
The Amish health care system - bookofjoe
https://slatestarcodex.com/2020/04/20/the-amish-health-care-system/
======
tathougies
I thought the most interesting part was the commentary on non-Amish care in
the past

> I asked my literal grandmother, a 95 year old former nurse, how health care
> worked in her day. She said it just wasn’t a problem. Hospitals were
> supported by wealthy philanthropists and religious organizations. Poor
> people got treated for free. Middle class people paid as much as they could
> afford, which was often the whole bill, because bills were cheap. Rich
> people paid extra for fancy hospital suites and helped subsidize everyone
> else.

In other words... allow rampant inequality in the healthcare system. The rich
would pay for their designer surgeries, and let that subsidize the rest.

~~~
pmiller2
That inequality is still present, except that now, the system is:

* Poor people either get hit with huge bills because they're uninsured, or, if they know how to navigate the system, sometimes get these bills written off through "financial aid."

* Middle class people frequently have insurance, but get hammered by deductibles and out of pocket maximums, rarely qualifying for "financial aid." This can be ruinous.

* The rich still get what they want.

If the rich are "subsidizing" things anymore, it's not to a great enough
extent to benefit the poor and middle class. The system has been broken over
the past 40 years by medical and insurance costs that have risen much faster
than the rate of wage growth for the average worker.

~~~
specialist
I currently believe rising administrative overhead accounts for most of the
cost increase. Single payer is a straightforward proven solution.

Switching from fee-for-service to prevention (capitation) would give us
another 25% savings.

But I'm newly interested in notions related to cost disease. Am keen to hear
anything anyone has to say about mitigation.

~~~
ineedasername
The biggest administrative costs in health care are the insurance companies'
costs. [0] To the tune of more than $200 billion dollars/year.

[0] [https://time.com/5759972/health-care-administrative-
costs/](https://time.com/5759972/health-care-administrative-costs/)

~~~
AzzieElbab
You have to be able to see that the numbers do not add up, right? 200b is how
much out of 3+ trillions? Also, just because Canadian adminstrative costs are
hidden, does not mean they are proportionally lower than in the US

~~~
lippel82
What do you mean, the numbers don't add up? From the article: "Insurers’
overhead, the largest category, totaled $275.4 billion in the U.S. in 2017, or
7.9% of all national health expenditures, compared with $5.36 billion in
Canada, or 2.8% of national health expenditures."

~~~
AzzieElbab
What I meant is that if insurance costs disappear completely, US healthcare
will remain 5 times more expensive than Canadian. It is percentage based
markup on already super overpriced system. Therefore, real reasons for why it
is so expensive are elsewhere

~~~
specialist
Thanks. I've reluctantly come to agree with your conclusion. There is no
silver bullet.

Repeating myself:

Another low hanging fruit is transition from free-for-service to rewarding
wellness (capitation). Some are already doing this.

I'd like to understand if, how, why cost disease is a factor.
[https://en.wikipedia.org/wiki/Baumol's_cost_disease](https://en.wikipedia.org/wiki/Baumol's_cost_disease)
I have zero understanding, intuition about this. Feels like black magic. But
some of the experts I've read say it's important.

There's no shortage of management efficiency and quality of care innovations
to explore. In the spirit of Atul Gawanda's book Better, like specialized
clinics for cystic fibrosis, diabetes, and whatnot. And whatever we're calling
people traveling for procedures. Like USA people going to Thailand and Mexico
clinics.

USA's R&D and regulatory overhead (FDA) carries the world. That first adopter
expense might be easier to accept if the accounting was transparent.

Any way.

I designed, implemented, supported 5 regional healthcare exchanges. Even in
our little corner of the problem space, there was so much room for
improvement. Alas, most of it was prevented, because our participants were
competitors, so the incentives were all wrong. A single payer system (or rough
equivalent) completely moot most of those roadblocks.

------
motohagiography
Why does nobody look at the medical profession as the racket it is? You don't
need to be an MD to handle %80 of hospital visits, and you can train trades
people to handle most emergencies.

Insurance companies are awful, but seriously, we can train field medics to do
stitches and set bones, why should it cost $3000 to have an MD do it?
Listening the hand wringing about it is infuriating when you realize that the
reason you have to wait for simple procedures that barbers used to do is
because there is a med school bottleneck.

