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Why Medical Bills Are Killing Us (2013) [pdf] (uta.edu)
71 points by ScottBurson on Nov 14, 2016 | hide | past | web | favorite | 89 comments

Here's an in-depth article explaining it:


tl,dr: it's because people who incur the costs are not the people who pay for it.

That's a thoughtful piece, with some interesting suggestions toward the end. Your "tl;dr" is not inaccurate, but I hope people will read the whole thing.

If anyone is interested, you can look up what single payer costs[1] are for various procedures in Australia, you can pay more than what is listed if you go private, but it still isn't anywhere near the cost of what procedures cost in the USA.

[1] http://www.mbsonline.gov.au/internet/mbsonline/publishing.ns...

Can you get a private MRI without a doctor's requisition in Australia? I know in Canada they try to burn you at the stake if you do that.

Why would one get a private MRI without doctor's orders?

Because you don't have claustrophobia and you're interested in what the MRI might show.

Why should curiosity be covered? A similar scenario involving car insurance, and curiosity of "what's inside", would surely be considered fraud.

It doesn't need to be covered just don't try to restrict me from diagnosing my own health when doctors have shown their shit at diagnostics

Why did the patient in the first story absolutely need to travel from Ohio to Texas for treatment? Isn't medical knowledge shared between providers?

Some of the blame in many of these situations should fall upon the patients for choosing the care they did. Especially when it is a planned operation. I haven't finished reading the whole article, but so far it doesn't seem to be considering this point. I don't wish to defend the existing system in any way, but these providers just seem to be giving people what they ask for.

I used to work at M.D. Anderson and I can attest to their quality of care. People travel from around the world to receive treatment, for good reason.

Also, my mother was a patient there. She started treatment just a couple of months after I got my job actually. She's still doing well years later, and is glad she waited an extra month to get into M.D Anderson. The decision to wait was excruciating though.

But...Ohio has Cleveland Clinic, Case Western University Hospital, Ohio State Medical Center...it is not like it is a total medical backwater. Cynically, Cleveland Clinic has an InterContinental hotel inside the hospital for visiting dignitaries/medical tourists...

Definitely not - but in cases where healthcare is involved, especially cancer, people are motivated to travel to what is considered the best. In cancer's case, it's the big three: MD Anderson, Sloan-Kettering, or the Mayo Clinic.

One more data point: Our pediatrician has always been great and keeps up with new treatments and such. When her husband was diagnosed with cancer, she said immediately they were leaving Iowa to get better cancer care. That said a lot.

The reasoning seems pretty cut and dry as well in consideration with cancer - the patient wants to live, and is likely going to be spending tens of thousands of dollars on care already - what's another few thousand to relocate and live where the best care is available?

You seem to have some firsthand knowledge of the situation, maybe you can help me with the question I posed earlier.

This medical center in Texas seems to be providing a great level of service. I am wondering why patients need to attend directly to get this level of care. I thought that medical findings were published in journals and shared among professionals in the field.

If M.D. Anderson has a dozen (or a hundred) doctors that are experienced in the treatment of certain diseases, why aren't they sending half of those doctors out to other parts of the world to spread that knowledge?

Your questions are very good, and I answer them below briefly in the interest of expediency, not to be rude.

1. Some knowledge is shared in journals; most knowledge isn't published until years after it's established. Much is never published, and is learned through word of math, and institutionally encoded. MD Anderson is world-renowned for being a center for excellence in cancer care.

2. Doctors don't read every article published in every journal related to their work. Even if they did, or read much of it, synthesizing into practice is a very different (and difficult) matter. Many of them don't read at all.

3. Why would MDs want to be send worldwide? And why would MD Anderson want to send them all over? Who pays for this? How can a doctor affect change in a large hospital system?

I think the systems of institutions and people that treat cancer reflect the complexity of the problem itself. The research atmosphere and constant professional development are just as important as individual bedside interactions.

That said, all of the hospitals mentioned here are doing amazing things every day, and finding the best place for treatment really does come down to the specifics of each case.

Someone I know was diagnosed with cancer. In Oklahoma they were prescribed a treatment plan. They went for a second opinion at MD Anderson. Anderson said that plan was dangerous and very well might lead to a bad outcome. The Oklahoma team said MD Anderson's plan would lead to a bad outcome. MD Anderson gets tougher cases and has the best overall outcomes of any hospital in the world so they went with them.

