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Bloomberg Healthiest Country Index – 2019 edition (bloombergquint.com)
90 points by gfiorav 20 days ago | hide | past | web | favorite | 77 comments

> "Primary care is essentially provided by public providers, specialized family doctors and staff nurses, who provide preventive services to children, women and elderly patients, and acute and chronic care,"

The public healthcare here in Spain has an endemic problem of ever reducing budgets, and it's so saturated (because of that) that most people that can also get private healthcare. When politicians touch that is to reduce the budget even further.

Yet people think that the main problems in Spain are other things... damn the propaganda machine.

Indeed, the public healthcare system in Spain, while still great compared to most of the world, is a shadow of what it once was, with the rampant privatization done by the Government in the last decade. A really sad situation. That being said, decent private healthcare here is about 100€/month, so while private healthcare is still considered "a luxury" (because public one is pretty good), it's still very very far from the cost of US private healthcare.

Rampant privatization?

Spain's public healthcare expenditure[1] was:

    38.552 €bn in 2002, and
    66.678 €bn in 2016 (latest official year),
this is a 73% increase in 14 years.

On other hand while population was

    41.31 m in 2002, and
    46.48 m in 2016,
A 13% increase. This is a 53% net increase in expenditure per capita. I'm curious to know what "rampant privatization" to you means, as government/public expenditure has by no means slowed down, quite the contrary.

In my opinion, healthcare expenditure is out of control. But that is a completely different debate.

[1] http://www.mscbs.gob.es/en/estadEstudios/estadisticas/inforR...

I'm curious to know what "rampant privatization" to you means, as government/public expenditure has by no means slowed down, quite the contrary.

I don't know about Spain, but at least in Sweden there's an argument that the increase in privatization in the health care sector has resulted in higher costs (and thus higher government expenditure) without matching improvement in heath care outcomes.

Don't know about Spain, but in some countries privatization means basically that functions that used to be handled by government employees or such are now handled by private enterprises, however the money still comes from public expenditure. The idea is that private enterprises are so much more efficient than government that they can do the same job cheaper while making profit at the same time. Not many success stories for the public in those cases.

Are those numbers inflation-adjusted?

Raw expenditure tells us nothing about whether or not it has been privatised, too. Often the privatised services are more expensive - after all, they have to pay dividends.

1. the numbers are government healthcare expenditure, not private healthcare expenditure

2. CPI won't change a the bottom line take-away. Feel free to run the numbers.

1. the numbers are government healthcare expenditure, not private healthcare expenditure

Sure, but what percentage of that government expenditure is going to private health care providers? And how has that number changed over time?

Please refer to the url provided, it's there for a reason

I tried, but as someone not familiar with the intricacies of the Spanish health care system (or the Spanish language for that matter) the numbers are tricky to parse out.

So, you don't take into account inflation, not GDP per capita grow, not population ageing, but the take-away should be the same.

There is an argument made towards "rampant privatisation", i.e. a transfer of a business from public to private control. However, data shows that government expenditure has increased above CPI, the driver of prices (not an output like "GDP per capita", which for some reason you refer too as an economic driver of sorts). I cannot observe, from official data the I link to, a slow down in public healthcare investment by the Spanish government, and definitely not an increase in expenses due to the Government paying private healthcare players. Feel free to dive into the data and indicate otherwise. I'm not here for armchair politics.

The data you request (if I'm reading it correctly) is in your link, in the "2002-2016 series" document, page 9, point 3.3

The transference to the private sector in 2002 (thousands of Euros): 25017

In 2010 (the highest of the serie): 81997

In 2016: 54913

I didn't say the "rampant privatization" thing, but, as you can see, the spending more than doubled. Should we take into account the inflation here or not?

GDP per capita is, I think, important as an answer to your opinion of "expenditure is out of control" by the way.

>>"I'm not here for armchair politics."

Good to know, but until where I can see, we were discussing numbers not politics.

EDIT: I keep reading and that data is not right. The number are low, but I can't make sense of the tables. It would take a while to understand it. The good news is the data is there.

Page 6.