~~~
amiga_500
Other countries have fully trained doctors yet they don't have this problem.
Therefore fully trained doctors setting bones is not the problem.

It's another problem or set of problems that occurs in the USA.

~~~
anon09809809
The 250k+/year US salary of the fully trained doctor setting bones could be a
problem. Many doctors are paid significantly less in many of those other
countries.

~~~
gowld
It's not, though. It takes under an hour to set a bone, so that doctor's time
is not driving the expense.

~~~
new_time
Why do I need to see a doctor to get a mole or skin lesion checked? Why is it
necessary for someone to go through 4 years of undergrad, med school, etc etc
just to examine a mole and remove it with a scalpel?

~~~
cmendel
Are you trolling? Are you legitimately asking why you need a doctor to check
something that might be, amongst the million other possible complications,
Cancer?

~~~
HPsquared
The mole-specific training is probably a couple of months, max (if that's all
the person needs to do). Division of labor.

------
lordnacho
I think what he's getting at is the concept of a "trustful society".
Essentially one like the Amish he describes: people act responsibly with the
community's money.

You might well think this has broken down in America. There's both a lack of
formal restraint in the form of laws holding down the price, like in the Swiss
private health system, as well as a lack of informal rules like he's
mentioned, preventing people who've hit their deductible from going nuts with
their treatment. And the culture of suing doctors has led to even more issues.

The trustful society thing is interesting. A friend of mine lost a grand-uncle
in Denmark a couple of years back. Now this guy had grown up before the
welfare state, and took pride in not taking handouts that he didn't need. He
lived on a family farm on an idyllic island called Bornholm. When he died, the
authorities called and asked what to do with nearly 2M DKK of pension money he
hadn't collected.

At the other end, you get people growing up having never seen what preceded
the welfare state. You often get debates about whether the kids are spending
their student allowances wisely, because obviously you see them around town
and they are having a good time. This is a cash grant from the government that
you don't even need to use for tuition. Are they being profligate with the
state's money? It's a debate that keeps going.

~~~
pdonis
_> The trustful society thing is interesting._

Yes, it is, but it doesn't scale. It only works for communities that are small
enough that everyone can keep track of the trust relationships and how well
everyone is honoring them. The problem we moderns have is that many of us
either don't want to live in such a community (even Scott notices this when he
says there is something to be said for not having your neighbors judging your
lifestyle all the time) or don't have access to one. So we have a different
set of priorities, and we therefore have to make different choices and
tradeoffs.

------
zucker42
Is comparing the per capita cost of healthcare to that of U.S. really fair,
especially when advocating adopting certain elements of the "Amish system"?
The U.S. is pretty _the worst_ example of keeping costs down; other first
world healthcare systems cost much less than the U.S.'s with similar or better
outcomes. I suppose it's reasonable because the Amish live in the U.S. but I
guess the question is do the Amish do particularly well or does the U.S. just
generally do particularly poorly?

I do think there are some interesting insights in the article though.

Edit: another observation is that the author is probably not putting enough
emphasis on the additional cost of end-of-life care (though he does mention
it), especially if he's correct that the Amish tend not to spend as much on
prolonging the life of older people.

------
chkaloon
This model already exists in other forms in the US. One of them is called a
healthshare. Usually a religion-based scheme where you pay in a certain amount
a month, and then you negotiate with the doctor yourself, pay the bill
yourself, and then get reimbursed by the healthshare if there is enough pooled
money.

This does a number of things:

1) It puts patient skin-in-the-game in that they have the direct incentive to
shop around and/or negotiate lower bills since they have to front the cost.

2) it removes the costly middle-men referenced in this article and all the
administrative cost that goes with that.

3) It puts much more of the administrative burden on the patient because they
have to negotiate and pay, keep track of things, then get reimbursed.

These three things result in reduced monetary costs, but add other costs like
the patient's time and stress level.