They're fine now and the standard of care at MD Anderson is mind blowing. At MD, a nurse comes in to draw blood and the whole routine is an organized set of steps. If one step changes, they throw away the kit, wash their hands and start over. In Oklahoma nurses just kind of did things however they wanted and gloves seemed more to protect them from the patients than to protect the patients from an accidental infection. There was just zero comparison in the overall standard at MD Anderson. Add in their outcome averages and the question becomes why wouldn't someone travel from Ohio to Texas.

The medical system should choose the most viable care for them. They are not meant to be experts in this stuff, right?

Speaking as an extremely pro-Capitalist person, this is the kind of area where Government interventions are required. Capitalism and fair markets require a few basic things:

- Informed consumers (most consumers of healthcare either don't know enough about it to make any solid judgement) - Competition (most hospitals in any given area are grouped together and rarely compete, if at all) - Choice (if you're in an ambulance, you can't exactly instruct the EMTs to take you to 'the better hospital'), plus when it comes to niche treatments like chemo, there often aren't any choices, just the closest one to you that offers the service you need.

And again as a Capitalist: You take a high value, required product, mix with a group of consumers who don't have a choice whether or not to buy, and a business minded person with no ethical compass whatsoever and you'll have record profits and screwed customers. Simple as that.

As a person who consumes capitalist medicine in India, I don't see how any of your issues are fundamental to capitalist medicine.

There is plenty of competition among hospitals. You can choose which one to go to (from an ambulance or any other time). Customers are strongly price sensitive and prone to comparison. There are plenty of choices as to where to go.

Assuming I'm well enough to travel, I'll always fly to capitalist India to have my medical work done.

And again as a Capitalist: You take a high value, required product, mix with a group of consumers who don't have a choice whether or not to buy, and a business minded person with no ethical compass whatsoever and you'll have record profits and screwed customers. Simple as that.

So do you believe that Indian doctors/other medical types are just vastly more ethical than the (very often Indian) doctors in the US?

I can't comment on India's medical system, never used it and never really researched it. However:

> You can choose which one to go to (from an ambulance or any other time).

In theory, yes, in practice, it's a little harder. I mean if you were just in a car crash it's not a guaranteed thing that you're going to be capable of speech, let alone coherent enough to make your choice. And more importantly you shouldn't have to, your concern at that moment should be "put my head back together please" not "is this lifesaving treatment going to cost me my home."

> So do you believe that Indian doctors/other medical types are just vastly more ethical than the (very often Indian) doctors in the US?

This is not American doctors doing this (or at least, not the topic of this article): This is American businessmen who have no background in medicine that are making these decisions.

I mean if you were just in a car crash...

So in that case, lets have $YOUR_FAVORITE_SYSTEM for emergency medicine and capitalism for the rest. The vast majority of medicine consumed is not consumed in an emergency situation.

This is not American doctors doing this (or at least, not the topic of this article): This is American businessmen who have no background in medicine that are making these decisions.

So are Indian businessmen with no background in medicine more ethical?

The examples in the article are before ACA. Both prices and insurance availability have changed since then.

No doubt, prices have gone up even more.

I came across this last night and stayed up too late reading it. It's a fascinating exposé of where at least a good part of the money is going -- the extra money that we Americans spend on health care that doesn't bring us any better outcomes.

I think it's relevant to HN because a lot of us with families and/or in middle age can't risk quitting our jobs to start startups without assurance that we'll be able to buy adequate health insurance at a price we can afford -- and every dollar counts in a startup. I know I've seen people post here that Obamacare was an enabling factor for them, and it's now obviously at risk. So the policy discussion about what it should be replaced with is very relevant to us.

This piece, along with others I've read recently, suggests to me the following overview of the problem:

() The market for health care services is highly distorted. Not only is there no price transparency, but patients don't even have the authority to make purchase decisions on their own behalf -- that's done for them by the doctors. To the extent patients have any say in the matter, they are unlikely to be in an emotional state conducive to hard-nosed negotiating, if there is any urgency to the matter at all.

() Multiple special interest groups have gotten themselves politically entrenched. The service providers may be the most successful of these, but there are also the insurance companies and the malpractice lawyers. The amount of money flowing through the system supports armies of lobbyists, who have compromised legislators of both parties.

