I moved to the US from a country with socialised medicine. When you include premiums then taxes in both were roughly similar if not a little higher in the US (ignoring cost of living differences).
But even that doesn't include the real sting on the tail of US medicine. You pay a fairly high health insurance premium, but if you actually need health services you then pay again through the nose even with insurance "discounts."
For example my under one year old needed to go to the emergency room due to a high fever for several hours, we paid over $300 on top of paying over a thousand in combined employer/employee premiums each month. That's with insurance picking up at least that much.
Can't even find out what stuff costs beforehand either. I had to get a blood test. I had gotten burned before where my insurance said they covered a physical, but it turns out their definition of a physical didn't include the doctor's definition, which included blood tests. So before I had my blood drawn, I asked them to tell me what the tests would cost if my insurance didn't cover it. "It depends on how it's coded," they said. So I asked them to check how it was coded and tell me what the "code" cost. They looked it up. It was coded wrong, apparently. They would have to talk to the doctor and couldn't, so I would need to make a return appointment, or I could just let them draw my blood. Still don't know what the coding was or was supposed to be, or really what that even means. I just needed to get life insurance and get back to work. I found out the price once I was billed for it.
'You should know the price before you agree to buy the product' seems like such an innocuous principle. Why isn't their broad-based support of it for medical care?
If you need emergency care then sure, there isn't time. The vast majority of interactions with the medical system aren't that type of emergency though. People have time to choose the better of two options. They can't decide on better if they don't know the price.
Because of insurance. It often leads the peculiar case that a healthcare provider might have no real clue about how much a person will ultimately end up being required to pay for some procedure they're undergoing. It has no clear connection to the price that the provider will bill the insurance for.
In many developing nations insurance is the exception, rather than the rule. This changes two big things. The first is that you're expected to pay for things that would have more than a negligible cost before these procedures are done. If you don't like the cost - you go somewhere else. Emergency care, like the US, is an exception - and nobody can be turned away, so you are billed afterwards.
But the really big thing this changes is that costs are such that people can actually pay them. For instance in one procedure I had a consultation, x-ray, and medicine. Total cost was about $20, and that's not government subsidized in any way - the hospital is making profit on that cost. And this is not a "hospital" with "doctors". Most of the medical staff are educated in the west and then come back home to work afterwards. As an aside, it also means they generally have great English. It's why developing nations are increasingly a destination for medical care - 'medical tourism'.
Yeah, this has baffled me before. I remember learning in my Family & Consumer Sciences class about the importance of being an informed consumer. Then, in college I had to get a dental procedure done and I called around to try to find out the price from different dentists and no one could give me any actual numbers. I ultimately just had to pick a place based on reviews and found out the price after the fact with no knowledge of how it compared t other places.
They used to but it's dwindling. A friend of mine is a dentist and he said when he first graduated from dental school some 15 years ago, his father and his practice dealt directly with the patient and had a list of all of their prices on their website and in their office. As customers increasingly wanted to have their insurance cover dental they had fewer and fewer people paying out of pocket and going through insurance. So prices went up due to increased complexity of the business.
At my dental office, they can tell you the total cost without insurance which is the maximum they would charge for any procedure. If you paid in cash in full, they would do a discount (for non-insured).
For those insured, it depended on the insurance you had but they would give you a rough estimate based on the plan you had (mostly because they can’t be 100% certain what the insurance will cover down to the exact dollar amount.
In my experience the estimate is often off but close enough that I am not worried I’d owe an insane amount afterwards.
The current federal administration has mandated the hospitals to publish their prices online since 2019.
I have no illusions, a person without a degree in accounting probably won't be able to decipher these prices, but that could be a step in a proper direction.
List prices are not the whole information: you want to know for your insurance, how much you will get charged. And that is a completely different question.
> Why isn't their broad-based support of it for medical care?
IMHO, it is because folks are overly deferential to medical doctors.
While a lot of the problems are actually caused by the insurance industry (a constantly changing billing code system) rather than the doctors themselves, I think folks are growing tired of being yanked around by the system.
This deference is decreasing based on my limited experience (i.e., just talking to people about their medical experiences), and it may drop precipitously soon. My guess is that most/all of the good doctors going to "concierge" will be the breaking point.
> Why isn't their broad-based support of it for medical care
Because the American medical system is perhaps the finest example in the world of regulatory capture, ironically masquerading as an example of pure capitalism, while decrying the "socialism" in other countries.
> You should know the price before you agree to buy the product' seems like such an innocuous principle. Why isn't their broad-based support of it for medical care?
This is not a probleam of health-care as much as it is of insurnace. If you paid doctors cash you will get straight up pricing.
Thing is the market is like 95% insurance.
I believe this will change in the near future. High-deductible plans and DPC's will bring back some sane price sensitivty into the system. But while patients with great PPO plans pay 20 bucks for a 300 dollar visit, its not going to get fixed itself by "posting prices somewhere"
Its even more absurd because your health, well being, and potentially life is held hostage. Like, if the choice is "you pay this or you die", it's not exactly a choice. They can charge whatever BECAUSE OTHERWISE YOU'RE DEAD.
But the mere fact that you can go get a surgery, and not only will you not know what it will cost, you don't even know who you're doing business with: you're going to get bills from the doctor, from the hospitals, from the nurses, from the anesthetist, and god know what else from, for the next 6 months. You don't even know if you're done paying all your bills or not!
You can't find out the price on most things and procedures that are the highest value (cancer care, dialysis, sickle-cell, etc.) are usually those with the least flexibility in price.
I think of this every time someone acts like U.S. healthcare is a market in any positive sense: our son had his first birthday before we got the last hospital bill (they were hoping we’d gift them money beyond their negotiated rate with our insurance company) while nobody I know from another country has ever had any experience with that.
The billing for health care in the USA is also rediculous. Last week I got a bill from the doctor's office for a visit back in November that my insurance company decided not to pay. What other business takes 4+months to send a bill?
My partner works for a large hospital network dealing with insurance payments. Their department is not even able to figure out how much bills "should be," which prevents them from being able to prioritize their work based on total costs.
When the process is voodoo for the people who actually deal with insurance payments, normal people stand zero chance because it's unlikely you'll ever find a person to talk to who can find this information out.
Oh it can get even more ridiculous... yesterday I got yet another $300 bill for an ER visit from October 2017. Now I have figure out whether it will cost me more in lost billable hours than to just pay this bill, knowing that contacting my $1700/mo insurance company to help sort things out will prove to be fruitless.
I was at the dentist today because I managed to chip a tooth yesterday, and needed it fixed. Before the procedure, they asked if I wanted an estimate, I said sure, and got one in a minute.
The dental industry works the same as the medical, I have a half-useless insurance that covers too little, and out-of-pocket expenses are always higher than you expect. But if they can do estimates before a procedure, why the hell can't the medical industry do the same?
Yeah I was able to get an estimate on the birth of my child, too. But then lawyers had to get involved between me and Banner Health a year later, over a bill from an anesthesiologist they said didn't exist, with contact information at which no one said I owed any money, that was never billed to my insurance company, for an epidural that ended up being done quite poorly. In the end it was considered to be my responsibility because of a paper my wife signed while in hard labor agreeing to pay the bill. Fuck the whole industry. That's not even my worst experience - just the most recent. I basically don't visit doctors or dentists anymore because the biggest health threat I see in my life is the massive surge of blood pressure I get at the mere mention of insurance companies.
Just to put my cautionary experience in on that, I woke up after some oral surgery about ten years ago to find out that my estimate was worthless and the actual cost was twice what was estimated. I was fortunate enough to have recently gotten a good paying job and could cover it, but it was certainly a shock.
I agree this is all a huge pain. I've been burned on "this test cost you x because of the facility it was done in and if you had gone to one of our partner labs (which you'd have no way of knowing without calling us), you could have had it done in <dedicated, partner lab> for 1/4x".
I recently learned that there are 2 different codes involved and that it's the combination that matters.
1. The diagnostic code - the reason why you need that test
2. The procedure code - what the test is
My insurance tells me that their coverage (as in whether they cover a service or do not) is different for the same procedure code with a different diagnostic code. I'm not sure if that implies that their coverage price for the same procedure code also varies by the diagnostic code.
Your doctor can give you both codes for the test they're prescribing. In theory, your insurance company can tell you what they'll pay for the combination, and then you can contact each lab / hospital / service provider to get an estimate for what they'd bill. It's unclear how much recourse you have if the bill turns out to be significantly different than the estimate… that is once the bill actually arrives, sometimes 30–60 days later. I'm not sure if the service provider's bill varies for the same procedure code with a different diagnostic code.
Admittedly this is all a huge pain and with my insurance company at least, cannot be done online, you must call and wait. It's all such a time sink that I usually just get the service done upfront and hope. Sometimes the end consumer cost is practically free, sometimes it's hundreds of dollars or more.
It should be more feasible for us to know a rough estimate for a procedure across providers upfront.
Just had all the blood tests done here in Japan. Walked out paying a total of $80. Had I been employed by a Japanese employer, it would have been free. They told me the fee up front.
Yeah, and cost of health insurance in Austria is just 7,65% of your income, and it covers your children. When I've worked in the US, I've paid just as much for health insurance and still had high out-of-pockets and deductibles on top of that.
I will pay $4,800 to cover a family of 4. If I need to use it, I have a $6,000 deductible (company pays first $4k and I pay last $2k). All doctor visits are 100% deductible until it is fully paid, then $50 / visit. The HSA can be used to pay the deductible and pharmacy costs.
Yup, and that's about what you pay for a single person health insurance in the US that isn't very high deductible. I think my employer pays about $6K/yr for me and another $6K/yr for my partner, (I know this 'cause I've gotta pay taxes on hers, as we're not married) but it's a reasonably good plan. Same provider, but more expensive/better coverage when I was buying through my own company. When I see the doctor, they charge me a symbolic fee, but it's usually around what the ride share to get there costs me. (the parking there, ugh.)
Personally, I avoid the very high deductible plans, mostly because I have the option, but also because I don't want to deal with hospital billing. I've got an HMO (kaiser) and they charge me almost nothing at point of service, and I get to consume all the medical care my doctor thinks I need.
Unfortunately, my employer has a really juicy high deductible plan that a lot of my co-workers use. Like they actually give you money to put in your HSA that covers most of your high deductible. It's a good plan. But I don't like it because it means my co-workers get to keep extra money for not going to the doctor when they are sick, and instead they come into the open plan office and cough all over the place.
I mean, I do okay, and I'd be happy to kick in a little extra money if it meant my co-workers were more likely to go to the doctor when they are sick rather than sharing the love with the office.
Just because they don't go to the doctor doesn't mean the have to come into the office, unless you have a terrible employer...
I hate policies that require a doctors note. Yeah, I have the flu, going to the doctor is just going to spread it, unless I have some sort of complication.
True, but I think they are both symptoms of skimping on medical care, which I don't think people should have to do in general. (I would be happy to pay more taxes to make that happen.) I especially think people shouldn't ration medical care where I work; I suspect the median annual income here is closer to $200k than to $100k.
When you are sick, don't go to work. If there is any question of if the doctor can help, talk to the doctor. (Via phone or video chat, if necessary)
For me it's the opposite. I moved from Denmark to the US, and I pay around $400 in health insurance premiums (health, eye, and dental) for a whole family. In Denmark, only health is covered, so for eye and dental many go out-of-country to get it cheap.