Healthshares previously could only exist if they had been grandfathered in via
a special provision in the ACA. Since then enough of the ACA has been eaten
away that new healthshares are taking advantage of the resulting loopholes.

------
floren
I'm surely hopelessly naive and ill-informed for even asking, but is there a
reason a hospital or clinic couldn't operate 100% without dealing with
insurance? Do such places exist in the US? We always hear how the hospital
sends a bill for $40,000, then the insurance company argues that down to
$2000, but woe unto you if you DON'T have insurance because you'll have a hard
time getting that same deal yourself. Couldn't a hospital just... send you a
bill for $2000, and if you can't pay it you either ask about their low-income
waivers, get into a payment plan, or I guess get blackballed as a deadbeat?

~~~
bmelton
There _are_ cash-only doctors, or doctors who will accept cash as payment, and
for what it's worth, the discounts for not using insurance can be substantial.

More importantly to me though was this less-talked-about perk of having a
doctor who -- once he knows he's not just going to receive a negotiated rate
from an insurer -- will actually take a little bit longer with you and hear
out your complaints. Knowing that if you take longer, he can bill you more is
actually a net good, IMO.

~~~
La1n
>Knowing that if you take longer, he can bill you more is actually a net good,
IMO.

You can easily flip that around too. The healthcare system would become less
efficient because time spend gets valued instead of results.

------
MaxBarraclough
> Amish people spend only a fifth as much as you do on health care, and their
> health is fine. What can we learn from them?

Given this opener, it seems bizarre that the article doesn't use the word
"diet" even once. The comment there by "Scoop" seems right on.

Google tells me the USA is estimated to have around 300,000 obesity-related
deaths per year. Apparently [0] obesity is around 10% as common in Amish
communities as in the USA as a whole.

Aside: this is compared to around 35,000 gun-related deaths, around 40,000
traffic-related deaths, and around 50,000 opioid-overdose deaths. Presumably
the Amish are spared these too.

[0] [https://time.com/5159857/amish-people-stay-healthy-in-old-
ag...](https://time.com/5159857/amish-people-stay-healthy-in-old-age-heres-
their-secret/)

~~~
OrderlyTiamat
Both obesity in the "english" group and the healthier lifestyle of the amish
group are discussed by Scott in this article.

~~~
MaxBarraclough
No, they aren't. The article makes no mention of obesity, and does not discuss
the Amish's healthier lifestyle. Unless I'm missing something here? Do please
be specific if I am.

I'm seeing a single relevant sentence:

> As far as I can tell, most of the secret is spending your whole life outside
> doing strenuous agricultural labor, plus being at a tech level two centuries
> too early for fast food.

If that's what counts for improving health, why doesn't the article discuss
that, rather than discussing only healthcare? (That's not to downplay the
important issues the article raises, of course.)

I think my point stands here. There's an unfortunate trend to treat the
healthcare system as the answer to health problems, and to dismiss the
enormously important lifestyle questions. Compare the opening paragraph of the
article with what the article goes on to discuss:

> Amish people spend only a fifth as much as you do on health care, and their
> health is fine. What can we learn from them?

An article that explores what we can learn from the Amish regarding health,
should spend more than a sentence on diet.

~~~
OrderlyTiamat
I think you're right, but I'd slightly disagree.

Of course you point does stand, and diet and obesity are important topics to
discuss, and perhaps scot should have gone into (a lot) more detail. But that
is not to say that _every_ article should focus on those, it seems to me that
having articles focussing on these issued as well is not a problem.

Like you said, more than a sentence should be spent on diet.

Perhaps you and I wouldn't be having this discussion if at the top Scot had
given a disclaimer that he's only focussing on this one side of the situation
and neglecting the other side for the purposes of discussion.

------
dehrmann
> This is how I feel about the Amish belief that health insurance companies
> are evil, and that good Christians must have no traffic with them.

That's not really what they believe. Here's a better description[1]:

> Amish commonly believe that commercial insurance plans undermine the
> religious duty of community accountability

They don't pay social security tax (really, an insurance premium_ for the same
reason, and were exempted from it on religious grounds.

1:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198134/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198134/)

~~~
throwaway_pdp09
> Amish commonly believe that commercial insurance plans undermine the
> religious duty of community accountability

As an atheist I find the Amish's religious view quite attractive. Ignoring
god, it becomes plain humanitarianism and about helping each other.

