution where price transparency is required and make it easier to
shop for non-emergency care, while the government continues to cover emergency
visits or full single payer healthcare with the government footing the bill.

Based on the moral logic that many U.S. citizens see healthcare and life
savings services as fundamental right, I think we inevitably will need a
single payer system in the US. I know the desire is to see something federally
mandated but I am quite surprised that not one state has taken up the idea of
single payer and made it a system available to all residence who prove they
have resided in their state at least X days. I'd like to see the different
solutions presented in each state and let the state with the best healthcare
solution win and eventually become federal.

------
mensetmanusman
The U.S. is supposed to be immune to this in principal due to the nature of
states being test beds of policy. The only reason this is happening in all
states is because of federal policy that has destroyed the ability of states
to experiment in this area.

When you ask for zero risk, you are asking for infinite cost.

------
xphilter
If you want to blame anyone, blame the RAND institute with poor studies that
pump up the hype around high-deductible plans:
[https://www.rand.org/pubs/technical_reports/TR562z4/analysis...](https://www.rand.org/pubs/technical_reports/TR562z4/analysis-
of-high-deductible-health-plans.html)

My last reading of their work was years ago, but at the time the study found
that folks will use fewer health resources when on a high deductible plan.
However--the study allowed folks to revert to their old insurance (i.e., lower
cost insurance) if they got sick. Meaning the study would show those in high-
deductible plan would use fewer resources only because the people in that plan
who used more resources quit the study.

------
throwawaysea
The entire health insurance industry makes ~$25B in profits a year, correct?
That doesn't seem overly large considering it is the entire insurance
industry.

~~~
Ididntdothis
It’s not only profit. They also cause a lot of administrative overhead. For
example if doctors had to deal only with one insurer or at least one coding
system they wouldn’t need four billing assistants as I have seen. In essence
insurance companies do a lot of unnecessary stuff. Their profit is only a
small part of that cost.

~~~
pg_bot
There are two coding systems (ICD - for diseases, and CPT for procedures) that
are mandated to use by medicare/medicaid and all the insurance companies use
them as well. Most of them even accept the same forms. They need those billing
assistants for other reasons.

~~~
Ididntdothis
”They need those billing assistants for other reasons.”

Whatever it is they do exactly it deals with insurance companies. Germany also
has private doctors but they have much smaller staff and dealings with
insurance are very straightforward. American insurance companies cause a lot
of friction. I don’t know exactly why but they do.

~~~
pg_bot
Insurance companies are mainly trying to combat fraud. They kick back claims
if they are formatted wrong (why did you code an operation on the left knee
when the right knee was the problem), or they deem that the work done was
improper, unnecessary or does not fit the standard of care. Billing staff also
handle accounts receivable and collections.

The biggest problem IMO is how we structure payment for health services in the
USA. The fee for service model is highly inefficient and disincentivizes
preventative care. All of the current proposals for universal healthcare do
not address this fundamental problem, and so long as this remains in place we
will continue to have the highest costs in the world. (disclosure, I am
working to try and solve this problem)

If you were to pick countries to emulate, I would pick Singapore, Japan, the
Netherlands, and Switzerland instead of Canada and the U.K.

------
non-entity
I was just thinking the other day. Every job I've had has offered health
insurance through the state BCBS. Those plans are ways a little over $100/m
(for a single worker)

Meanwhile, I've had people brag to me about paying $10/ for damn to near full
coverage. I'm starting to wonder if BCBS employer plans are just garbage

~~~
ceejayoz
The average health insurance monthly premium for individuals is a couple
hundred dollars ($321 in 2017 per [https://www.cnbc.com/2017/06/23/heres-how-
much-the-average-a...](https://www.cnbc.com/2017/06/23/heres-how-much-the-
average-american-spends-on-health-care.html) ; it'll be higher now). $10 or
$100/month both mean the employer is chipping in a bunch, they're subsidized
via the exchange due to low income, or they've got absolutely garbage coverage
that won't actually pay for anything significant.

This is why the linkage to employers for coverage is so insidious - it hides
the true cost of the system in lowered salaries. People look at an
unsubsidized exchange plan like mine, with its $2,144/month premiums, and go
"holy shit, I only pay $10/month for mine at work, that's horrible!"