The US is much cheaper for all health insurances, except if your poor. Obama tried to fix that, but made it worse and more expensive for everyone (socialism).
If you're employed and your employer is generous, then your insurance premiums can be inexpensive (low double digits per month if you're single, low triple digits if you have dependents) . My wild speculation is that most employers aren't as generous as they could be.
If you're "poor", insurance is actually cheap, because that's when you get public insurance. However, if you're just middle income, health care is a non-trivial portion of your income. One major health incident will bankrupt you and you're likely to become poor. But once you're poor, hey, you can get cheap health insurance.
The critical problem is that obtaining reasonable health insurance requires you to be employed full time at a large company. This must stop. Obamacare was a first step toward cutting the employer out of the picture.
When I made less than $30k/year in Los Angeles and had Obamacare, I was paying $144/month to see a nurse associated with a second rate doctor (I also went to a couple urgent care facilities with nearly the same level of quality). The wait times were an average of two hours and I paid at least $75 /visit without any real resolution to my allergy problems. I probably had 10 visits without that needed resolution.
When I became a salaried employee in the Bay area I went to an urgent care recommended by Cigna and my allergy problems were resolved inside of 15 minutes with a $20 copay.
Obamacare is anything but cheap when you are poor.
The last step is a full-coverage default public option, paid for out of taxes. Enough to eliminate the billing departments outside of actual luxury medicine.
As far as cost controls/etc, set by something like a dutch auction within a given metro area, and then some bean counter will get to figure out if it's cost effective to ship people that are outside of metro areas in to them to provide non-urgent care.
Yeah I don't know how it is in the US but in my country everyone is employed on a temporary basis. The days of actually getting a stable job for life are long gone. Getting a two year contract is the best you can get.
> I pay around $400 in health insurance premiums (health, eye, and dental) for a whole family
I would love to pay $400 a month for health care for my entire family all inclusive in the US! Can you please state the name of your insurance company and your specific policy so I can get this too? My rate is over $20,000 a year right now so that would be a tremendous savings. Thank you so much!
> I moved from Denmark to the US, and I pay around $400 in health insurance premiums (health, eye, and dental) for a whole family.
My health alone is $2,100/month for a family of four. I suspect your employer is paying a large portion of your premiums as a benefit.
This is quite common in the US, and a significant portion of the problem, as people think they're getting great insurance "cheap". They're not - it's just being paid in a way that's not visible. As a result, any discussion of "it'd be cheap to implement national healthcare, it'd only cost $X" is met with "but I pay peanuts for mine now!"
I've noticed that a lot of employers don't tell workers how much they are paying for health insurance. Because for large companies the number gets rolled into a negociated contract.
In my case I do know. My employer pays $930 some a month. My rent used to be $860/month.
The other thing the happens is just because you have insurance doesn't mean that healthcare providers aren't trying to jack more money out of you. Any procedure/service will be up coded to increase your out of pocket share.
Yeah I only pay like 20% of the cost of the premium for my plan for my wife and I. Which means the actual premium is over $1k a month... yikes. At least the deductible is only a few hundred dollars...
Ha, that's cheap. Last time I checked the medical system gets over 20 grand a year from me(some via my employer). Works out to like 4 to 7 grand a visit, and that's mostly routine checkups/vaccinations for my kid. There's a reason doctors and medical/insurance execs are so wealthy.
According to the article, workers in Denmark see 26.7% of compensation go to "compulsory payments" including taxes and health care. Workers in US pay 43.2%.
Why should I trust your figures over the article? Are you including the "employer contribution" toward your taxes and health care premiums?
Yeah, that's the thing. The true cost is somewhat hidden because of the employer part of the premium. And the costs you pay out of pocket when an actual health event happens.
I imagine you can still pay $1000+ out of pocket to have a baby in a US hospital, even if you have great insurance.
Also, the article talks "average", while I imagine US health costs are highly variable depending on whether you are young, old, smoker, non-smoker, fat, skinny, pre-existing conditions, etc...
Some people pay $1500 per month in health care. And some, $400.
Can confirm the same in NYC. NYU Hospital with nothing fancy other than delivery of a beautiful Daughter. We had to go back due to some Jaundice but were told to visit NYPH for this instead. I imagine we will be well north of 9000 USD when all is said and done.
Did you check your employers contribution? Because at my US job, I paid around 340$ to insurance but the employer matched it with another 340$ to insurance, so insurance was actually 680$/month. A ridiculously bad deal considering there were still deductibles/out of pocket of a few thousand dollars and some differences based on whether I get in-network or out-of-network treatment.
> In Denmark, only health is covered, so for eye and dental many go out-of-country to get it cheap.
That kinda sucks for Denmark. In Austria, everything is included in the 7.5% that health insurance costs.
Well, in Austria there are a lot of people going to the dentist to Hungary as well because it's cheaper. The situation is a bit more subtle than you pretend it is.
Health insurance typically only covers the minimum at the dentist, and almost nothing of what is considered "cosmetic" or would be good in the long-run (e.g. oral hygiene, braces).
It gets expensive quite fast.
Depends on if the individual's state accepted Medicaid expansion funds from the federal government (states like Texas and Florida haven't) and whether the individual makes less than ~$16.5k/yr.
I wouldn't call either $0k/yr in North Carolina, or $17k/yr in New York, lower middle class. Neither of those incomes in those places would give an individual access to Medicaid.
Every doctor I see is a Medicaid provider. Yes, there are doctor who don't accept it, but it's not hard where I'm from to find a doctor who does (perhaps we have an oversupply of doctors?).
"Medicaid provider" and "Medicaid provider taking new patients" are not the same thing. They'll usually set a maximum number of Medicaid patients for the practice, and there'll be a long waiting list for that.
not only billionaires. How about completely unauditable $700B defense budget producing beauties like F-35 plus additional supplemental couple hundred billions per year on actively establishing and maintaining democracy in a bunch of places far far away!
Then there's education costs in the US, say you want your kid to go to CalArts, that's $50,000 a year just for tuition, so your kid gets out of school $500k in debt with a degree in performance art and a $3,000 a month student loan payment for life.
Including room, board, and books, you're looking at something in the $20,000 range, and it varies a lot by state. If you live in Virginia, for example, undergraduate total cost of attendance for UVA is around $32,000 (https://sfs.virginia.edu/cost/18-19).
EDIT: There is also the case where you may live in a state with insufficient opportunities for higher education. For example, neither of North Dakota's two public research universities (U of ND, ND State) rank inside the US News top 200, and both of those schools will still charge you around $20,000 per year. Germans or Brits will be able to receive subsidized educations at any university in their countries.
I went out of state for university. But I do live in the ND/MN region and I can tell you I know an entire community of NDSU computer science students who graduated and now make over 6 figures. Sure they say it wasn't amazing, but it got the job done for really cheap. Also NDSU is only 7k per year in state before assistance. No idea where you are getting the 20k figure from.
You'd probably have access to a better education at U of M in Minneapolis. But it's going to be quite a bit more expensive and I'm not sure it would have that large effect on your career.
I didn’t have the grades, legacy or extracurricular activities to get into the Ivy League. I could get into good engineering schools, but couldn’t imagine the debt or bankrupting my parents. So I went to a SUNY school, and everything worked out fine.
You'd probably also find the amount of amenities provided by universities ridiculous. I mean we had a free olympic pool and rented puppies to pet before finals. Its no wonder it costs so much
I found a stark difference in German and American higher education that the German higher education system treats you like an adult, including accountability for your own schedule, whereas in comparison American universities appear an extension of middle school. Carefully created and controlled curriculum, etc. That's in no way a statement about the academic merit in either direction, of course.
This is very much aligned with the direct cost and services provided. Attending German universities is virtually free, and under certain conditions, the country will give you very cheap loans to pay for your living expenses. My spouse had a single digit number of thousands of Euros to pay back after graduating.
PhD students are often underpaid employees and are treated that way (for better or worse) instead of being considered as and treated like students. This doesn't imply one is preferable to another, just that it is a continuation of treating them with and expecting a higher degree of maturity and independence.
An upshot for me was that when I applied to my first industry job, the time as a PhD student was treated as work experience.
So yeah, I think you're spot on in that many folks from continental Europe would find the amenities bewildering. :)
Ten years ago in France, it was around 279€ and since my familly was in the lowest quintile, it was covered by the state. But i've hear that the true cost was in fact 3.8K€ per student, up to 7K per student if you count lodging. Or around 10K$.
For "Elite" schools the upfront cost is between 7K and 15K, and you can add 2K for the true cost (paid in taxes, VAT or income) and 3k for lodging. I say elite but the best school in France for math is actually a public university (ranked 5th in the world or around that), and you can get this for almost free if your parents are poor.
In the Swiss system (as I understand it) it's about $600 to attend classes, but if you don't hit the minimum on the semester exams twice, then you're done in the country.
If you miss it the first round then there is a massive incentive to transfer or find an easier program, otherwise you face the prospect of being forced to go abroad to complete a degree.
I would tend to believe it does considering the people I work with from university like the EPFL.
But more generally, it might be a today problem where people has to be hand carried to do anything with 0 critical thinking.
The tuition fee in the UK isn't really a fee at all, at least for most domestic students. In practice, it's more like a graduate tax. Student loans are only repayable if you're earning over £25,725 per year. Your repayments are 9% of your income over that threshold. Your loan is automatically forgiven after 30 years. Because of these terms, the vast majority of students never fully repay their loan.
Actually, if we assume the previously posted £10,000/year, and three years for a Bachelor's they'd have a £30,000 debt. Assuming no interest, since it's only the amount over £25,725 that's taxed they'd have to average £25,725+((£30,000/30)/.09), or £36,836.11, over 30 years to fully repay, which I think is a much more reasonable number outside of HCOL areas.
I'm not sure if they account for inflation or have any fixed interest on the loans. 30 years without any would be pretty crazy.
They have above interest earnings for higher earners, and a lot of students take out loans of nearly twice the size to pay living costs, so a lot of people whose earnings average over £40k in 2019 money won't pay all their loans back either.
Nitpick: you can't really generalize about education in the UK as Scotland has a completely different system to England and Wales (and I don't know about NI).
For example, tuition fees at Scottish universities are "free" (i.e. paid for by the Scottish Government) for Scottish residents and people from other EU countries (but not the rest of the UK).
And the real tuition is that high is because there’s an endless supply of students willing to dump insane amounts of money into a degree program that will, at best, lead to a $40k/year job. Cut the head off the snake and things will come back to earth.
Can confirm. Moved from US back to Australia. Had one child born in USA, one in Australia. Neither birth was super-complicated (both in maternity hospitals)... The most expensive thing about the Australian birth process was the parking - had to pay an exorbitant $24/night to park in an open lot. So the whole thing cost about $36 or so.
I forgot the fees on top of our insurance in the US (it being >16 years ago) but it was pretty steep.
When I looked up private health insurance in Ireland I kept thinking "gee that's not much better than the US". Then I realized I was looking at an _annual_ premium.
I moved from Canada and while I lived there I didn't have two nickles to rub together. Payroll taxes, sales taxes, fee's, cost of living and under employment robbed me of a decent life. The medical system was hurry up and wait while you die. Anything in between full blown Cancer and a cold was a situation where you would wait or fall between the cracks(9 months it took me to see a Neurologist, 3 months for a shoulder expert).