() There are no easy solutions here, no free lunches. You can’t have all the good parts of an unregulated insurance market (freedom to buy what you want, when you want, with market pricing) without the bad parts (steadily rising premiums and insurance that is unaffordable for people who are old and sick). At the same time, you can’t have all the good parts of a socialized system (universal coverage at affordable prices) without freedom-reducing mandates and regulations and large doses of subsidies from some people to other people. [0]

So, HNers, what's the solution? Would love to hear people's thoughts.

Personally I can't resist fantasizing that Trump will come to the same conclusion I have: single payer is the only solution. It would be like Nixon going to China. Trump (whose election I vigorously opposed) is unencumbered by considerations of who donates how much to which Congressional campaigns. And for all his flaws, he's a hell of a salesman. If he gets it into his head that this is the solution, it could really happen.

A pipe dream, I know. But would you like to see it? If not, what do you think would be better?

[0] https://www.washingtonpost.com/news/wonk/wp/2016/11/12/donal...

There's hundreds of things that can be done to chip away at them.

A pet peeve of mine is certificate of need laws:


The notion is to reduce capital expenditures and save costs, but they are a big part of why the hospital in the article can get away with charging so much for cat scans -- there's no competition. Of course it is going to be difficult to go to an outside imaging center during an emergency room visit, but when the outside imaging center advertises $500 prices, the patient will at least know there is something a bit fishy about the $3000 bill from the hospital.

They probably make a lot of sense for something like an ER, where there is a high up front cost and a lot of staffing costs and you can make reasonable predictions about demand. They don't make any sense for equipment that only used to be expensive.

Seems like what you're saying is, we're damned if we do and damned if we don't. If we allow hospitals to build out as much as they want, they'll be underutilized and will have to raise prices to cover their capital costs; if we restrict them with CON laws, lack of competition will allow them to raise prices anyway.

Given that, I don't see how CON laws are either the problem or the solution. The problem seems to be more that patients just have no leverage to negotiate with providers.

I acknowledged that some; I'm pretty sure they shouldn't apply anymore to CT machines. Creates a profit center for the hospital with little or no offsetting benefit to the public.

Whole hospitals is harder to say, but build out will be treated like any other investment, not done willy-nilly, and a hospital going out of business is probably better over the medium term than a hospital being propped up by limiting market entry.

There are good reasons to maintain levels of service geographically, but for stuff like that we should be doing direct grants, not obstructing markets and hoping it works out the way we want.

A great book on this is Healing America by T.R. Reid, who saw doctors in eight countries about his bum shoulder and wrote about their healthcare systems. Interestingly, single-payer isn't the only good option, or even necessarily the best.

Canada was the only country with single-payer like we talk about in the U.S. The U.K. is single-payer but also single-provider, the doctors work for the government-run healthcare system.

But the best results were in France, Germany, and Japan. They function a lot like Obamacare (multiple insurance companies, though all non-profit, and mandates to buy insurance). However, they add several critical features:

- Government controls on the price of services. Doctors make a lot less money than in the U.S.

- No claim denials allowed for anything on the national price list. If a doctor prescribes it, prompt payment is guaranteed.

- Good digital medical records.

According to Reid, a lot of German doctors don't bother hiring office staff. They swipe your medical card, get all your records, prescribe what they want, and get paid in a week. They can charge less because their costs are lower.

At least one of those countries also has subsidized tuition for medical school, I think Japan. Japan has the lowest costs (only 5% GDP on healthcare, with great outcomes despite an aging population of smokers), and the tightest cost controls; e.g. they make do with simple MRI machines without a lot of bells and whistles, but they do the job, and an MRI costs $100. Japan implements their mandate in an interesting way: you're free to not pay, but if you go to the doctor and you want it covered, you have to pay your back premiums.

Anyway, it's a fascinating book if you're interested in this stuff.

I've never been to a doctor in Germany that doesn't have office staff (though I suspect that it would be possible). You still need someone to deal with incoming calls, organizing the file cabinet and looking through the insurance rule changes of the week. Usually this is done by people who do limited medical work on patients as well (think nurse). Having one employee per doctor is not uncommon.

Doctors only send their bills once every three months and payment takes a while after that - a week would be a dream. Insurance can deny payment if they determine it wasn't medically necessary (and they do checks if they find a trend) but that comes out of the doctor's pocket. And for expensive things (like psychotherapy or dental) it needs to be preapproved by the insurance but they are are very limited in what they can deny.

And good digital health records? I don't think I will live long enough to see that in Germany. The only thing that leaves your doctor's office digitally (within they are free to work with paper or computer or whatever they wish) are the procedure and a short code for the diagnosis. If you need to see a specialist, paper still gets send around.