~~~
vkou
My wife just took a job at a place that has a 'good' health insurance plan.

If she opted into it, her contribution would be ~$300/month, her employer's
contribution would be $900/month.

If she wanted to cover me with it, her contribution would be $1,500/month, and
her employer's would be $900/month.

Unsurprisingly, we did not take advantage of this, and she remains on my
insurance (Since my employer handles 90% of the premium for both of us.)

When we were still dating, I had a good look at what the $300/month health
plans provided. Absolutely flippin nothing. Deductibles of $8,000/year, and
co-pays of 25%. If all you can afford is a $300/month plan, there's no way in
hell you can afford an $8,000/year + 25% medical bill.

Meanwhile, Canada provides universal healthcare for $5,200 USD/year/person,
with similar health outcomes.

Edit: fixed a typo in the employer's contribution.

~~~
dannypgh
Coinsurance is paid only until the out of pocket maximum is met, no?

I have a plan on the state exchange for around $300/month and an out of pocket
max around $8k (I'm 34 years old).

I just budget $12k/year for healthcare and move on. This seems reasonable for
people who can afford to take the risk of potentially having to pay anywhere
from $4-12k/year.

------
camhenlin
Definitely feeling this during my company's health insurance renewal this
year. I used to think that I had it pretty alright, but over the past few
years, things have gotten worse and worse. This year, for our "gold" plan,
which was sold as the equivalent of the previous year's "gold" plan, our
insurance provider increased our monthly cost by approx $120/mo, and increased
our deductible by $5,000, up to $15,000.

I used to be against single payer, but now I'm rooting for any politician that
thinks they can pull it off. I'm willing to pay a bit more tax in exchange for
no longer having the "best" health insurance plan that I can afford that,
quite frankly, I am terrified to use. Health care costs in this country are
completely out of control. We need to have the system burned down and
rebooted.

------
black6
The American health insurance system is not insurance--it's a long-term
payment plan. Why does insurance need to get billed when I go for a yearly
checkup with my doc, or when I pick up some prescription-strength ibuprofen?
My auto insurance company doesn't get billed when I get the oil changed in my
truck. My homeowners insurance company doesn't get billed when I have to
recharge the refrigerant in my heat pump. The insurance companies have taken
all the monetary interactions between clinics and patients away, except for
the (oftentimes criminal) balance billing that occurs when your claim was
denied for some ass-hat reason like "You didn't tell your insurance company
whether or not you had other insurance."

------
vkou
Of course they are, healthcare costs are growing in an unbounded manner, way
ahead of inflation.

~~~
blahyawnblah
Why is this? Are there more sick people or just more people?

~~~
mywittyname
The healthcare system has become a symbiotic relationship where providers and
insurance companies work together to funnel money from just about every
business in the US into their pockets.

Hospitals increase staff to justify billing more, then insurance companies use
increased costs to justify raising rates. Internally, hospitals and insurance
companies are also in a tug of war over their slice of the pie. These
conflicts introduce even more people-hours into the treatment of patients, in
the form of revenue cycle managers, lawyers, medical coders, etc.

Each new layer added to the cost onion of healthcare results in the pie
growing, since most insurance providers can only take in some percentage of
what is spent. So they need to spend more to make more.

~~~
Nuzzerino
Incentives. There is no incentive for a doctor that sees a patient to provide
a favorable outcome for the patient. Whether the patient stays sick or not,
the doctor still gets paid. But here's the kicker: The doctor gets paid even
more if the patient has to come back. The payments come from the insurance
company.

Take this concept to the level of a very large health care network (but non-
HMO). Patient has early signs of serious but uncommon condition, goes to
doctor. Doctor checks for common, obvious things. Finds non-specific symptoms,
refers patient to a specialist or three, and the patient is diagnosed with
"Not-My-Problemitis".

Disease progresses and the patient is now able to tell the majority of the
symptoms are vascular in nature, not muscle or bone as previously thought.
More referrals are given. The specialist orders a battery of tests, but they
yield false negatives as the symptoms are not occurring at the time of the
test, and the patient was not advised that the symptoms needed to be occurring
during the test for it to be valid. Patient is again diagnosed with "Not-My-
Problemitis" and possibly referred to a research institute, where they'll have
quite a long wait time.