Page 9 is central administrative costs, and then, if we put your private expenditure figure into perspective: in 2010 (highest of the series) private costs were €82m vs €69,000m total healthcare costs in 2010. That is a 0.12%

Out of interest i did a very rough calculation of what inflation-adjusted numbers might look like. I pulled 4% per year inflation out of my ear, and came up with:

    38.552 €bn * 1.04^(2016-2002)
    66.76 €bn
..which is uncannily close to your numbers. Inflation probably wasn't exactly 4% YoY, but if it is, then in real Euros, the expenditure per population has decreased.

The average inflation was closer to 2% according to https://www.inflation.eu/inflation-rates/spain/historic-infl...

That plus a roughly 12% growth in population over that range.

Please be a bit more serious, change rate between 2002-2016 is closer to 30%. If you want to make up numbers and conclusions be my guest. I'm not here to play Trump-mathematics

Privatisation has nothing to do with reduction in government expenditure on healthcare: it's merely about where that expenditure goes.

As far as I've seen, privatisation seems to normally lead to increases in government expenditure: the US has the highest per capita federal health budgets in the world (and Switzerland, in second place, is far behind)

When you compute per-capita expenditure in 2016 Euros, it's a rather more modest 20% increase.

€1191.25 per capita in 2002.

€1434.55 per capita in 2016.

The US has the highest healthcare expenditure and the most privatization. I think I’m seeing a pattern.

Feel free to share with us another official source that shows that this increase in expenditure is a result of capital going to private players. There is a big difference between "seeing a pattern" and "believing in a pattern".

So what are the main problems in Spain, according to what most people think? (I'm not very familiar with Spain)

Sadly, the political landscape has been pretty much monopolized by the Catalonian independence issue, with politicians using it as a smoke screen to cover way more important issues like constant corruption scandals, rampant privatization of health care, double-digit yearly increases in utility bills, housing rent bubble, etc.

National politics (Catalonia, etc). But there's also an endemic issue with spending on unnecessary infrastructure while underfunding heavily used infrastructure (such as public transportation in large cities); our budgets never seem to be able to reduce debt, and our pension system is doomed to explode, because eventually there will be more retired than working people.

Given that the life expectancy is so high maybe it makes sense to raise the retirement age here by a few years more.

Spanish healthcare is among the best in the world despite the problems.

Also, quite bold calling propaganda a report from United Nations analyzing population health. What do other problems the country has have to do with the people health?

Maybe your comment contains some propaganda too.

I think you misundertood my comment.

Propaganda is what is done in Spain to make people look at fake problems instead of the real ones.

I don't think this report is propaganda.

I know you are not saying the report is propaganda, but I understand you mean appearing in media is.

What I am saying is that besides the intention of the article (which is Bloomberg giving UN results) these are facts.

Seeing this facts stated might help others and it does not mean stop fighting for other causes in the country.

> I know you are not saying the report is propaganda, but I understand you mean appearing in media is.

No, I do not mean what you are saying.

I was talking about what is on the newspapers these days on here:

* Catalonia

* Next general elections (on April)

* "Minor" cases of corruption (relative to others in either money amount or the person affected)

* Football (Soccer for the people from USA)

* Venezuela

* "Famous" people (only famous because they appear on media as "famous")

* Bad migrants

* Memes

What is not talked about is:

* Mayor cases of corruption

* Dismantling of the public sector (before it was in big steps, now it is in small ones)

* Housing bubble (again)

* Low salaries

* Bad support to small entreperneurs

* The reasons why there are more migrants and what to do

I'm sorry. I keep seeing much more political intention in your comments than the article per se.

I didn't want to say anything more than what healthcare we've got is good, and it is despite the budget cuts. If I had wanted to introduce more politics I would have done so explicitly at the end of my comment, instead of a general lament. So I'm sorry if that whas the impression I gave you.

On the other hand, and repeating myself: I do not attribute any political intention to the article at all. How many more times do I have to deny it? You not letting go of this act like some bad actors when doing clumsy manipulation of debates.

Wow, that's surprising to me because of smoking alone. When I lived there briefly in the early 90s, it seemed like everyone smoked. I wonder if that's changed dramatically or is just drowned out by other metrics...