After moving to the US I have earned more money in 10 years then I could have earned in my entire life in Canada. My medical is outstanding and my taxes in TX are a pittance.
It seems where you live in the US might make a difference.
> But even that doesn't include the real sting on the tail of US medicine. You pay a fairly high health insurance premium, but if you actually need health services you then pay again through the nose even with insurance "discounts."
That's mostly not true if you have an HMO plan, but your employer may not offer HMO plans if it offers insurance, the HMO may not be a good one if it is available, or it may not cover good providers in your area.
> That's mostly not true if you have an HMO plan, but your employer may not offer HMO plans if it offers insurance, the HMO may not be a good one if it is available, or it may not cover good providers in your area.
I think you meant that tongue in cheek, but essentially that means it's true for a significant number of people whose circumstances meet any of those criteria.
Employers of a certain size have to offer insurance that covers at least 60% of the cost of certain services and meets certain affordability requirements. They are not required, under federal law, to offer HMO plans.
You could definitely include the out-of-pocket costs (and how they differ between high deductible plans vs. low deductible vs. single-payer), and you should, for a fair comparison. This is researched to death effectively at this point but the overwhelming consensus is that single-payer delivers 100% coverage at around the same cost to individuals as the employer-sponsored plans w/ the same healthcare quality / outcomes. If you went on to compare the time-costs for every person that has to navigate insurance company shenanigans, the savings would be off the charts.
$300 [1] is more than I’ve spent on (non-dental) helthcare, in total, over my entire life. That includes one count of general anaesthetic and emergency surgery because of testicular torsion which happened while I wasn’t registered with any local doctor, one burned arm, one being knocked unconscious by a trampoline, and one being hit by a car.
[1] “after premiums” is roughly the same as “after taxes”, right?
In the US, I've already payed thousands in after-premium medical expenses for my very healthy young children, just in copays and ER visit fees for normal accidents that kids get into, and that after having what in the US is considered amazing health insurance, so I'm a very lucky person.
I had to go to the ER in the UK as a tourist recently. They refused to take payment since I wasn't admitted to the hospital.
> [1] “after premiums” is roughly the same as “after taxes”, right?
For the purposes of comparison between the US and other OECD countries, yes.
I left the US recently with a few thousand in an HSA (a pre-tax account designated for healthcare expenses). I have no idea how I'm going to get that out of there now.
You can keep it there and withdraw it after 65 penalty free (have to pay taxes like a traditional IRA) or you can pull it out now and pay taxes plus a 10% penalty.
you can just withdraw it. Their website should have a way to do a bank transfer or write you a check. You will owe taxes, but if you're never coming back to the US, then whatever. If you're coming back, then you can generally invest your HSA in a mutual fund(most have some limited investment options accessible via their website) and then your HSA basically turns into an IRA retirement fund at age 65.
My family in Germany throws a fit when they have to pay 50 Euro for something. In the US you can happy if your cost for seeing a doctor is less than 4 digits.
> In the US you can happy if your cost for seeing a doctor is less than 4 digits.
My wife and I have never paid four figures for a doctor visit, despite having two surgeries (one oral), a calf strain, and a dislocated shoulder (with ER visit) between us. The state of medical care in the US is bad enough as it is; you don't need to make up hyperbolic bullshit to make it seem worse.
You walked away from multiple ER visits including surgeries for less than four digits out of pocket? Maybe consider that your experience is the exceptional, not the people you call hyperbolic.
My son had a laceration glued together (dermabond in lieu of one or two stitches) and that was either close to or slightly over four digits after totaling the hospital bill and doctor bill, both in network.
My son just had a laceration that needed closed up a week ago. We didn't even take him to the ER, just his pediatrician who saw him for all of 5 minutes. She didn't even use any skin adhesives to close up the wound, she just taped it together and called it good. $120 for literally putting on a bandaid that came apart before we even finished the car ride home leaving us to tape it up properly ourselves.
How much support stuff does your doctor have? Industry wide, admin expenses are now 5x the cost of the care providers. Your doctor probably needs $X revenue per hour just to keep the lights on.
You didn't pay $120 for the doctor to slap on a band-aid. You paid $120 for the peace of mind of having a "trained professional" do it and tell you that was an acceptable solution. It's the same reason people call plumbers to snake drains and pay mechanics to change brakes. Those are basic things that the least trained workers in those industries are capable of doing but you pay a premium to not have to think about it.
Nothing about the situation required an expert opinion and the pediatrician made a pretty poor decision to boot. It was abundantly clear that the wound just needed stitches, that's not something I can do myself. In the future I might just get some Vetbond, because if I had that on hand that would have been preferable to the care received from paying an expert $120. No other developed country on the planet is this backwards when it comes to health care.
I'm fine with paying a premium for trained professionals, I'm fine with paying doctors a high wage. $120 is crazy for a doctor who already has an opening in their schedule taking less than 10 minutes to glance at a wound and slap some steri-strips on it.
I fell down the stairs and had a muscle spasm in my back. Had to go an ER. I had insurance that was considered good and it still cost me $350 for 10 minutes with the doctor and a bottle of muscle relaxers.
An ER visit is not the same as a simple doctor's visit. If ER visits are necessary (questionable in this case), they are covered by insurance - by law. Your deductible still applies.
Who cares about the deductible? It’s still a ripoff. My girlfriend had an eye infection while we were in Germany. We went to an eye doctor and paid 25 Euro cash including an ointment. The US is just horribly expensive and very unpredictable.
"You should care about the deductible, cause you entered the contract, silly."
This is stupid. There is no real way to shop and bring down health insurance costs in the US. It's tied to your job, meaning you would need to get many job offers, and turn them down when you find out the actual insurance costs until you find one that's better, and ignoring other employment factors.
And then everything can change the next time open enrollment comes around. Don't like the deductible, time to start the job search again! Oh, and the deductibles are probably about the same at all the other companies, anyway.
It's just a stupid system from top to bottom, locked into place because our political representatives are completely uninterested in governing.
When I worked at HP/HPE, we had decent insurance. My family rate was average, not too expensiv.
After they spun us off to DXC they claimed to be contributing the same amount, but our rates went up to about double or triple per pay period (varied some with the different plans).
Insurance isn't tied to your job. You can (and often should) forego the employer's plan and purchase insurance on the open market. Most insurances have some form of deductible, it's what keeps them affordable. Insurance should be protecting you against a huge financial fallout, not against petty expenses.
I agree it is a stupid system though and I'll tell you why: People want something for nothing. They want coverage for everyone, they don't want a tax, but they don't want compulsion to purchase and they also want to force insurers to take people with pre-existing conditions. Insurance can't work that way, the money has to come from somewhere.
If there was a compulsion to purchase, the system could work, as it does in many other countries. That's probably unconstitutional though, so it probably wouldn't stand.
Lastly you have "Medicare for all" which would basically bankrupt hospitals if you extrapolate from what current Medicare does to them financially.
You honestly can't blame representatives for dealing with voters that understand nothing and want everything. They voted for Obamacare, then they voted for Trump to make Obamacare even worse. I don't even want to know what's next...
Thanks for engaging, your comments are interesting and thought provoking.
"If there was a compulsion to purchase, the system could work, as it does in many other countries."
Wasn't that one of the major points of Obamacare, to make strides in that direction? And it did pass Supreme Court scrutiny, who decided yes it is a tax, and yes the government is allowed to tax us.
"Lastly you have "Medicare for all" which would basically bankrupt hospitals if you extrapolate from what current Medicare does to them financially."
Across our economy, competition and technology drive higher quality at lower cost. Doctors and hospitals need to have an incentive structure that rewards keeping the most people healthy at the lowest cost. "Capitation" models are meant to provide these incentives, where you don't get paid for "doing things" to patients, like ordering tests or performing surgeries. You get paid a fixed sum per patient to keep them healthy, adjusted for the "risk" associated with the patient (for example, if they have a chronic condition that needs ongoing treatment).
So an intelligent "Medicare for All" system could be designed to incentivize innovation and cost cutting and overall patient health, if implemented intelligently.
It’s tied to your job because health ins through your employer gets an effective tax discount compared to that bought through the ACA market. There is no way for latter to be as economical.
I've priced insurance outside my job. It's never even close and your employer isn't going to hand you the money they were spending on your policy. You basically pay at least 150% and give you employer money if you want to self-insure.
You still won't be able to pay your policy if you get critically injured, so what's the difference.
What is included in that fee is malpractice insurance premiums (because it isn't that nothing can go wrong in that 10 min interaction which causes you to sue the doctor) paid by the doctor.
On the top of that, he didn't charge you for what it was, but for what it wasn't and confirming it.
Take for instance if that muscle spasm actually lead to something darn serious, the doctor ruled that out, that's why he sent you back after 10 mins. For some weird reason (or counter-intuitive economic reasoning which everyone has got), if you had a serious problem, and the doctor had identified it in that 10 mins, then you'd be ok with that billing.
See it this way, if you're tech security contractor and the CEO calls you urgently to come take a look at suspicious behavior on his computer which he thinks might be a hacker hacking his computer, but it turns out to be a quite known windows bug, that doesn't mean you shouldn't charge him your regular fee if it was an actual hacking attempt. You're getting paid for being on call.
That price has little to do with malpractice premiums. You're paying for the fact that the ER was there, fully staffed, ready to treat literally anything that you could have walked in with at a moment's notice. That and you're subsidizing people who don't pay.
I went to the ER thinking I was having a heart attack, and it turned out there was nothing wrong. The doctor who saw me afterwards thought it might have been intestinal spams. I got to pay $6,000 for that bit of entertainment.
Yes. I couldn’t find an angle to negotiate with. I could afford to pay, so trying to use hardship as a lever to bring down the bill wouldn’t have been honest.
Not so easy if you’re google-able and clearly work in tech. They won’t squeeze blood from a stone, but if they smell money, they aren’t going to negotiate. The advice frequently found on reddit about negotiating is good, but keep in mind it’s targeted at individuals with, best case, 0 net worth and worst case hundreds of thousands in debt.
Your mileage will vary depending on the bill collector, hospital system, staff etc., but keep in mind someone has to be paying the bills. American, work in tech, post on Hackernews? It’s probably going to be you.
Always worth a shot though. Worst case they’ll usually let you go on a 0% APR payment plan for years and years.
If you're willing to risk your credit score for a bit, just don't pay the bill. Eventually some entity down the line will accept less. If you don't want to do that, then you have to eat it; immediately or in installments.
That’s not what I’m saying at all. I’m saying that the cost was way too high.
How much does an ER visit like that cost in a sane country? I mean the actual cost, not the “free” that the patient might see from a socialized system. It’s nowhere near that high.
I stepped on a coal that was knocked out of a bbq grill at a 4th of July party. I went back and forth on whether I should go to the doctor, but the nurse line suggested that I should. 30 minutes, a nurse and doctor saying “don’t pop the blister”, and two Vicodin later I had a $2500 bill to pay off as a broke college student.
I guess I shouldn’t have gotten injured on a federal holiday.
Wait until you need dental surgery. I've never found a dental insurance that allows paying out more than $1,500/year. One gum graft alone is about $2,000. Dentures, replacement teeth, these all cost multiple thousands of dollars.