By this point, the patient may have lost their employment due to the frequent
sick time and time off for appointments, and generally being frustrated in
general. They can qualify for Medicaid but will have to start the process over
again, but much slower as providers have to tread carefully with care received
under Medicaid supervision, as if they were treading on thin ice. But oops,
the patient has now gone into critical condition and is sent to the ICU, which
is statistically likely to be owned by the same health organization that had
their hands involved in the patient's earlier care.

Due to the patient's hospital visit, regardless of whether the patient
survives, a payout of Six or even Seven figures is rewarded. Ka-Ching!
Insurance companies are hesitant to deny those kinds of claims now, if they
involve life or death. Too much bad PR. Thanks, Michael Moore! Of course, it
doesn't work out as well for the hospital if the patient had lost their job
and is back on Medicare, as there isn't much profit to be made there, if any.
That's just the collateral cost of doing business.

------
glitcher
This is the first year I have had to really utilize my healthcare coverage to
its fullest due to a cancer diagnosis in my family. I work at a very small
company doing its best to provide a decent healthcare plan, but with our
numbers we have very high monthly premiums plus a high out-of-pocket maximum
for me to reach (which will now likely happen every year).

I can't help but wonder if I am paying WAY more with my current healthcare
plan than if I didn't have any insurance at all and negotiated the "uninsured"
price per each service myself.

------
wpdev_63
They really should offer the employee the option to take the benefit in cash
instead of getting the health insurance then you could barter with the
healthcare centers. The health insurance and healthcare
centers(hospitals/clinics) are a cartel and the only way to bring down prices
is through competition and that doesn't happen when you give an arbitrary
amount of your paycheck to a clandestine insurance agency that has dubious
relationships with the hospitals.

------
marklyon
Because you can’t buy true insurance. You are buying a combination of prepaid
healthcare - often including things you don’t need - with some insurance
features attached.

------
ijpoijpoihpiuoh
Does anyone know the extent to which this is happening faster or slower than
the background increase of medical care costs? I know that historically
medical care costs have been outpacing inflation. So it's not altogether
surprising that, in an unsubsidized environment, the costs to the end-user of
that care would also increase, by roughly the same amount.

------
bluedino
Where I work (in the USA), we have an employer-paid plan. There are no weekly
premiums paid by the employees. There's a minimal deductible, around $500-1500
maximum per year.

The employer gets the bills, they pay them. They belong to a cooperative and
get negotiated rates, they have a provider network and everything.

Why isn't this more common?

------
simonsarris
Is there even a single _non-political_ way that plan buyers can, even in
aggregate, do something about this?

~~~
ativzzz
Stop getting sick and having to use the healthcare system. So no, not really,
unless we change our living habits as a civilization, but then we get old
anyway.

~~~
simonsarris
Well, I think there's some literal truth to that.

Even though I seem weirdly unable to get sick, and I've been to a doctor once
in 15 years (just to get a note! required by other insurance), I still have to
pay unfunny premiums. So being super healthy still doesn't help.

AND YET if everyone in aggregate used less healthcare, I bet it would do more
to move the needle than anything a politican plans. Americans are deeply,
deeply unhealthy and I wish I could convince them all to eat better. To me it
is just wild that so many people complain about non-insurance healthcare costs
but do not want to invest in better food/behaviors for themselves.

~~~
kaybe
I'm a lot less salty because the money I pay is being used to treat everyone
who gets sick, including poorer and older relatives and neighbours, and nobody
looses their house and life due to healthcare costs.

Even if you pay a lot (because you can, with high income) there is a clear
benefit for the people around you, not just cooperations. Basically, everyone
around you is safe, and that's a good feeling.

(Germany)

------
CyanLite2
It's the supply, stupid.

Congress limits the number of medical school students, thus limiting the
supply of doctors.

You see all kinds of programs to introduce more STEM or coding camps into
public schools. But you won't see schools encourage more doctors. Why? Because
of special interest groups.

------
DocTomoe
Hm, 7100 USD for a single person seems pretty affordable. Sounds to me like
the US healthcare system is a lot more affordable than they made us believe.

In Germany, with my income level, I pay about 17000 EUR (roughly 18600 USD)
per year (of which my employer pays 50%).

------
_bxg1
Our healthcare system is so wildly (and increasingly) inefficient, I don't
doubt there will be a breaking point when politicians will finally be forced
to nationalize it. Let it keep getting worse. Let them see the bed they're
making.