It did change! In fact now smoking is prohibited near schools and inside bars and clubs. Some people smoke, but not almost everybody as before.

and begging of 2000s, my first job as programmer was in a small design company(<10 employees), people were smoking at the office while working, it really suck to come back home with smelling clothes, it wasn't until 2006 when it became forbidden to smoke at work and other public places like bars or restaurants (with some exceptions if they have special space for smokers and enough size).

Besides that, sun light is very healthy, we see all the time articles about vitamin D, I think the way of living of Italians and Spanish of being more in the outside because the good weather might influence too, hard to know for sure.

I remember people smoking everywhere in the US, too, though.

In fact, moving to NYC I was struck by how I still saw people smoking because of how infrequent it was elsewhere

I'm Spanish and live here and I'd say people smoke a lot less than they used to after laws were passed a few years ago banning smoking from pretty much any indoor space that isn't residential. I know few people who smoke and those who do don't smoke _a lot_. French people on the other hand, pretty much every person I know, even here living in Barcelona, smokes like crazy.

This seems to have massively changed all over Europe. When I was a kid in the 90s you could go into bars that were foggy with smoke. TV characters would do it.

Nowadays it's generally not cool anymore, it's seen as a vice and people will sdmit so when they ask if it's okay.

The laws changed and smoking inside public spaces was all but abolished. There are still holdouts in the countries that passed these laws more recently but the trend is clear and it's acceleration.

I also noticed that one big factor that actually worked in discouraging teens from even starting is the "uncool" image built around smoking.

Unfortunately it look like the coolness factor is moving to electronic cigarettes and there's not much data to discourage the use yet.

What's going on with Luxembourg? 6330.9 cigarettes, per person, per year (which is over six times the US consumption). And, they're ranked still 11th on the Bloomberg list.

Cigarette taxes? Maybe they are lower there, so people buy them to sell in other countries?

Exactly, 20 to 30% lower. So like gas(fuel for cars) a lot of people going via Luxembourg taking summer holiday take the opportunity to stock up.

You are right about that, I lived in Trier, a German town next to the border to Luxembourg. A lot of people in the area went there just to fill their tanks (gas is around 20 cent less per liter) and stock up on cigarettes and coffee.

Love how 'click HERE' is not a link.

> To access the Bloomberg 2019 Healthiest Country Index data set for all nations, click HERE.

The article seems to have been taken from the main Bloomberg site: https://www.bloomberg.com/news/articles/2019-02-24/spain-top...

The "click here" link is for terminal subscribers only so I guess Quint might not have been able to resolve it properly.

Plus the browser back button is hacked. Can't comeback to hacker news

I'd be curious how individual US states stack up here--it seems like there would be quite a bit of variance (and I'm sure the US isn't the only country whose stats become much less informative when aggregated to a single number).

Wow. Russia looks worse off than I thought. Congrats, you share Egyptian health standards.


Why do you assume the problem is with the methodology of the study?

Cuba has a longer life expectancy than US.

As a European, I'd say there's something wrong with US approach to health: people living under a dictatorship in a poor country have better health than Americans.

One problem with life expectancy is how countries report infant deaths. USA has different standards than most countries, which as a result, it hurts their health statistics.

> well-known issue with cross-country comparisons of infant mortality is possible reporting differences for infants born near the threshold of viability. Extremely preterm births recorded as a live birth in some places may be considered miscarriages or stillbirths in other countries (Golding 2001; Graafmans et al. 2001; Sachs et al. 1995; Wegman 1996). Since survival before 22 weeks or under 500 grams is very rare, categorizing these births as live births would inflate reported infant mortality rates (which are reported as a share of live births).


I’d love to see real stats on that. All I ever see is the statement that there’s this huge problem in the US. Yet, when I travel I see tons of people without teeth, starving in the street, etc. It’s anecdotal, but I cannot imagine these countries are equivalent.

I’ve even seen the claim healthcare is super good outside the United stares. Although it costs more, the US had a top notch system for medical care. They can see a doctor in minutes, get open heart surgery, and go home for <$8000 within a week, with a high chance of survival. The only requirement is insurance, which the vast majority of people have. It’s the insurance part that gets people upset, the health care is not.

Further, Longer life expectancy means little by itself doesn’t mean much. What if a group is predisposed to disease via their genetics? Is that country not counting deaths of children, are the mothers less likely to carry to term, etc? Even if you controlled for everything, you’d also need good records are kept (something I doubt on Cuba).