With insurance, more complicated births aren't that much more. We were out of pocket $4k for the birth of our twins (maxed our deductible). The total 'sticker price; was over a million USD (they spent a combined 10 weeks in the NICU).
Our local hospital tried to charge our insurance $20k for 1 hour of the recovery room and $25k for 1 hour of the surgery room.
We have a friend whose hospital tried to charge them $15k for a delivery room they never used - never used because the doctors forgot about them and she delivered her own baby in the hallway. Talk about two major fuckups in a row.
When I had back surgery I was with a public employer PPO. Total out of pocket was like $300 for about $500k of procedures. Half the people in my recovery PT were selling cars and emptying 401ks to make the mortgage.
That’s the crazy thing about the US system. For a lot of people things work smoothly like it did for you. Then you have a significant number of other people who get totally screwed with out of network stuff, billing errors and the insurance declining payment for random things. These people now have to have to negotiate often for years, fight collection agencies and often end up owing thousands and tens of thousands of dollars. It’s a big gamble and there is pretty much nothing you can do to protect yourself.
That is generally the failure mode of complex systems. Say if you made flawed software a couple of decades ago, chances were it crashed. Today flawed software will produce many different errors. Not that the former is necessarily better, just that it is something to understand about the modern world were we aren't limited by scarcity. Same thing with e.g. food or education.
Just one of my blood tests alone cost $4,600. Surprise billing. "Out of network". Didn't even know to ask. Doctor, lab, everything all under the same roof. Why would any one even think to ask?
> My family in Germany throws a fit when they have to pay 50 Euro for something.
Socialized insurance rates in Germany are 15% of income. Unless your family doesn't earn any money, they have been paying far more than 50 Euros.
> In the US you can happy if your cost for seeing a doctor is less than 4 digits.
That isn't generally true. Every insurance plan is different. Cheap plans have a high deductible. It's similar to private insurance in Germany.
It's basically like this: If you're gonna be poor, go to Germany. Everyone else will pay for you. If you're going to earn well, leave Germany, otherwise you're going to be paying for everyone else.
1. The 15% of income has a cap. It's something like after 60k EUR in wages you don't pay anymore. Also, only 7.5% comes out of your paycheck, the employer pays the other half. When I was there a few years ago I was self employed so I had to pay "both sides". It would've worked out to roughly 750EUR/month for health insurance which had _0 deductible_ and _0 coinsurance_ for doctors visits or ER care and would've covered my entire family no matter on my children I had. Compare that with a typical HDHP family plan offered in the US and you're looking at $400/mo in premiums, with a $3k deductible and max OOP of $6k. The final cost is comparable.
2. The 15% is only if you participate in the public system - the private is not tied to your income.
>> Also, only 7.5% comes out of your paycheck, the employer pays the other half
You might delude yourself that this "other half" is paid by the employer, but in reality your employer takes that cost into account when employing you, so they offer you lower gross salary because of that. In other words: it's still paid by you, just indirectly.
> Also, only 7.5% comes out of your paycheck, the employer pays the other half
This just means that paychecks are 7.5% lower then they would otherwise be. It is a mistake to think that the employer paid benefits are "free". The market adjusts. You find that out right quick of you are self-employed (at least in the US).
The difference is that the other 7.5% (plus a few more such line items) don't appear in your progressive tax rate, and they also don't appear in "how much do you earn in country X" comparisons.
In most countries, even the first 7.5% don't apear in your tax rate.
But still, if you count everything together, for a 2keur net paycheck you have to charge your customers 4.8k in my country (slovenia), and the government takes 2.8k (social benefits, pension, health, income tax and VAT). Say what you want, but 4.8k->2k is a huge amount of taxes.
> The 15% of income has a cap. It's something like after 60k EUR in wages you don't pay anymore.
...at which point progressive income tax starts kicking in badly.
> Also, only 7.5% comes out of your paycheck, the employer pays the other half.
Guess what, the employer pays 100% of your paycheck, including your vacation, pension, healthcare and taxes. It doesn't really matter to the employer how the cost is labeled. That's why you get to charge more when self-employed.
> The final cost is comparable.
Comparable? It's almost double if you don't take any care. Also, what if you don't have children? It's apples and oranges.
> The 15% is only if you participate in the public system - the private is not tied to your income.
Caveat: You are forced to take part in the public system unless you earn well or you are self-employed.
"It's basically like this: If you're gonna be poor, go to Germany. Everyone else will pay for you. If you're going to earn well, leave Germany, otherwise you're going to be paying for everyone else."
You should add this to your algorithm for location choice: If you get a serious health problem and want to become poor, come to the US.
You’re not that far off from reality. I’m currently in the US because career opportunities are far superior here.
However, if I were to get seriously and chronically sick I would back to my home country. Not that i couldn’t get very good care in the US, but the system here is just a massive burden compared to countries with universal coverage.
> You should add this to your algorithm for location choice: If you get a serious health problem and want to become poor, come to the US.
If you already have a serious health problem, you'll be hard pressed to find any country to take you and just take care of it pro-bono, if you're uninsured.
German public insurance only covers the bare minimum. I know enough people who are poor because of serious health issues. Sure, their medical costs were covered, but they're now welfare cases. They can't afford many treatments that would make their lives better. They would've had to buy extra insurance, but they chose not to, or couldn't afford it.
Relating that to the US: Don't skimp on insurance. Don't get an insurance that is capped at a low number, otherwise you will go bankrupt if shit hits the fan.
>Don't get an insurance that is capped at a low number, otherwise you will go bankrupt if shit hits the fan.
But shit will not hit the fan for the overwhelming majority of people. There's no good reason for someone in their 20s (or 30s) with, no dependents, no history of medical problems and doesn't partake in a dangerous lifestyle to load up on coverage. Loading up on coverage in that situation might make you feel warm and fuzzy. It might win you internet points. It is not financially sound.
> Socialized insurance rates in Germany are 15% of income. Unless your family doesn't earn any money, they have been paying far more than 50 Euros.
And that's kinda the point of the parents' post, I think. If I were paying 15% of my income for socialized health care, I would be pissed if I ever had to pay anything out of pocket for my own medical needs.
>>Socialized insurance rates in Germany are 15% of income. Unless your family doesn't earn any money, they have been paying far more than 50 Euros.
Comments like this always miss the larger point, which is that healthcare overall is cheaper in socialized systems because the government as a large entity negotiates on behalf of citizens and puts strong downward pressure on prices.
Guess what, private insurance companies will also negotiate prices.
What happens in socialized systems is that the government does price fixing, which makes healthcare worse and it limits supply. Try getting a specialist appointment with socialized healthcare in Germany, it can take several months. Get private insurance (or pay out of pocket) and suddenly appointments become available. Doctors are leaving the country in droves.
Some of the hospitals in Germany are in an abysmal state, MRSA rates are extremely high:
>>Guess what, private insurance companies will also negotiate prices.
They negotiate prices based on the size of the pool. This is why if you are a small business the rates you will get will be worse than if you were a large enterprise.
With socialized healthcare, the pool is the entire citizenry, which is what gives the government substantial leverage when negotiating.
The German government doesn't negotiate anything. They set prices, period. Set them too low and you create shortages. Guess what the German healthcare system has, it's a shortage of doctors, especially specialists. German doctors are leaving for greener pastures, like Switzerland. They are replaced by doctors from Eastern Europe. Quality suffers. Waiting times are high. Most Germans are too uninformed or arrogant to admit it (especially to Americans) but the system sucks.
That's not to say the American system is good, but I can't stand all this talk about how socialized healthcare is so great. It isn't. A lot of what people are calling "socialized" systems are actually private systems with a compulsion to purchase insurance, for example Switzerland, Netherlands, Australia. Even Germany technically has a dual system (public and private) but only the top earners are allowed to go private.
> The German government doesn't negotiate anything. They set prices, period
Incorrect. In the public system, the fees are negotiated between the GKV Spitzenverband (federal association of public health insurers) and the KBV (federal association of public doctors).
Germany still is in the top group regarding quality of care indicators.
Australia doesn't have any compulsion to purchase insurance. It's perfectly normal to skip it and receive treatment on Medicare. However, if you don't have private insurance, and have a relatively high income, you pay a tax surcharge.
You have a point. There are a lot of people comparing the worst parts of the US system with the best parts of the single payer systems.
As a Canadian, I will say there are a lot of people dissatisfied with the Canadian system. Likely to a lesser degree than in the US, but the system is far from perfect.
Health care can never be perfect unless you (personally or government) are willing to pay an indefinite amount of money towards it. The positive with an imperfect socialized system is that it's under democratic control. In other words society decides what to prioritize.
The greatest trick healthcare companies have pulled is convincing Americans that after hours visits for things like high fevers and broken bones isn't basic care.
I'm 40, and my Mom was telling me about how my brother cut his head as a child, and the local small town doctor came in after hours to stitch it up. Different era.
Yeah, it's relatively low-probability but still essential. Getting a broken bone fixed seems like more of a basic human right than a "premium service".
What do you do when they’re closed? Guess how many urgent cares within 15 miles of where I live are open at 3:30 AM? I live in a major metro area, and the answer is ZERO.
It is a basic visit. I attended a first-aid training for new parents here in my home country and the general advice was to seek help if in doubt, at night times by calling an ambulance or visiting, well, the emergency room.
In two years we were there with our baby two times. Not charged a penny. During this time, I went once, my wife went once. In all instances we were reassured that it was appropriate to visit the hospital instead of visiting the GP the next day.
Yeah, taking a kid with a high fever to the ER in Toronto is a total no-brainer since it's 100% covered by OHIP. Now living in SF, and I've found myself mentally doing risk probability calculations, and concluding I'd be better off skipping the ER and instead following the instructions from off-the-shelf motrin because the ER visit is likely not worth the cost.
My wife firmly believes the US healthcare system is a giant scam where insurance companies leech off people without actually providing any value.
> My wife firmly believes the US healthcare system is a giant scam where insurance companies leech off people without actually providing any value.
Health insurance in the US is built around providing value to employers. Most employers are concerned about which network is going to upset the fewest key employees and cost the least amount of money for the employer, while fulfilling all legal obligations, without making the employees spend too much time dealing with the insurance company when they could be working. Nicer employers may want to cover more of the cost, or want to upset fewer employees, or have specific things they want covered that aren't legally obligated.
There's also the problem that different groups of people want totally different things from the system. I like integrated care, because it provides me with a single place to go, that handles everything, even though it may not always be the best care. Other people are more focused on getting the best care, and are ok with (or prefer) to pick the individuals who provide each service, even though it means visiting multiple locations. Nicer employers offer you a choice of providers, but it would probably be less expensive for them if everyone was on one plan, at the cost of upsetting more employees.
Technically I did, since my taxes pay for it. What I didn't pay for is the overhead of clerical work from two different corporations for mailing me letters informing me of how arbitrarily priced my doctor visit was.
You did pay for it. Half of the Ontario budget goes towards it.
The fact that you would go without thought of the cost but in a similiar situation would avoid because of the direct costs shows why the Ontario system is a poor model. The costs are hidden so more services are used. If costs were direct paid for out of your Ontario fund (a yearly budget that if not used would be carried forwarded or removed from your taxes) than a better balance could be found.