~~~
onemoresoop
They are covered %100, they won't feel the bad they're making.

~~~
_bxg1
Fortunately, pressure on politicians doesn't come solely from how their policy
affects their own lives.

------
afarrell
If any of y'all have questions about the process for getting a Tier-2 visa in
the UK, I know waaaay more about that than I wish I did.

(I'm an American living and paying income taxes in the UK as a software
engineer. It is an option.)

~~~
tempguy9999
Genuine question, what is the link between a tier-2 visa in the UK, and the
subject of the story. Thanks.

~~~
flyingfences
GP is implying that us Americans all want to flee our country for his just for
their "perfect" healthcare system.

~~~
afarrell
Why would a Brit know anything about the visa system in the UK (unless they
were a solicitor)?

NHS isn’t perfect. But its cost structure is miles more navigable and we’ve
found wait times better.

------
throwawaysea
How much of this problem goes away if price transparency is required by
regulation?

------
dang
[https://news.ycombinator.com/item?id=21074455](https://news.ycombinator.com/item?id=21074455)
is a related article, whose thread we merged into this one.

------
ckorhonen
I thought it was fairly common among tech companies to provide 100% paid
health, dental, vision for the employee and dependents?

(Current company does, and I’ve had this at previous jobs also)

------
tylerl
And here I was expecting that an environment that suppresses price information
and and eliminates competitive pressure would just get cheaper and better over
time.

Silly me.

------
29_29
Is it possible for an American to move to Switzerland?

~~~
atemerev
Yes, it is possible. Our health insurance is only slightly less expensive,
though (and can only be paid with post-tax money). We hold the proud second
place in healthcare costs.

You’ll also have some issues with opening a bank account here — Swiss banks
are not particularly fond of US customers, because of reasons.

------
zeppelin101
If this is the price of living in the land of the free (and the home of the
brave), then count me in. Freedom isn't free, folks! /s

------
greenonions
What makes health insurance cheaper is a larger pool of people. There is no
other mechanism by which costs can be reduced.

This is why a single payer system is dramatically cheaper. It ensures complete
coverage, reducing the cost of insurance to it's minimum. Furthermore, it
leverages the collective bargaining power of all subscribers.

There is no substitute for a national health insurance, and the United States
slowly bleeds money, time, and health outcomes every day we continue with our
current state.

~~~
fennecfoxen
What makes health insurance cheaper is _not paying for as many expensive
operations per capita_. While there are a host of factors making US health
insurance expensive, the critical factor since 2008 is laws: laws which
require that the insurance cover patients who will have very expensive
operations, and do so at the same rates as other patients.

The primary advantage of a national health insurance scheme is that it can
ration its care for expensive operations, and people won't be able to yell
"Greed, greed!" at insurance companies as a scapegoat (ignoring that the
profit margins sit at about 4%, which is not exactly the sort of health
insurance savings that would fix anything).

~~~
shkkmo
There is little evidence to support the "US consumes too much healthcare"
narrative and some good evidence that our total healthcare spending is inline
with our level of wealth [0]. There is quite a bit of evidence to support the
"Prices for equivalent healthcare are significantly higher in the US".

[0] [https://randomcriticalanalysis.com/2018/11/19/why-
everything...](https://randomcriticalanalysis.com/2018/11/19/why-everything-
you-know-about-healthcare-is-wrong-in-one-million-charts-a-response-to-noah-
smith/)

------
purplezooey
Stop voting up all these people that don't want to fix it. It's that simple.
Just stop it.

------
jswizzy
We have politicians now saying they want to ban private health insurance.

------
abstractbarista
Is it possible that it is due to more people becoming insured that are
burdensome on the system?

I thought it was pretty expected that as you get more of the unhealthy parts
of the population into healthcare, costs will rise for everyone else.