My point is a lot of time this data is so fuzzy, it’s meaningless. Give me 100 stats and I can mess with the weights until Spain is #1 or #50 easily in healthcare. There needs to be lots of care to make solid claims and I don’t think that was done here, I think they wanted viewership.

Maybe the Cubans and the Spaniards have some magic genes on them, but I think is more probably that you vision of those countries is distorted.

Personally, and this is my intuition talking, I think that the most important fact is primary care.

If you need open heart surgery you probably would be better (marginally) in the States than Cube (assuming you can afford it), but what really makes a difference is to get diagnosed in the early states of a illness or, for old people, constant follow up by a doctor.

Interesting, it seems that both Italy and Spain have primary care totally public, that means, the doctors work for the National Health System. It would be interesting to check if this the case for the other top countries in the list.

I agree, and would add „lifestyle“ to the relevant factors. Cuba has a lot more „communal“ life. Eating alone, as but one example, just doesn’t happen. Even something like watching TV is more of a group activity. Even if the cause of that is an inability to afford your own TV, chances are it could have an impact on psychological well-being.

Physical activity is also far higher. Again, this may be a result of relative poverty. But walking or taking public transport to work just happens to also be healthy.

Interestingly, these are factors somewhat shared across Cuba, Spain and Italy, even though there is no similar economic pressure in those countries.

On the other side of the divide, I live in Germany. We have universal insurance that is functionally equivalent to government-run healthcare (I, and everyone else, can visit a GP any time without paying). Yet outcomes here, and in Britain and Canada, are closer to the US.

Out of curiosity, are primary care German doctors employed directly by the state, or are they private business that invoice later to the public health budget?

They are independent businesses. Most people have public health insurance. These are still entities distinct from the general budget. You can chose between different insurances, which have some minor differences in terms of extra services they offer. Rates also differ, but only very slightly. It’s around 12% of income.

There are also private insurances. They offer flat rates (not indexed to income) and are attractive to high earners and some young people.

> They can see a doctor in minutes, get open heart surgery, and go home for <$8000 within a week, with a high chance of survival. The only requirement is insurance, which the vast majority of people have.

See, that's one of the problems I have with the American system right there. Why do you have to pay for life-saving surgery when you already have insurance? That's absurd.

>People die on the list to get treatment.

This doesn't appear to be any different in the US, though -- people die often in the US from either waiting to get enough money for copays or from having their treatment be rejected by their insurance enough times until they die.

It’s called a co-pay and it’s because you’re expected to pay a portion along with all treatment. This is to make sure you aren’t going when you don’t need it.

$8000 for lift saving treatment is nothing really. I can go to the doctor for $20 - $40. However, if I need open heart surgery, $8k is fair.

In Ireland, Canada, etc you have to wait months to get treatment. People die on the list to get treatment. That’s my issue with that setup. I agree the US healthcare can be improved. However, don’t let the propaganda fool you (that’s for political campaigns), it’s expensive and we all want to fix that, but it’s very effective.

I really doubt anybody needs to be discouraged from frivolous open heart surgery by co-pay.

Also: nobody does on any waiting lists in Ireland or Canada. Or, more accurately: There may sometimes be waits for elective procedures, and people may get hit by busses while on such a list. But there’s no causality. The only waiting lists where people die are for organ transplants, as in most any country.

> . This is to make sure you aren’t going when you don’t need it.

This just does not compute. If you have a health concern, YOU NEED TO GO TO THE DOCTORS.

Trying to scare people away from visiting a doctors until it is bad-enough that their fear for their health overpowers their fear for their wallet is just sadistic madness. Utter utter madness.

>However, if I need open heart surgery, $8k is fair.

No this doesn't seem fair to me at all. No one should have to pay so much out of their pocket for a life saving operation.

> However, if I need open heart surgery, $8k is fair.

A "one-off" treatment such as this is one thing, but the co-pay system really breaks down for the individual once you start talking chronic conditions that require regular treatments for life.

In that case your insurance company may start to see you as a liability and raise the co-pay until treatment is no longer econically viable for the patient.

>The only requirement is insurance, which the vast majority of people have.