Aside: I suppose one could well argue that _non-commercial_ insurance plans
would be just a formalisation of community accountability. Edit: and that's
pretty much exactly what's described in the article, only without calling it
insurance.

------
peterwwillis
Remember to question your assumptions. "The Amish health care system" is like
saying "The Christian church system". Amish communities can vary greatly, as
does their income, transportation, diets, lifestyle, etc. The only time I've
ever gone to Fogo de Chão in downtown Philly on a Friday night, a large Amish
family was eating nearby.

> For people who rarely leave their hometown and avoid modern technology, a
> train trip to Mexico must be a scary experience.

You mean when they're not traveling all over the states to do business with
the English, or carting themselves around in wagons with electric lights, or
fueling their diesel generators to power batteries to run power tools and
heavy machinery they use to create products for English customers? .... I'm
pretty sure boarding transport technology that's been around since well before
the 16th century to talk to "outsiders" is nowhere near scary to them
(especially after Rumspringa, for example).

It's easy to get into a romantic, over-simplified idea of a general people
based on some preconceived notions about them, and those can often cloud
further ideas and lead to things like cherry-picking data to support a theory
that "sounds right".

------
bluejekyll
“ The Amish have had a life expectancy in the low 70s since colonial times,
when the rest of us were dying at 40 or 50. Since then, Amish life expectancy
has stayed the same, and English life expectancy has improved to the high
70s.”

~~~
jpab
I found that curious. Why were the Amish living so much longer than others in
colonial times?

~~~
kyuudou
They lead non-sedentary lives involving manual labor, keeping their bodies in
good health. They also don't have frankenfood and tend to have actual food
instead. I'm surprised people don't understand just how important these 2
factors are towards longevity.

~~~
jessaustin
This doesn't answer parent's question. In "colonial times", most people did
physical labor and ate real food.

------
peter_d_sherman
In general, the healthcare profession could do the same double-blind studies
they do on drugs -- but on substances that are not patentable, such as
vitamins, minerals, fruits, vegetables, natural herbs and plants, etc.

They could even do double-blind studies on things that are not ingestable,
like sunlight, doing enough exercise, getting enough rest, etc., etc.

But will they, ever?

No they will not.

That's because they will not make any money if these studies are successful.

Quite the opposite.

If there is any successful study in one or more of these areas, it could very
well have negative and damaging economic impact to the medical community.

I like Doctors, and believe that most of them are good, honest, decent, hard-
working (especially now, during CoronaVirus!) people.

They are not the enemy, quite the opposite!

But we really need to think about double-blind studies on non-patentable
things that could potentially cure people, or at least alleviate their
condition in some small way.

That, and the FDA needs to allow those things as treatments that Doctors may
legally prescribe, if the double-blind studies prove successful...

~~~
grandmczeb
> the healthcare profession could do the same double-blind studies they do on
> drugs -- but on substances that are not patentable

But... they do? Pretty much everything you mentioned is well studied, although
a lot of times it’s hard to get conclusive evidence when the effect size is
small.

~~~
peter_d_sherman
Why are those things not prescribed then?

Why are only pills, pills with which pharmaceutical companies (and usually
doctors, via commission payments) make money, prescribed, and nothing else?

Maybe it's not the Doctors' fault however.

Perhaps the mindset was taught to them via most Medical Colleges and
Universities, who accept large amounts of money from big pharma to teach that
prevailing, patented-pharmaceutical-drug-centered mindset... and perhaps it
was regulated into them by well-meaning, yet exclusionary and limiting
government regulations...

I hold Doctors harmless... but they could prescribe less man-made products for
profit, and more that are made by nature for free, or pretty close to free...

~~~
grandmczeb
Because prescribing them doesn’t improve people’s health very much.

~~~
peter_d_sherman
How would this be known, without conducting double-blind studies?