Edit: I just read the Germany chapter of that book. While it contains some (not really significant) errors and is a bit outdated (now six years old) I would still recommend that book based on this chapter.

> Japan implements their mandate in an interesting way: you're free to not pay, but if you go to the doctor and you want it covered, you have to pay your back premiums.

That's a brilliant solution!

Routine medical care should be like food and shelter: something you are expected to pay for yourself. That would put price pressure on providers. Insurance should be a backstop for catastrophic accident or illness. It should be sold by competing local and national providers. It should be untangled from employment as a benefit. You should buy it like car insurance.

Obama, Trump, Clinton. senators, representatives -- none (or very few) of these people have any medical background and really can do little else but screw it up as badly as if the government was the single provider of all software.

Maybe it should be that way, however in practice it doesn't work. The ACA specifically requires free preventive services because research has shown that when patients have to pay they often skip it. And when they skip preventive care that causes the spread of infectious diseases, and allows small problems to turn into serious problems that are more difficult and expensive to treat. So this is important from a public health standpoint regardless of concerns over economic efficiency or personal responsibility.


Preventative care that actually works is super cheap and not controversial (mostly vaccinations). This idea that we can save vast sums via preventative care is a fantasy. You may find anecdotes to support it, but the serious literature doesn't bear it out.

> Preventative care that actually works is super cheap

The same's true about car maintenance, but plenty of people drive on dying brake pads and stretch oil changes anyways. A hundred bucks for a checkup is still more than many folks are willing to pay. As an example, here's a kid who died for want of a $80 dental procedure: http://www.washingtonpost.com/wp-dyn/content/article/2007/02...

> not controversial (mostly vaccinations)


Well they usually want to do more expensive procedures along with the dental extraction. I've been delaying mine a bit because they want to take it out then put in a bridge, which will cost $1800 (normally $6700, but I have good dental insurance). In fact the extraction will be free, the cost is all in the bridge. But now you've got me paranoid again. Damn.

from a personal standpoint i often skip preventive care even if its free. I am either just lazy or scared my doctor will tell me something bad.

I agree with this. Obamacare should have created rules for a national minimum policy, largely targeted at catastrophic incidents. Remove the ability of employers to buy coverage for their employees (a holdover from WWII staffing shortages) and let be more open and market driven.

We also need to reform pharma. When even K-mart has a pharmacy it shows how much money could be removed there.

Lastly, we need to change our perspective about aging. If you live long enough, you will (most likely) get cancer. This is how the body works, not specifically a "disease". We need to stop paying $1M for the 75 year old who gets brain cancer so that they can live for 2 extra months. Feel free to spend your own money but Medicare won't. They already have laws like this in France, etc.

> should

and minimum wage should be enough to live on, housing should be affordable a reasonable distance from where you work. but for some strange reason, the world doesn't work that way.

I suspect many will skip it entirely...there was a reason car insurance was made mandatory.

Relevant quote from the article re: what an effective solution needs to achieve:

>The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market. Congress has given Medicare that power when it comes to dealing with hospitals and doctors, and we have seen how that works to drive down the prices Medicare pays, just as we’ve seen what happens when Congress handcuffs Medicare when it comes to evaluating and buying drugs, medical devices and equipment.

> Stripping away what is now the sellers’ overwhelming leverage in dealing with Medicare in those areas and with private payers in all aspects of the market would inject fairness into the market. We don’t have to scrap our system and aren’t likely to. But we can reduce the $750 billion that we overspend on health care in the U.S. in part by acknowledging what other countries have: because the health care market deals in a life-or-death product, it cannot be left to its own devices. Put simply, the bills tell us that this is not about interfering in a free market. It’s about facing the reality that our largest consumer product by far — one-fifth of our economy — does not operate in a free market.

The article's list of actionables seem like a good first step:

> We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them.

> we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000

> We should outlaw the chargemaster.

> Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head.

I agree with most of this, but

> We should outlaw the chargemaster.

I don't know how that would work. My thought was to require it to be published.

That's when we built pricepain.com in 2013 ... The article definitly inspired several efforts to allow market forces to operate by facilitating price transparency.

Or rather the chargemaster should at least be based on the price you could purchase an item on Amazon.