My taxes pay for the doctor's time, the nurse's time, the receptionist's time, etc. And that is entirely fair. It does not pay for clerical workers in different companies to be sending paperwork back and forth to satisfy some systematically complicated pricing structure, because such a thing does not exist. And it certainly does not pay the salary for the CEO of CollectiveHealth or whatever your provider is.
> The fact that you would go without thought of the cost but in a similar situation would avoid because of the direct costs shows why the Ontario system is a poor model
The pricing is hidden from me regardless, except that in one case people get the care they need and go on with their lives, and in the other I hear stories of people getting a surprise 4-digit bill in the mail three weeks later, after already paying through the nose for insurance.
When you look at international rankings of standard of living, the Ontario system is considered a good model (along with other similar healthcare systems such as those in nordic countries). The US model is poorer on several fronts, from pricing opaqueness to availability for low income people, and let's not even go into medical bankruptcies...
> and in the other I hear stories of people getting a surprise 4-digit bill in the mail three weeks later, after already paying through the nose for insurance.
Lol. I wish. For me it was 5 digits. Closer to 6 than 4. And I had a $1,800/month premium for a family of 4. Spent multiple hours per week for months on end playing phone tag for the hospital and insurance company until it got resolved. Hospital billing also told me to not worry because nothing ever gets paid until both sides start suing eachother.
Yeah, this is peak efficiency. I just love taking up "resolving medical bills" as an unpaid part time job for the better part of a year.
I agree incentive structure matters, and it's why I consider the OHIP model superior: "I need care and it's already paid for, so I get it", vs the US model "I pay more upfront to do the triage nurse's job myself so I can then pay again if I do decide to see the doctor after all and geez I hope I can afford the bill when it comes"
And provide us with a dedicated phone number staffed by people trained to identify whether it is, in fact, an emergency, who will tell you to call an ambulance if necessary.
Not really. There are non-ER/non-hospital urgent-care centers, but they usually keep to roughly normal business hours. For after-hours care, the ER at a hospital is often your only option.
For those from tri-state area: folks, PM Pediatrics is a blessing. They're open till midnight, waiting times are reasonable and they are billed as PCP by the insurance.
An emergency room is a fairly regular visit if you are a parent. I have three young kids and all of them have been to emergency at least a few times — you'll call the government hotline, they'll tell you how urgent it sounds, then you go
They don't want anyone to risk staying home with their child if there's a chance that they are in danger
This is in Australia and there is no cost for this
I'd be careful you're talking about the same thing as a US ER because there are two other places you can take your kids in an "emergency" in the US that are not called ER: you can go to the kid's pediatrician who will have emergency appointments during roughly the same hours stored are open (e.g. Saturday and Sunday); and there are Urgent Care centers that are usually open late into the evening 7 days or possibly 7*24h. Urgent Care have basic X-ray and will stitch up pretty bad gashes. I have two kids and we've only been to the ER one time when my son was in anaphylaxis. Broken arms, facial lacerations, were handled at Urgent Care.
I've been to the ER half a dozen times with my son (reactive airway issues every time he gets a cold). It's totally something we could manage at home, but it took forever to convince our GP to prescribe the necessary meds (she was more comfortable with us going to the ER, despite the cost (both financially and the added stress of packing up a 1 year old to go to the ER)).
In Australia, you can also call a home visiting doctor outside business hours & on weekends, they'll come to your house in O(hours) and diagnose you for free. If you have some private health plans on top, they'll dispense basic meds like antibiotics on the spot as well. Far more convenient and likely cheaper to the taxpayer than waiting around ER for hours with a cranky baby with an ear infection.
In Norway you max out your copay at around $250/year for everything except some prescriptions. Once you hit the cap, they send you a card in the mail that you show your doctor, pharmacist, etc. so they don't charge you a further copay.
Yeah, I saw that and thought "sign me up!" I paid $1200 for a chest X-ray at the emergency room in San Francisco (I was fine, but they understandably freak out about an adult male complaining about chest pain).
When I lived in SF I once cut into my finger with a rusty fish filet knife (don't ask). I went to the bernal hospital ER and they gave me a tetanus shot, but nothing else. A few weeks later I went to my family doc and mentioned this, and he said, "You went to an ER for a tetanus shot?" Me: "Uh, Yeah." Him: "That's like a $1500 tetanus shot."
They didn't have urgent care back then, but I understand there were "clinics" that could give those shots.
You should go to a his doctor's walk-in clinic instead (it cost $100 here). But yeah I completely agree.. it is a lot cheaper if you don't have money and are not insured (they cut you a huge break).
This old, but I was ridiculed at my ER visit w/ my >1 y.o - after waiting for many hours they mocked us since her temp was only 104.8, not the truly urgent at 105.1, or some such numbers, an arbitrary distinction at least to us non-pediatric physician types. The little thing was clearly in trouble and the creeps had no compassion.
I agree. I think in US you pay a lot of taxes to get pretty much nothing in return. You have no universal healthcare, students have to make huge debts to be able to study, there is no maternity leave, no support for childcare, seriously there is basically no welfare whatsoever. Not to mention property taxes (at least in California) that are outrageous.
And if you get seriously ill and lose your job you are pretty much ... done! oO
By the way, the reason your comments are marked [dead] and many users cannot see them is likely because you don’t have an email in your profile. If you add one it won’t be visible to anyone but the site operators, if you’re concerned about that.
If you do you can disregard this message. I hate to see legitimate new users being turned away because they feel like they’re shouting into an anti-spam void.
Like to bring this up when we talk taxes: I think it's totally crazy that we give the feds 25% or more and our states soo soo sooooo much less. I think it should be the other way around:
5% for the feds, and maybe 20% to the states. The reason is that our cities are filled with bums, and have absolutely no money to either give them jobs or make new programs. The feds don't give a shit and are busy making missiles or creating massive social programs that enrich the wrong people. I think the current strategy is broken. The other nice thing about this, is that we'd pay less in taxes AND the states/cities would be able to handle every damn thing it needs. It would be like 2x to 3x the money they are getting right now.
When people who are fans of the "Scandinavian model" in the U.S. try and hype it up, this is what they seldom understand (or at least publicly recommend).
In Sweden, until you hit ~$65,000 in yearly income, all of the taxes you pay on income (which is a relatively high rate) goes to your local government. Only after that point, your extra income goes to the federal government. [1]
This model cuts out the immensely large federal government which serves as a middle-man for distributing the income you contribute to your local community, while simultaneously sucking out so much of it— either siphoning it to federal causes, or people's salaries chipping away at it as it's sloshed around.
It's much more efficient when the majority of your income taxes support your local community directly. In the U.S. right now, these localities rely on property taxes, which is _much_ smaller of an income stream. People supporting the Scandinavian model should understand that this is necessary, and that's even more true when your country is larger.
[1] https://www.nordisketax.net/main.asp?url=files/sve/eng/i07.a... Heard this point from Swedish family and having trouble finding it online, but the typical municipality income tax is 29-34% and corresponds to equivalent tax deductions from federal taxation, which seems to effectively have the same (or near same) result.
Is there some kind of balancing which prevents the nice areas (i.e. containing more affluent people) from becoming really nice, and the poorer areas becoming worse?
There isn’t explicitly, and I know that’s part of what the federal top-down model tries to prevent, but is it really working? The United States’ affluent areas are night-and-day to the poor ones.
If we think about the per-capita income in poorer areas of the States, and what can be taxed off of that, it seems like it’s still enough for that community to function.
The current U.S. model seems to result in everyone getting a much smaller pie, even if the government manages to change the portions of who gets what.
This is actually a huge lever of control for the federal government, and I think has contributed greatly to increase of federal power over the states. The reason being that states can tap into that large federal stream... If they meet the federal criteria. This kind of carrot system is actually how many federal laws that seem to effect the states work. For instance, no state was ever mandated to implement the No Child Left Behind act. They just wouldn't get federal education funding if they didn't... Transportation is another area where this is pretty common.
Yeah, like did you know that 18 is the legal drinking age in the US? That's why 18 year old soldiers can drink alcohol in the military. BUT, if a state increases the drinking age to 21 in their state then they get sweet sweet federal highway funds. For a long time Louisiana was a holdout, so 18-21 year olds would go there to party for mardis gras, and the road quality showed it.
Yeah, but then we'd just be dominated by states like Minnesota, California, Delaware, New York, etc. Basically, ginormous pools of money would start to build in the old Union and out on the west coast. But almost everyone in the middle would be hosed. (I mean places like Oklahoma and Colorado would likely be pretty happy, but everyone else would take substantial financial hits.)
> Yeah, but then we'd just be dominated by states like Minnesota, California, Delaware, New York, etc. Basically, ginormous pools of money would start to build in the old Union and out on the west coast. But almost everyone in the middle would be hosed.
Not really. States like California are net payers, but only just, because they have large diverse populations and end up getting back almost all of what they pay in.
It's true that a lot of the middle states are net recipients, but most of them are still below $4000 per capita.
And the bigger problem is that so much of the money is wasted. Each Congressman goes to Washington to bring back pork, and they do, but pork is inefficient. So they bring back $10,000 per capita in funding after paying in $6000, but only $5000 of the $10,000 is put to productive use. Does that really help the states compared to just keeping their original $6000 and using all of it productively because you don't have to negotiate with 49 other states for how to spend your own money?
I think you have an incorrect understanding of pork barrel spending. Of that $10,000 that you put into the government. $6000 go to social security/medicare. $2,000 to military+veterans. Then another $600 to debt. And the remaining $1,400 goes to education/food+ agro/education/transportation/housing/science/energy/internal affairs. I don't know how much of that is pork barrel spending but I doubt it's more than a couple of hundred.
You're using national average math, not net-recipient state math. It's rarely the case that states that receive more than they pay do so as a result of social security. It would also be pretty hard for a state's net receipts to be interest on the debt absent some kind of sovereign wealth fund that held US treasuries, which most US states don't have.
Moreover, the military budget is where a sizable chunk of the pork lives.
And the problem isn't just pork, it's the general inefficiency of hoovering up your state's money and then sending it back with strings attached. Federal programs can require hot garbage like designated "affordable housing" (i.e. cordoning off a slum to concentrate poverty in) as a condition for housing grants, or "teach to the test" education programs like NCLB. It's not a stretch to claim that the states could be better off with less money but without the strings attached.
Sure it can, when the "simple transfers" have qualifiers that induce unfunded inefficiency and other externalized costs.
If you have to spend five hours a month to prove that you qualify for a program that pays $80/month when your labor is worth $10/hour, you're not receiving net $80/month, you're receiving net $30/month and then getting paid to labor for five hours, the second of which you could have done for any other employer using the same five hours, so the value of the program is $30/month even though it costs $80/month to the taxpayer. Plus whatever administrative costs exist on the government's side. And then whatever value the alternative employer would have derived from having a worker available to work those extra hours.
It's even possible for programs to have negative value. They can cost money and then destroy more value than that. A lot of housing and other subsides can do this, e.g. you give some people $500/month for housing, but that only causes local rents to increase by $150/month -- on everyone, including the people not eligible for the subsidy. So on paper you have a thousand people receiving $500/month and you think you've gained $500,000, but then you account for the five thousand people who now pay $150/month more, cost of $750,000, and you're net -$250,000. Meanwhile the taxpayer still had to pay $500,000 to make that happen.
I know in theory you can spend money that destroys value. You don't even need to rely on weird supply/demand curves, you could just pay for bomber jets to literally firebomb a city.