~~~
grandmczeb
Again, pretty much everything you mentioned has been studied quite a bit. Yes,
even with double blind studies (e.g. [1] to pick one at complete random). Some
of the things you mentioned (diet, exercise, sleep) literally have entire
subfields of medicine devoted to them.

[1]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514135/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514135/)

~~~
peter_d_sherman
If it's been studied a bit, and it helps people's health, then why isn't it
prescribed?

~~~
grandmczeb
When the evidence says they help they usually are. Losing weight, sleeping
more, prenatal vitamins, etc, are all regularly recommended or prescribed by
doctors. But, again, the issue is that most of the time the evidence is either
inconclusive or says they don’t help.

------
foolinaround
one major reason why our health insurance is high is because of its wide
scope.

When you take car insurance, it does not pay for oil changes, tire repair etc,
since these are considered regular maintenance. If you don't do this, then
your car will fall apart faster and again, you are on your own...

Not a straight analogy, but if we make people pay on their own for regular
visits, mandate tha they must visit a doctor (their choice) etc which they pay
out of pocket -- then only unexpected events are actually covered by insurance
-- and the cost is lower.

The employer spends less, and hopefully, a substantial portion gets back to
the employee's paycheck.

~~~
maxerickson
Regular office visits don't cost much to provide.

They are sort of like paying to fix chips in windshields, if you want an
analogy.

(The actual billed cost for those sorts of visits is ~$100, which doesn't add
up very fast compared to ER visits or any sort of complex care)

------
oconnor663
> For the [non-Amish], the “other people” are faceless insurance companies,
> and we treat people who don’t extract as much money as possible from them as
> insufficiently savvy.

This is just a side comment in the post, but I think it's an important
observation. People really, _really_ don't like feeling (or looking) like
suckers. When we see other people breaking the rules, we're much more likely
to break the rules. Some of this is that we're seeing evidence that breaking
the rules won't be punished, sure. But I think the larger effect is that now
we feel like suckers for following the rules.

------
kwhitefoot
One of the most striking things in this article for me was the remark about
Amish women having five to ten children. If this is the case and if all women
have children then the Amish population should be increasing rapidly. Is it?

This page: [https://amishamerica.com/how-fast-are-the-amish-
growing/](https://amishamerica.com/how-fast-are-the-amish-growing/) says that
the doubling time is about 19 years.

How do they find enough suitable land to practice their way of life?

~~~
barry-cotter
Agricultural land is cheap and plentiful if you don’t want to live within
commuting distance of a major city. The US is really big and comparatively
empty. Wyoming is bigger than the United Kingdom and has less than 600,000
people and there are plenty of other states with an abundance of farm land.

~~~
kwhitefoot
But that doesn't seem to be motivating the Amish to move to such areas.
According to
[https://en.wikipedia.org/wiki/List_of_U.S._states_by_Amish_p...](https://en.wikipedia.org/wiki/List_of_U.S._states_by_Amish_population)
the Amish population of Wyoming was 130 last year. Mind you that appears to be
130 more than before.

It seems that, at least until very recently, they prefer to be where there are
already substantial numbers of Amish people already (quite sensible of
course). The biggest increase in absolute numbers 2010-2019 was Pennsylvania
which is also the state with the highest Amish population.

------
sct202
This article cites obesity, diabetes, and other health metrics that do not
appear to be adjusted for differences comparing different population's age
ranges. The Amish have very large families (6+ children per family) so they
have as a percentage fewer old people who have more health issues overall.

------
DeathArrow
We have universal healthcare in most parts of Europe, either founded from
taxes, either partly funded by mandatory low cost state owned medical
insurance and partly by taxes.

I think Spain has one of the world's best health care systems.
[https://en.wikipedia.org/wiki/Health_care_in_Spain](https://en.wikipedia.org/wiki/Health_care_in_Spain)

I guess US can apply the same principles. Some things might be more important
than making money.

~~~
Gibbon1
> Some things might be more important than making money.

Not to the people that run the US it isn't. They are pushing to fix the
pandemic problem by just letting a couple of percent of the population die.