How about capping the salaries of doctors at, say, 100,000 and nurses at 60,000? US salaries in health care are incredibly high. Administration and the like could be capped at the nurse level. Only a very small minority could realistically get higher paying jobs outside the US anyway. If your main motivation is to make a lot of money, choose a different career.

Also, cap profits to almost zero while moving to a completely not-for-profit system.

Capping admin salaries makes a lot of sense. Maybe not at nurse level, but at doctor level for sure.

Capping doctor's salaries at $100,000 is probably a bad idea. Some cap might make sense, but definitely not $100,000.

$100,000 may sound like a lot, but keep in mind that US doctors take on a lot of debt -- both actual and in terms of opportunity cost. And they also take on a lot of personal risk up until the point where they become doctors. And sometimes even after thatn.

So you're not really saying that should make "around what a software dev makes". You're actually saying that doctors should make significantly less than your average software developer.

Driving smart and driven people away from medicine doesn't seem like a great idea.

The idea that Trump is unencumbered by campaign contributions is a pipe dream, because he has to buy the loyalty of Congress in order to pass laws, and they are more encumbered than ever.

It is immoral for someone to profit from denying someone healthcare. As I see it healthcare is a scare good and the Canadian system is the way to go. But socialism and all that... won't happen in the U.S. any time soon.

I'm for single payer but it will never happen until Democrats get the White House and congress. Paul Ryan is planning on privatizing Medicare asap

The public option was removed from the eventual Affordable Care Act when it passed in 2010. The Democrats did have both houses of congress and the white house at the time, but that part of the law was brought down by a filibuster threat from a small group of 'blue dog' democrats. Had it passed, it would surely have been a trojan horse for universal coverage.

The public option had the support of all 59 Democrats. It was Lieberman, an Independent who often voted with the Democrats, who got the public option removed.

I don't know that Paul Ryan's opinion matters too much at this point.

I also am not sure the Democrats could do single-payer even if they had the White House and Congress. They take plenty of money from the special interests too.

The democrats couldn't do it when they had WH and Congress... they had to go with Plan B - "Obamacare".

Personally, I believe that Plan B was written to fail. Government creates problems. How do you solve the problem? More government.

Obamacare, imho, was created as the groundwork for single payer. I just don't think they expected it to fail so hard and so fast.

I have no faith in single payer... for example, look at the VA. Months of wait times for those who need the help... while those at the top get lavish bonuses.

Single payer works well in many places other than the US.

People on private insurance plans in the US die or suffer while waiting for care their plans allegedly offer, while executives of those private insurance companies get "lavish bonuses".

The US is the wrong level of government for a healthcare system. If a place like California wanted to offer free healthcare to its residents, that's fine, but the federal government should only be responsible for war, negotiating trade deals, handling immigration, and other external issues.

Keep in mind that "many other places" are smaller than a single US state.

Your view went out of fashion with the Articles of Confederation; the ultra-limited "only for a handful of external-facing issues" federal government was an abject failure.

Consider that Californian's pay about $290 Billion to the Feds and the state collects about $70 billion. Do other small countries pay most of their taxes to a larger central organization? Much of that Federal money gets shunted to other states.

For consistency, I also support repealing the 16th amendment and removing the interstate commerce clause. Then California would have more direct control over its citizens' tax money.

Why stop there?

You seem to want not a nation of 50 states, but 50 completely independently sovereign nations which will somehow miraculously also agree to cooperate on the handful of things that you personally feel they should.

This has been tried, and failed, and was replaced with the Constitution we have now.

The reality is in the middle. We are ONE Nation AND FIFTY Nations.

> which will somehow miraculously also agree to cooperate on the handful of things that you personally feel they should

That's what the constitution is for... it states what the Federal Government does... everything else SHOULD be state issues.

Those clearly drawn lines have been eroded over the years and is one of the larger points of contentions between the "Constitutionalists" who think that we should have a government actually limited by those rules... and those who think the government has all the answers and should have no limit

At one time it was more common to use "These United States of America" and "the United States are …"


the people who die, i assume are the ones that cant afford that care and need to knoww beforehand its going to be completely covered?

Plenty of things require referrals and authorizations and those can be processed at a glacial pace, yes.

Check out healthcare costs by age:


Hence the importance of research into life extension technology combined with provision of assisted suicide for those who wish to die.

That's spending though right?

Part of what the article is saying is that spending isn't a great proxy for cost.