But realistically how could Montana get an 80% increase in efficiency while providing similar services to the federal government?
And according to normal economics textbooks increasing market rent isn't destroying value. If more people move to a city which drives up demand and rent. Economists don't think of that as value destruction. In classic economics textbooks the value destruction caused by subsidized rent is that some people will spend $1000 on rent that they would never rent without the subsidy because they only get $800 of value from it + the dead weight loss of the taxes that funded that subsidy.
> But realistically how could Montana get an 80% increase in efficiency while providing similar services to the federal government?
By removing all the strings. The problem with the existing federal programs is that they're numerous, complex and individually small, which is the recipe for inefficiency. That results in high administrative costs -- not only for the government but also for the recipients, and only the first cost is actually accounted for in the government budget, even though the second is much larger. Because government agencies do their tasks as a full time job but the recipients are novices who have to amortize the cost of learning and using the system over only their individual use of it. Again, suppose someone has to spend five hours a month to navigate a program that pays $80/month. Then if their labor is worth $10/hour, just their side of the transaction contains $50/month worth of inefficiency.
Even the fact that housing grants have to be spent on housing is inefficient, because it distorts the market for the thing being subsidized:
> And according to normal economics textbooks increasing market rent isn't destroying value. If more people move to a city which drives up demand and rent. Economists don't think of that as value destruction. In classic economics textbooks the value destruction caused by subsidized rent is that some people will spend $1000 on rent that they would never rent without the subsidy because they only get $800 of value from it + the dead weight loss of the taxes that funded that subsidy.
But this isn't caused by more people moving to the city, it's caused by the people who already live there getting a bunch of money they're only allowed to spend on rent. Then some of them would prefer to have fewer roommates or a bigger apartment, so they try to use the money for that, which requires the people who would otherwise live in those other apartments to have to outbid them, causing everyone to have to pay higher rents on the same apartments.
Meanwhile the rent increase goes to landlords who typically remove it from the local economy, either because the building isn't owned by a local to begin with, or because the owner is a wealthy person who then invests the money in index funds etc. which transfers ~98% of it out of the state. So the value isn't "destroyed" but it immediately leaves the state, which from the state's perspective is basically equivalent.
The whole point of allowing people to deduct their state tax payments was to solve exactly this problem. Let the states that want to tax more and provide more social services do so without harm to their citizens.
Of course that deduction is gone now, which just further solidifies government power.
My own suspicion is that we got rid of that because government wants to harm the citizens of certain states. That's likely one of the benefits of having federal power, the ability structure the system to perpetuate your hold on it. In the US, our politicians do this all the time.
Well, there are actually good arguments to be made on both sides of the issue. For example, one argument is, "why should people who live in high cost states pay less federal tax for the same federal services?" The counter-argument being "they don't need as many government services since they get the same benefits from their state" and also "their incomes are higher so their total dollar contribution is still just as high".
It's a tough issue. From the Federal perspective is makes a lot of sense to get rid of the SALT deductions, and I suspect the next time the Dems are in charge they will "be unable" to restore the deduction for "reasons", since both parties want the extra revenue.
My alternative suspicion is that SALT harms smaller and poorer states, since they can't lower local taxes to attract large businesses without also raising those businesses' federal taxes.
The state tax payments were a deduction, not a credit. So even before the recent SALT limitation raising state taxes would "harm" your state's citizens in the sense that you used "harm".
As an example, if your federal marginal rate were 25%, paying $4k in state taxes would only get you $1k off your federal taxes, not $4k.
Not sure how states taxing more don't harm their own citizens. If I make $100, with 30% federal tax, then I keep $70. If my state raises their tax from 0% to 20%, then I pay $20 to the state, deduct that from my $100 to get $80, and pay $30 on that which is $24. So I keep $56.
IIRC New York City actually has higher rates of housing/sheltering homeless than most other cities in the USA. However, due to population size + density it would still be possible to see the homeless people who refuse/cannot access housing fairly regularly if one lives in or commutes to the densest areas. (For example, I've only ever seen homeless people in the heart of manhattan. I commute to Astoria and Flushing and long island fairly often and hardly ever/never see homeless people there.)
That is a perspective from somebody living in a place with state income tax. Life is so much better when you are not paying state income taxes. Texas, Florida, and a few other places have no state income taxes.
Your reply is to a post that is talking about taxes generally, not income taxes specifically. Texas has no income tax, but has sales[0] and property[1] taxes that are above the national average, as well as tolls on many public[2] roads. Texans are heavily taxed, but in ways which are based on overall footprint/usage rather than the ham-fisted distribution of income taxes that other states prefer. I agree with your assertion that life is better because of that.
who are the "wrong people" that massive social programs enrich? Can you give an example? Most of federal spending is medicare, medicaid and social security; which are immensely popular with voters of all kind.
> who are the "wrong people" that massive social programs enrich? Can you give an example? Most of federal spending is medicare, medicaid and social security; which are immensely popular with voters of all kind.
If you ask people if they support the abstract idea of having a military so we're not invaded by foreign forces, or having a program to prevent the elderly from dying in the streets, they say yes.
But then you ask them whether social security should send a larger check to a retired Jeff Bezos than a retired firefighter on a fixed income, or the government should spend billions of dollars on equipment the military itself says it doesn't need but the Congressman from the district which is getting the contract to build it says that it does, and the public support for that falls off pretty fast.
And those "features" cause those programs to cost hundreds of billions of dollars more than they need to, which money could otherwise go to infrastructure and schools and tax cuts for the middle class, all of which are also immensely popular with voters of all kinds. But won't happen when the programs absorbing more than three quarters of the total budget are administered in a federal system where the Congressmen are rewarded for bringing home the pork and Florida is an important swing state full of retirees.
Military is like 15% of federal spending, social security and healthcare is 50+% of federal spending.
I agree that there is military excess, but I'm skeptical that reducing it would make THAT much difference.
The military used to be a significantly larger percentage of the budget than it is now, but it's not because the military is any smaller. It's because spending on retirees is exploding. Nobody really wants to admit this because the reason the costs are exploding is that there are so many more people over retirement age, which also means that there are more voters over retirement age, which makes it politically very difficult to do anything about it. But it's a serious problem -- how are we supposed to sustain spending more than half of the government budget on retirees?
And the DoD and the VA are also considered separately, but let's not pretend they're unrelated. If you have twice as many soldiers today then you need twice the VA budget tomorrow.
>Most of federal spending is medicare, medicaid and social security...
Well, there's also Defense, and then service payments on the debt. Those are the big 3 without question. So "the wrong people" must be in there somewhere?
But the real reason we give more to the feds is because if we didn't it would be AWESOME for places like New York, Minnesota, Texas, Delaware, California etc, and TERRIBLE for places like Wisconsin, Alabama, South Carolina, and Florida.
That second group of states is half states in the black belt. Those state governments are bought and paid for and their people largely disenfranchised, same for much of Appalachia. (Like, c'mon, Mississippi is around 40% African American, you really think them electing Donald Trump reflects the true will of the people? Of course not!) They're run by shitty rich people with shitty agendas who are just out to further enrich themselves and have a vested interest in maintaining the power structures that be. That's why the South "votes against its own interests." It's literally a narrative invented by the coal industry so it could justify and get away with brutalizing West Virginia and leaving it far worse off than it was before. Coal owns WV all the way down to the school boards and sherrifs.
The reason for this is that if one state has better social programs then another and higher taxes the poorest are going to move there, and the high earners are going to move away.
This doesn't seem to be a major problem for the EU, which has unrestricted internal migration but social programs are administered by the individual member states.
The idea that the poor will mass migrate to California and the rich will mass migrate to South Dakota is pretty unrealistic. The poor can't afford to live in California even with social assistance, and the rich don't want to live in South Dakota no matter how low the taxes are.
Because money buys stuff taxpayers want. Middle class people want good schools and functioning transit and to know they're going to have a secure retirement. The premise of having the government do these things is that they can do them at least as well as the market. If they succeed they'll have no trouble attracting people to come there and pay taxes in exchange for receiving those services. If they fail and are then out-competed by other states that do better, whether by leaving things to the market or otherwise, isn't that a good thing? It requires the underperforming states to improve or lose population.
> This doesn't seem to be a major problem for the EU, which has unrestricted internal migration but social programs are administered by the individual member states
I might be off the mark here, but from my understanding wasn't unrestricted migration one of the big drivers behind Brexit? Or at least the idea that the "poor countries" were "taking advantage" of the "rich countries"?
A lot of the drivers behind Brexit have a tenuous relationship to facts. There are some legitimate reasons to leave, but there are also self-interested parties telling people the lies they want to be told. And "mistaken people believe this" is no support for a position.
The thing about rich people moving to places with lower taxes and poor people moving to places with more services is that it's the sort of thing that seems intuitively obvious until you actually think about it, and you realize it's like arguing that lakes are impossible because water evaporates.
It's not that water doesn't evaporate. It's not that poor people don't prefer more services and rich people don't prefer lower taxes. It's that everything is not one dimensional and there are other factors that outweigh that one by enough that the lake is still full of water.
My understanding is that unrestricted immigration has the opposite effect: rich countries taking advantage of poor ones, via “brain drain”. That’s why the average age of medicine doctors in Poland seems to be around 50: all the younger ones went to Germany or Scandinavia.
It’s true for blue collar workers as well: try hiring a contractor to remodel your house and then watch them leave the job unfinished because they got a better paying gig in UK (that actually happened to a friend of mine)
Both is true. There is brain drain as well as welfare migration. My hometown in Germany with a population of ~300k now has ~11k migrants from Romania und Bulgaria. Aside from various social problems this is also a big strain on the social systems. 85%+ of households are dependent on child support checks.
There's also the fact that Western European countries desperately need immigration for covering future pensions. Countries like Germany and Finland are the next to follow Japan's crippling issues with aging population and poor dependency ratio.
The studies I have seen referenced suggest that EU migrants to the UK are generally net contributors as they pay their taxes like everyone else but tend to travel here without dependents, be younger and eventually go home before they are too old. Migrants from outside of the UK on the other hand tend to be older and come with families so tend to be a net drain on services.
Leaving the EU will mean more migrants from outside of the EU - so will actually cause the situation a lot of Leavers were worrying about to get a lot worse.
That's taking about external migration (refugees and illegal immigrants), not internal migration under the EU's freedom of movement. Of course, the latter was a major factor in the Brexit referendum, so I wouldn't say it's not a major problem for the EU...
What's even the point of the distinction if the EU is not adequately restricting immigration from those other countries? The point remains the same: people from poor countries are mass migrating to rich countries with the most social programs. This is a major problem for the EU.
The point of distinction is that EU internal immigration and the refugee situation are entirely different things. Refugees leave there home countries because of war and terror. Members of the UN are obligated [1] to give shelter to those people.
Inside the EU there is indeed some welfare migration. This is however not only driven by social systems but also by available jobs.
Those high earners will screw up the economy of their destination state accidentally gutting the lower middle class, institute social programs to deal with the all the problems this creates, realized they just created the same dystopia they fled and move again.
It's like a perverse form of rolling upgrades.
You can see this process in action in places like CO and the PNW states which are starting to flip from "rich people move here" to "poor people move here". TX will probably start flipping soon.