------
amelius
Very interesting article. But wouldn't it make more sense to look at some
European health care systems which outperform the US in many respects?

------
bookofjoe
I just read every word of the 220 comments on this post and not once did I
encounter the word "rationing" when it came to debating the merits and
negatives of single payer. It is the elephant in the room: people pretend it's
not there by saying things like "there's a long wait, sometimes over two years
for such things as elective hip replacement."

~~~
philjohn
Except it's not rationing per se, it's demand outstripping supply. You'll
still get your elective procedure, but since it's not life-saving in the
strictest sense you may have to wait a bit longer for it.

But the flip side of that is a bout of cancer, a heart attack, baby needing to
spend a month in NICU doesn't bankrupt you.

~~~
bookofjoe
a bit longer ≠ 2 years IMHO

>But the flip side of that is a bout of cancer, a heart attack, baby needing
to spend a month in NICU doesn't bankrupt you.

>Cancer services may be rationed to those most likely to survive, says NHS
report

>National Health Service insist limited care for cancer patients is 'unlikely
scenario'

[https://www.telegraph.co.uk/news/2020/03/22/cancer-
services-...](https://www.telegraph.co.uk/news/2020/03/22/cancer-services-may-
rationed-likely-survive-says-nhs-report/)

------
adultSwim
Frightening austerity being pushed

------
daenz
>How do the Amish keep costs so low? R&D (plus a few other sources) identify
some key strategies.

>...the Amish are honorable customers. This separates them from insurance
companies, who are constantly trying to scam providers however they can. Much
of the increase in health care costs is “administrative expenses”, and much of
these administrative expenses is hiring an army of lawyers, clerks, and
billing professionals to thwart insurance companies’ attempts to cheat their
way out of paying. If you are an honorable Amish person and the hospital knows
you will pay your bill on time with zero fuss, they can waive all this.

Imagine how many social problems would disappear if people had more integrity
and stronger morals. Literally every aspect of life would improve. But
instead, we have to bulletproof everything (largely without success) from
people who scheme and scam their way through life. We sink enormous costs into
this, and it slows the progress and complicates life for everyone else.

I'm not a religious person, but the thing that the anti-religion movements
have failed spectacularly at is providing a universal, teachable framework for
basic morality. Religions, for all their faults, and for all of their
misguided morality, at least had morality frameworks that were more or less
unified and teachable. What do we have now in their place?

~~~
GuiA
_> Imagine how many social problems would disappear if people had more
integrity and stronger morals. Literally every aspect of life would improve. _

Granted, everyone in the world is suddenly moral and of utmost integrity and
everyone gets used to this new reality. The economic upside in lying/cheating
is now so high that a few minutes later the world is back to exactly what it
was, except for the first few persons to decide that lying wasn't such a bad
idea, who are now a few billion dollars richer.

 _> Religions, for all their faults, and for all of their misguided morality,
at least had morality frameworks that were more or less unified and teachable_

This is your daily reminder that the Catholic Church is the organization with
the most identified pedophiles in the world. (I'd have written "convicted",
but they work really hard - and are really good - at preventing that outcome).

~~~
LeoTinnitus
I think Islam may like a word with you on that one. There it's not just the
priests. It's very common for minors to be married off, young boys to be sold
as sex slaves (common in the turkic -stans areas although not sure about
today), and the "it's only gay if you take it" reasoning I believe in one of
the hadith's which condones pedophilia.

~~~
jessaustin
Religion was _created_ in order that priests, mullahs, etc. could perpetrate
otherwise forbidden sexual acts on defenseless people. Some later offshoots
have forgotten this, but Catholicism and Islam remember. What was the ISIS
caliphate, if not organized sex crime? It seems the Protestants favor abuse of
girls instead of boys, which in their minds is more moral...

~~~
LeoTinnitus
However life back then was incredibly different. We can look at it in
hindsight and judge it with the morality of today but that's somewhat unfair
of how life was. I mean slavery was commonplace, death sentences for most
crimes, and not really any "true" justice system.

Although as of today? Yes I totally agree.