~~~
ceejayoz
Part of the goal of the individual mandate in Obamacare was to force _healthy_
people to obtain meaningful levels of health insurance to offset that.

------
objektif
I think Warren said it right in the last debate I also have never met anyone
who likes their health insurance. Medicare for all is supported by 72% of
people according to polls. I think it is time we go for it.

------
GrayTextIsTruth
Where's the regulation?

I'm upset that the democratic party has been increasingly more focused on
social issues than worker issues in the last decade. Once neither political
party cares about the working man then you'll start to see unregulated
capitalism like whats happening with healthcare/insurance costs.

The republicans are starting to care more (or at least pay lip service) for
the working person but neither party is fully committed.

------
nof1
Cadillac plans getting taxed?

------
notadoc
The American health insurance and payment system is a huge mess and is only
getting worse.

------
sarcasmOrTears
Open the market. Liberalize the selling and buying of healing goods and
services. Abolish patents. You can even keep some certification of ability and
quality, as long as they're on point (no 6 years training for stitches),
specific, free and unlimited in number.

Put current psychopats behind the medical industry under death penalty as a
warning for future generations. Seems harsh but they killed hundreds of
thousands, maybe millions, and all for unjust profit. They deserve it.

80% cancers cured in max 20 years. No more threads on hacker news about people
going around like dogs begging for a decent diagnosys. Stem cells for every
need at costco, top quality. Problem solved.

------
patientplatypus
So many healthcare deniers in this thread. This is, what, the second or third
_presidential election_ we've had where the central debate is about the
skyrocketing cost of healthcare? Government healthcare has been shown to work
in multiple other countries with lower costs, but I guess we can't let facts
get in the way of HURF DURF SOCIALBISM HURF DURF.

If only your local MD could cure criminal stupidity.

------
british_india
My BCBS plan has a $4,000 deductible per insured person per year.

------
tastygreenapple
Maybe things would be better if people paid for their own health care? Having
workers pay for their own healthcare along with the healthcare of those who
are unwilling/unable to work just means that things are going to be expensive
for workers.

------
bdcravens
Because medicine isn't paid for as a government-provided service. Insurance
companies exist to profit - they defer risk. It is not a public service. I
have a pre-existing condition, and I have a very mild case of Cystic Fibrosis:
my healthcare at market costs about $500k a year. There's a lot of nuance to
how much insurance companies actually pay out, etc, but looking at it in a
simplified manner, it takes 25 families at $20k in premiums a year (with no
claims to pay out) for them to break even on one of me.

tl;dr Health insurance is a for profit product, not a public service.

~~~
arcticbull
Time to change that! :)

~~~
bdcravens
No doubt. The tough questions are around where will the sacrifices be made?

~~~
arcticbull
Marketing, claims denial, billing and executive compensation budgets that
together amount for 20% of the expenditure of an average US insurer after they
were legally capped to that level.

~~~
bdcravens
Even eliminating those expenses doesn't really help much. It just changes the
numbers in the headlines. $16k in premiums is still tough for most US
families.

~~~
arcticbull
It’s still $0.6 trillion dollars saved per year, and a solid place to start.
There’s all sorts of other places that a socialized system saves of course.
This would at least make the US no longer far and away the worlds worst.

Bringing everyone under a single umbrella should reduce everyone’s cost of
coverage to the per capita cost, $10K (now $8K after savings). Then as a
progressive tax system yields costs that scale according to your income the
least able to afford it pay much less than that and the most able pay much
more. Done and done. This is what the rest of the world does, no new ground is
being broken here.

------
baggy_trough
If you think health care is expensive now, wait until it's free.

~~~
ceejayoz
We’re just gonna pretend Europe, Australia, Japan, Canada etc. don’t exist?

~~~
baggy_trough
Those countries are smaller and most likely have more functional governments
than the United States. Having a dysfunctional government is a feature, not a
bug, but it does mean that the national government would do a bad job running
the health care system.

~~~
ceejayoz
Germany's nearly 90 million people. What about a 90 million person health
system can't be done with 300 million? At what point does this magical
impossibility kick in?