Major urban areas with lots of job opportunity seem vacuum up the wealthy regardless of the state wide trend (no matter how bad NY state gets upper middle class people in search of a lucrative career will be moving to NYC). I'm not sure how that plays into things.
Just a quick note that health insurance premiums do not in fact get plowed directly into rents and administrative redundancies; we pay more than Europe (and Medicare) does in administrative costs, but far-and-away the largest components of health care expenditures in the US are in inpatient and outpatient procedure billings (outpatient by a factor of almost 2x inpatient, itself something like 3-4x all administrative costs).
We certainly do seem to pay far too much for health care! But the explanations aren't as simple as evil health insurers. The system appears to be structurally pretty messed up, and alterations to the payer-side alone, without radical changes to the provider side, are unlikely to solve the problem.
What I was wondering about was how much money is needed for the sheer administration of processing claims and payments in the US system?
In the UK in the NHS, there is none of the layers of beurocracy and paperwork related to call-centers and payment handling and claims inspectors (as far as I know anyway) that I assume is commonplace in the US hospitals and insurance companies. You go in, see the doctor, then leave. Usually the only "paperwork" required is booking another appointment if you need to come back - no forms, no invoices, no payment etc.
I guess it is the same argument made about universal income benefits - if we just gave everyone (rich or poor) in the country a set amount of money each year we'd save billions in not having to means-test every claimant individually and actually save money by giving it away to everyone.
This argument does hold significant validity, unfortunately there is an irrational need to ensure that a minority are not exploiting the system, even at the cost of those who pay for the system.
For example, I think all buses in London should be free. Look around the bus and you'll see that most people aren't directly paying (under 16, over 60, on benefits) and by taking away the need to check for payment we could get people on and off the buses much faster and completely remove the need for card readers.
Agreed! The way countries with cheaper healthcare manage to spend less is by paying healthcare workers much less.
Doctors and nurses in the US are high status. When they lobby against something, it’s hard to win.
When I read people discussing cheaper healthcare, I always go looking for the part where they explain that healthcare professionals will make a significantly lower dollar per hour. I rarely find this discussed.
I wonder how the earnings of American doctors compare to European doctors once you've removed the high cost of an American education/all those student loans they're paying off.
Not everyone. My host family parents are both doctors (psychiatrist and anesthesiologist) in the US, and my girlfriend is currently in a residency program in Long Island, so I can tell from my limited observations.
My host family father (anesthesiologist) works from 7am to about 3pm (works for Einstein medical center in Philly). He pulls weekend extra time (on-call) to make ~$1000/call on Saturdays (to support his hobbies like expensive bikes and lens for photography). Gets paid well above $400K/year until he retired in 2015.
My host mom works as at a quasi-private psychiatry treatment center where she manages about 20 in-house patients (almost always the same patients who she has been treating for many years). She goes to work just like any other 8-5 job. Very relaxed atmosphere. Gets paid very well (to the tune of more than $320K/year until she retired in 2016).
My gf and her fellow residents at the hospital do not have a lot of stuff going on during most part of the days. She is a bit luckier than average resident in that regard though because her hospital is in a suburban setting. Her friends who got into residency programs like in Brooklyn, Bronx or Queens (e.g., Elmhurst hospital in Queens) have to work harder in their first and second years (especially only the first year). But not as bad as like 80 hrs/week like what you read in exaggerated news articles. Sure they work more than 40 hours because of on-calls and night duties. But definitely around 60 hrs/week (never approaching more than 70).
All this is to say that the work hours of US doctors and medical residents (doctors in training) that we see in the news, I suspect, are a bit exaggerated (of course, they have to be bad/outliers in order to be in the news).
I'd like to add that my host parents practiced in the UK for almost 7 years, and decided to move to the US (practiced here for almost two decades) because in the UK, they made like a quarter of what they were able to make in the US.
Last but not least, all of them (my host parents and my gf) studied medicine in Burma (a third world country) for 5 years only (+2 years of residency). Certainly, the education one can get at Myanmar government-funded medical Universities isn't top-notch or state-of-the-art, but most med students learned on their own by supplementing with private classes, self-learning and practice (e.g., shadowing doctors). They (international medical graduates) score very well (usually better than their US peers--see chart #6, #7 in [1]). The point I'm trying to make is that we do NOT need 4 years of undergraduate education for wanna-be doctors (pre-med students) because that is not necessary and adds more debt burden to future doctors. This artificial barrier to entry is adding to the inflated healthcare price by making it very difficult for anyone to become a doctor in the US. We don't need 8 years of college and medical school education for most specialties; in the end, the garden-variety illnesses can be diagnosed by reading up references like [2], and it doesn't take 8 years of training to do that.
P.S. This rant is partly contributed by my experience when I got an ear infection (acute otitis media) last week and saw a doctor in New York, who charged me $200 for looking into my ears with otoscope for 10 seconds, and wrote up a prescription (the entire encounter lasted no more than 5 minutes). Since my deductible is high ($3K/yr), I had to pay $133 out of pocket. The oral pills (amoxicillin-variant and an antihistamine) for three days costs $30 (which I paid). The worst part is seeing the $283 price quote for ear drop (CIPRODEX). When I decided to not buy that and asked my doc for a more generic version, that costs $35. I asked my mom to buy the same generic version of ear drop from Myanmar as she is visiting me this week. The ear drop costs $15 a piece there; doctor consultation $40; oral pills $7 (for two weeks supply just in case I get the ear infection again in the near future).
I'm not from the US and had to look up "inpatient" and "outpatient", so to share what I've found: as I understand it it's different ways of recording what a patient is suffering from, with "inpatient" being used when a cause is known, and "outpatient" when a doctor can only describe the symptoms, without knowing what they are caused by.
And I guess the relevance is that discerning and switching between the two when a better diagnosis is made causes large administrative overhead?
The Canadian figures seem insanely low. 11.5% total? When I lived in BC making an approximately average income, my effective tax rate alone was 21% [EDIT: originally put 23%]. I paid pension, health insurance, and unemployment deductions on top of that. And that only counts the employee side of deductions.
This example is "married with two kids", so it's possible that there are massive offsets that I didn't have access to as a single person, but 11.5% still seems very low.
I would expect Canada to fare favourably in this comparison, though. The taxes are not as bad as most Americans think. Although they do ramp up very quickly for higher earners, which was an incentive for moving to the states as my income increased. Also, pay is higher in the US (by a factor of about 2 or 3) for the same job.
You might have a skewed sense of what median Canadian income is. And your job might be further above that median than you realize.
Median Canadian individual income is ~$35,000 [0].
In B.C., your average 2019 tax rate would be 13.34% not including non-refundable tax credits (and so the effective rate would likely be a point or two lower). [1]
A median tax rate of 11.5% against a median Canadian individual income seems entirely reasonable.
That 35000 number includes retirees (though I don't know to what extent retirements are income-funded in Canada) and kids still in high school and college (and possibly post-graduate education).
The median income for 45-54 year olds from that site seems to be $49,100. Median for 35-44 is 48,000. It's not $60-80k as you say below, but not $35k either.
One other interesting note is that there is a pretty big difference by gender. Median income for _males_ 35-44 is $56,300 while females are at $41,400. For 45-54 year olds those numbers are $58,000 and $42,400 respectively.
Those differences are big enough that I wonder whether this is being affected by the relative incidence of part-time vs full-time work. The statistics here seem to be looking at people with any income at all (including investment income), not "salaries"... Depending on the demographics of the people you talk to (full-time jobs, 35-55 years old, maybe toss in "male"), $60k is not an unreasonable thing for them to feel a "typical" experience is.
I agree that people with educations and in "good" jobs tend to over-estimate the median income, but I also think that once you account for lifecycle effects the median income of what people think of as a "typical worker" (which is not a 17-year old nor a 70-year old) is higher than the summary statistics suggest. And of course the thing that can really hurt is if you can't find full-time work at all....
It seems you're right. I know I was close to the average for my region, but that's a high cost-of-living city with a much higher median income than 35k. I may have also been conflating household and individual income.
Lessons: 1) I have no concept of the median experience in my country, 2) a single number can't answer the question "does this country have high taxes".
Truthfully, the only reason I had the numbers at hand was because I'd personally fallen for your "Lesson #1" before.
I spent my 20s far below median (which I knew), and my 30s far above median (which I didn't realize, at least not at first). Very different lived experiences :)
And I know many folks around me (friends, family, colleagues) look around (confirmation bias & availability heuristic, amongst others) and believe that $60k-$80k (or more) represents a "typical" lived Canadian experience. They are, to a person, universally surprised to see the actual median income (as was I when first tracking it down).
I once considered relocating with the same company to a similar role in London. The base pay in London is lower, and the marginal tax rates are high, but overall cost of living isn't too terribly far off (compared to the SF Bay Area), and doing calculations like these it seemed that while it would be something of a step down total compensation-wise, it wasn't nearly as large of one as it at first seemed. I didn't make the jump, but actually doing the math made it seem a lot more reasonable than it did at the outset.
The article decides to include employer-side payroll taxes in its US calculations as though this is an income tax - but this is not (appears not to be) done for other countries, where payroll taxes are often higher, so it's not a fair comparison.
Think of what it'd do to the insurance worker economy if we switched to a medicare for all system! It's pretty fucked up that such a large chunk of our country is now essentially parasitic.
(I say this while recognizing that runaway medical costs aren't solely the result of insurers)
VAT taxes (or sales tax in the US) will tend to more heavily effect lower income workers, which will not be the majority of people on HN. VAT taxes are heavily regressive and, outside of the luxury class of such would be nice to see phased out.
Most sales taxes in the US aren’t applied to staple good like food, blunting the impact on lower income workers.
I would disagree it doesn’t impact higher income works because you’re still paying sales tax on luxury items and because of the high prices, the tax is very high.
In Canada it’s not uncommon for the HST to be 15%.
Or really any public pension. I feel like if you're <40 then you should be planning for Social Security to not exist when you get old, anything else seems overly optimistic.
There's literally no analysis that shows social security completely failing at any point. That's spin you're getting from partisan media, and it's absolutely infuriating the people allow this to persist.
In a few years, given no changes, the cash flow will go negative and we'll begin spending down the trust fund. By 2035 or so (I forget the numbers, and the projections tend to vary widely anyway because of differing models and, yeah, partisan spin) the trust fund will be spent and the social security administration will need to adjust, as it will be taking in something like 80% of obligations.
A 20% shortfall is a big accounting problem. It's hardly "plan for it not to exist".
The trust fund is an accounting fiction that doesn't hold any economically productive assets. Congress spent social security's surplus in the general budget and issued special obligation bonds in return that accumulate "interest" on paper but do not ever collect from the government. They cannot be sold on the market. Taxes or debt needs to be raised or benefits need to be cut effectively now.
This is from a 1999 OMB report:
``These [trust fund] balances are available to finance future benefit payments and other trust fund expenditures–but only in a bookkeeping sense. These funds are not set up to be pension funds, like the funds of private pension plans. They do not consist of real economic assets that can be drawn down in the future to fund benefits. Instead, they are claims on the Treasury, that, when redeemed, will have to be financed by raising taxes, borrowing from the public, or reducing benefits or other expenditures.``
So... you don't think it's insolvent then and agree with the OMB that the bookeeping gets complicated but that money exists to pay the existing claims in full for the next few decades? What is your position if you aren't claiming it's going to go up in a big kaboom?