However, the vast majority of people do not have access to $8000.

> They can see a doctor in minutes, get open heart surgery, and go home for <$8000 within a week, with a high chance of survival. The only requirement is insurance

This is the same in any developed country (i.e. you can see a doctor if you pay), except that in addition to that most non-US developed countries also have the safety net of cradle-to-grave government run health care system.

This means if you dont have $8000 you can also get heart surgery and dont die.

Ideally with free & universal healthcare, you dont even get to the stage where you need emergency surgery in the first place. i.e. you'll be diagnosed and treated ahead of time when its not an emergency yet.

I've used both public and private in the UK. The benefit for the private health care is you generally get to pick when & where your appointment is (vs public when you are often told when & where your appointment will be and you need to change your schedule to get there on time ... although you do have some leeway in picking your clinic), and the places you go to do it are generally nicer places to be (decor, surroundings etc). If you need something truly urgently, the public system will generally get you seen as quickly as private. If its not urgent, then the public system has longer waiting times (because the truly urgent cases are getting seen first). Typically the equipment & treatments available in public clinics/hospitals is as-good or even better than the private clinics, and all the surgeons and doctors often do both public and private work.

tl;dr - Money generally just buys you convenience and nicer waiting rooms in non-US countries. The level of care is about the same IME.


The power of preconceptions...

I once worked with someone doing stats for a UN program. They used to say that the two most reliable statistics, in any country, are life expectancy and the murder rate. Because it’s quite hard to systematically hide murders or change the age in death certificates. In the Western Hemisphere, you can get a pretty good estimate just by taking a stroll of any cemetery.

Having been to Cuba, I can also assure you that despite all its shortcomings, starvation just isn’t a thing. Unless you’re allergic to rice and/or chicken. I even got to experience the health system (yeay climbing). And while „bare bones“ was the motto of the day, all the essential parts seemed to be working quite well.

You know that Cuban people live longer than American, right? How do you explain that if people are healthier in the US than in Cuba.

I personally would rather prefer live an average life in Cuba than in the US (and I visited both).

Plenty of people in the US do not have health care either.

Meanwhile, Cuba actually has a very high number of doctors per capita.

> There’s something wrong with the methodology here when Cuba is ranked higher than the US. People are starving in Cuba, with no health care...

[Citation needed]

Below are two, also when visiting it is very clear:

1994 - https://www.independent.co.uk/news/world/millions-of-cubans-...

2012 - https://www.poverties.org/blog/poverty-in-cuba

Apparently, it has improved since then - but that’s because international aid was sent, aka food.

The first one is 25 years out of date (and makes the starving claim but not the no health care one, though it does note that some medicines were subject to harsh rationing due to the embargo), the second one is effectively nearly as old (while it is from 2012, it cited data it notes was a decade old at the time) does not support the starving claim and directly contradicts the no health care one (and also notes a massive effort that made significant progress on the drug shortages by boosting local production.)

There is also a possibility what something is wrong with healthcare in USA, don't you think? Like, say, people not going to doctors because they cannot afford it. And when they finally go, it's already too late? Like obesity not adding to the health of the population. Etc. etc. And are people really starving in Cuba?

People are starving in the U.S. of A. as well. And healthcare is nearly inaccessible to them. And what they can get, some law makers want to take away or make even harder to get.

You get free food in the US as well as Cuba if you are poor.

I literally just bought 20lbs of pork for $20 and 20lbs of rice and 10lbs of beans for another $20. You can beg and easily make more than $20 a day.

But even then the US gives out food coupons and there are tons of soup kitchens.

You make it sound so easy. It really isn't. We foster, so we deal with "the system" daily. These poor parents, trying to get things back together are working a system that simply isn't always set up to help them. To get those coupons you speak of, they have to go stand in line during work hours. But they can't miss work because they'll not be able to pay rent. Do they eat? Or do they pay rent? This is an almost daily decision these people have to make. It's not just food coupons, it's meeting requirements[0] that they have to meet to get their family back together, it's all during normal business hours.

And before anyone gets to the argument about why they're in that situation, it often is cyclical. Go read up on trauma and trauma informed care (you can start with ACE scores).

[0] Counseling, court appearances, etc...

I think Bloomberg did an oopsie..

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