These debates about insurance and payment models are important, but still ignore the biggest issue. US healthcare expenses increasingly go to treating conditions caused by poor lifestyle choices: obesity, substance abuse, and sedentary lifestyles. Certainly there are ways to cut waste and shift costs around more equitably but unless we can improve those root cause factors we're only going to be kicking the can down the road. At some point we just won't be able to provide effective care to everyone regardless of who's paying or how much providers cut prices.

Even countries with socialized medicine are going to run into the same issue. Canada and the UK are only slightly better off in those lifestyle choice factors than the US, and their trends are moving in the wrong direction.

The root cause is aging. You can exercise religiously and never touch sugar, and at best that will result in racking up huge medical bills in your eighties rather than your sixties.

Also if you die in your 80s you will have collected way more social security money then if you die in your 60s. I wouldn't be surprised if things like smoking which tend to kill you right before retirement age actually saves us money as a society.

>US healthcare expenses increasingly go to treating conditions caused by poor lifestyle choices: obesity, substance abuse, and sedentary lifestyles.

Nice rhetoric, but source?

Current insurance plans don't help much with preventative care. While a yearly 'physical' involving an 8 minute talk with a doctor is covered, insurance only pays 10% of lab work and a basic blood panel would cost me $900. Checking things like vitamin D levels aren't covered at all.

Please clarify "Current insurance plans" - Current ACA insurance plans? Because I just checked my recent physical including blood panels and, yes, Vitamin D levels, and all I paid was a $15 copay.

The plans can vary, they just have to cover standard set of things:


Lab tests aren't on the list. So your plan probably has some additional stuff that it covers.

Victim blaming and false. End of life medical treatment (I wouldn't call it "care") is an enormously expensive and often ghoulish practice.

I think MRI's are a great example of the costs.

An MRI machine used on average 10 times a day for 10 years can do 36,500 scans at the cost of ~3 million for the machine. 3,000,000 / 36500 ~= 82$ for the machines time. (Clearly more if it's used less often, but also clearly not 500+$.)

This is a case where the actual cost has almost nothing to do with the machine it's all about manpower + some consumables. So, what's the manpower actually doing? A huge chunk of time in the US is simply billing aka waste.

Does that $3 million also include the expertise needed to operate and maintain the machine? You also need to account for the money the hospital needs to save to buy a new one when the one they have becomes outdated. Still might not add up to the actual cost they charge for a scan but it would look a bit more reasonable. My guess is the different negotiated rates for insurance plus the low income policies make everything convoluted and add a decent amount of overhead. I wish they would stop this negotiating crap and charge whatever it costs for them to do a scan. At least then I will know how much it will cost upfront.

It's perhaps more stark with the CT scanners mentioned in the article.

They pay off the capital cost in 1 year. If you figure they need two imaging technicians on site 24 hours a day, the labor to staff the machine is roughly 6 * $200,000, or $1.2 million per year. If they average 1 scan per hour (a scan can take as little as 5 minutes), the labor cost of those techs is $140 per scan.

If it costs more than $1 million dollars to service the machine per year (the machines cost less than that new), the service cost is $140 per scan.

Hospitals routinely charge $2000+ for CT scans.

It is good to live in a country where I only spend 50 euro per month in taxes for all the care I could need! Its great to be in the first world!

On average the Spanish pay $223/month on health care, not $50. Spain has a $GDP/capita of $30k and spends 9% of GDP on health care.

I hope you have a spanish pay slip (like I do) to see the figures for yourself. That, or you make a LOT of money.

The thing is, most people dont need to spend 50 euro per month so millions of people pay in order to not be left out the system if they need it. I need it when I was a kid, so now I pay gratefully.

In my opinion health welfare and security is a problem like the 'Three prisoners problem' where collaboration is better for everyone in the end.

What's the country?

Most of Europe

Monthly rates vary though. In the Netherlands you pay €90 or so a month for (mandatory) health insurance, with a €350 a year deductible. Low income households do get partly subsidized by the government of course.

The Netherlands spends ~$5200/pp on healthcare[1]. Where does the rest of the money come from?

[1]: http://www.who.int/countries/nld/en/

Taxes withheld from salary, just like ainiriand mentioned. In The Netherlands (and most other European countries) you pay for insurance directly (which here includes a mandatory basic plan that can be expanded to include things like full dental) and via taxation of income.

That link was confusing - I was expecting some research from UTA (The University of Texas at Arlington), but apparently it's an article from Time magazine that a UTA professor published on his personal web site.

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