Ugh. Why do these threads always turning into such a strawman mess.
"Big accounting problem", in fact, were MY words upthread when replying to a claim that SS benefits might not exist by then. And I agree, a ~20% shortfall is a big accounting problem. But it's not a social disaster and doesn't need to be treated like one.
Consider: reduce benefits by 7%, increase the FICA payroll tax by 7%, adjust incentives so people reduce their benefit-years by 7%. Seems like our society can survive that without planning on retirement without government assistance.
Oh sorry, I'll clarify... My concern is not that it will become untenable and money will run out - my concern is that it will be slashed into the ground as part of an "entitlement cut" - it's actually pretty unlikely given the party of cutting things that people like gets a lot of votes from the social security crowd, but there is only so much more than can slice off Medicaid before they start looking elsewhere.
that's totally self defeating. There are simple adjustments that can be done to make it viable long term. But there are quite few people in DC who desperately want it to fail to show that government is no good.
Social Security is so popular that either party trying to cut benefits will be voted out at the next election, especially if the other party runs on restoring it. So instead of cutting benefits to those currently receiving it, instead there will be a call to increase the retirement age. This is already happening in Denmark where the retirement age will be 67 by 2022 and after 2030 could be increased 1 year every 5 years.
Raising the retirement age is probably the only way to keep things going. People used to retire in their 60s and died in their 70s. Now they live up to 90 and more. Simple math tells us that this is not sustainable.
Social Security is just sending checks worth 3 or 4 percent of GDP to old people. It’s about the same as defense spending. Nobody ever worries about running out of money for defense.
Social Security spending is >2x the military budget, making up one third(!!!) of the US federal spending every year [1]. It's also a system that is inherently growing in terms of payouts and shrinking in terms of pay-ins [2]. This might not be a big deal if it was just a normal tax, but the idea behind Social Security is that your Social Security tax contributions pay off the current payouts. So if the system continued to exist as it is now, the amount paid into the system would have to grow significantly to ever pay out this generation's Social Security and the pattern would likely worsen over time.
You're paying into SS but that money is not being set aside for you, it's being used for current retirees. The next generation will have to pay into SS for you and betting that SS will not change it's payout conditions till then, in the midst of mounting debt liabilities and potentially shrinking contributions, is quite optimistic.
I'm not sure why you've been downvoted. Your statement has both facts and opinion, and forwards the conversation.
Personally, I agree with your opinion. I think that we're going to get to the point where SS is taking in less than it pays out and, combined with the large amount of individuals who don't like anyone getting government money and so push to get rid of it, the system is going to fall apart.
The worst part is that it's not even the government's money. People pay into the SS and take back out later. It's supposed to work like a savings account, to some extent.
Just to clarify, your payments aren't being specifically earmarked for you (this isn't a government run retirement plan) they are being pooled and that pool is being used to pay for current and future SS beneficiaries, but the pool isn't going to run out anytime soon. It's more likely that it will be diverted for political reasons and defunded - to speak precisely the "entitlements" you paid for will be taken away without recompense.
The SS trust fund is currently about $3 trillion. While the money you pay in isn’t specifically set aside for your own use (the whole point of the program is to pool everyone together), it’s not like a Ponzi scheme where contributions from people paying in are directly used to make payments to beneficiaries.
The SS trust fund is an accounting fiction. The vast majority of it is held as treasury securities and the cash has long since been spent. Thus the federal government has offsetting liabilities for all of those assets. Once SS starts spending more than it takes in, the feds will have to raise capital to cover the shortfall, same as if the trust fund did not exist.
Sorry, this comment missed a big point - the money wasn't spent on Social Security, the money has been borrowed by other agencies and expenditures that owe it back.
That's like saying "Oh man, your job isn't paying you enough money, you should quit." 'But I make 80k, that's plenty!' "Oh, you uh did, until I stole all but five dollars." 'Oh darn, guess I'll quit then.'
I'm well aware that the money was dumped into the general fund and spent on other things. That doesn't change the fact that the money is gone, so saying that the trust fund has $3 trillion doesn't really help with SS's fiscal viability.
If the US government was instead a group of private corporations then the balance for SS would be positive due to the assets they have in the form of debts, just because there isn't cold hard cash there doesn't mean the money doesn't exist - the only way to get to that point is to consider the other parts of the government as bad borrowers and assume the debt will need to be written off.
It's different because the private company didn't issue the securities itself. The equivalent for a private company would be creating $3 trillion in bonds, "selling" the bonds to itself, then claiming to have $3 trillion.
In this analogy, they’d be different departments or subsidiaries with different balance sheets, so there’s no need for the scare quotes: they really are selling the bonds. And they didn’t issue $3 trillion in bonds, they issued $20 trillion and sold most of them to other parties on the same terms.
At the very least it indicates that the company prioritizes the finances of that one department much more than any other.
The other problem I have with this complaint is that it implies that things would be different if it didn’t hold treasuries. If it had $3 trillion in a bank account, would that make it “real”? The US government issues dollars too, and can devalue the currency at will, so it’s not really better.
Ultimately, it’s a commitment mechanism. If SS were paid out of the general fund, it could be cut off to fund other projects at will, as long as Congress were willing to piss off old folks. (Which is already a big obstacle, admittedly.) By funding benefits from a gigantic trust fund holding government debt, cutting off SS to fund something else would require imploding the world economy.
I definitely place myself on the liberal side of politics and will support social security for people before and after myself, but the current generation of older folks definitely appear to be trying to pull that ladder up behind them.
So - in the UK you pay national insurance, which ostensibly pays for the NHS and retirement benefits.
If you earn £150k a year (top 2% of salaries in the UK) you pay £6,964.16 a year. That's an astounding deal. There are no deductibles, no co pays for hospital stays, GP visits are free, as are any tests and investigations.
You do pay £9 for each item on a prescription, but if you get more than 3 items a month you can pay a flat rate of £104 a year for a prepayment certificate.
Private health insurance is still a thing - it just gets you a nicer room in a private hospital and quicker treatment for non life-threatening conditions.
You pay around 40% effective tax rate at £150k. It doesn't really matter exactly where the money goes, at the end of the day the budget has to made by the chancellor and they'll funnel money from NI to other areas and vice versa if they need to.
The NHS is underfunded, sure, but in an emergency situation (you know, the kind that will bankrupt you in the US) you won't get treated privately, it will be done on the NHS. Sure, if you have cancer your Chemo will be given in nicer surroundings, but it's the same drugs administered under the same protocol.
All private insurance in the UK gives you is that - a nicer environment and quicker access to treatment for non life-threatening conditions.
Yes, emergency treatment is on the NHS but so what? That doesn't mean it's good! Emergency care is better in the US( even if it later bankrupts you). You can routinely wait for 6-12 hours in an emergency room in the UK (admittedly not for truly life-threatening situations). By most metrics, healthcare outcomes in the US are much better than in the NHS, quick google found this: https://qz.com/397419/the-british-seem-less-likely-to-get-ca...
"All private insurance in the UK gives you is that - a nicer environment and quicker access to treatment for non life-threatening conditions."
That report has some very interesting charts. E.g. Figure 9 shows that almost 25% of people in USA skipped going to the doctors due to cost, or almost 20% of people in USA skipped prescription medicine due to cost. For comparison on the NHS it was 5% and 2% respectively. Mind-boggling.
I'd agree though that anyone on 150K plus (and probably anyone in a job from the 40K range upward (if not lower)) would have private medical cover. As others have noted, private cover basically just means you get seen quicker/at a more convienient time and the waiting room is nicer - the care is no better or worse than the NHS IME (although I dont have any data on that - just a personal anecdote)
A good citation can be found in the one you provided:
Under Key findings:
Its main weakness is health care outcomes. The UK appears to perform less well than similar countries on the overall rate at which people die when successful medical care
could have saved their lives.
Among its strengths, the NHS does better than health systems in comparable countries at protecting people from heavy financial costs when they are ill. People in the UK are also less likely than in other countries to be put off from seeking medical help due to costs.
So: main strength - cheap, main weakness - health care outcomes!
It's no surprise that fewer people in the UK skip medical care due to costs when it's (close to) free. The problem is that the health care is bad when you get it (according to your own provided document)!
Nowhere in that report does it say it is "garbage", as you suggest it is.
Yes it is not as good as some other wealthy countries, but it is by no means "garbage", e.g. on page 35: "The results show that although the UK does well by global standards, it performs poorly compared with the other developed countries in our comparison group". "..does well by global standards.." completely contradicts the idea that it is "garbage".
There are some interesting comments in the document suggesting that some of the health outcomes might actually be social which was news to me an quite interesting - e.g. the british "stiff upper lip"/"keep calm and carry on" might be causing people to defer medical help, or that the large income disparity could be skewing it. Interesting & worrying stuff.
Does well by global standards?! Yes, we should definitely be comparing our healthcare system to those found in places like the Congo. It has bad healthcare outcomes and costs a lot for them, that is bad, don't get hung up on the single word 'garbage', it's called hyperbole.
Same personal anecdote - have excellent BUPA coverage, just allows you to skip the lines for non serious things, if you have a heart attack you'll be going to an NHS A&E whether you have private insurance or not.
Utter garbage is a bit strong but yes a lot of people on that income will have additional private health insurance. Insurance which is cheap as chips because it only covers additional things. Even if you're buying privately (not as a company benefit) you're paying £900ish a year per person.
Tangential: As a non-native speaker, I find the word PREMIUM highly problematic. You need a lot of contexts to understand that the article is talking about health care costs not covered by health insurance.
It's not because you are a non-native speaker. It's not a widely used English term without the word Insurance in front of it, however it is a standard American English term.
It is also not the costs "not covered by health insurance", rather the insurance premium is the cost of the policy itself.
Interesting, thanks!
But from what I know people in US often end up paying extra cash (on top of their health insurance) for procedures, checkups, and drugs. This is rather rare in EU. That should be included in whatever international comparison.
>It’s just that they pay it into a private insurance system that wastes large portions of it on rents and administrative redundancy.
Would love to see a breakdown of real estate and admin costs for private insurance systems throughout the States to understand how much could be saved by eliminating redundancy.
Private healthcare insurance has margins well below most profitable companies, in the us. If anything I'd hazard that the poor treatment of consumers by these entities stems from being barely able to hold the line, not because of greed. Rising medical costs, I think, have the blame elsewhere, but insurance companies sure do make a good Boogeyman for politicians, because they are very poorly understood.
I'm not sure you understand what circular reasoning is. And anyways, i can show you an industry with enormous redundant costs that also has high margins - hollywood - but of course they achieve that through clever use of corporate law; the median hollywood company loses money but the wins all go to the margins of the major holding companies.
It seems like the argument you are making is that a sector cannot be wasteful because it has low margins. In order to accept that argument, one would have to agree in advance that the sector has a net positive value to society and should definitely exist. Agreeing that the sector should exist makes it impossible to seriously discuss whether the sector should exist.
The value of a sector to its host civilizaiton is the amount by which its externalities exceed its revenues. If the sector were eliminated, those revenues could be directed elsewhere.
In the case of Hollywood, the value of the movies produced is worth at least as much as people are willing to pay to see them. Solvency here is evidence of net positive value.
Even in a vilified industry like big tobacco, the value of the product is worth more to the people paying for it than their money is. Solvency here is evidence of net positive (perceived) value.
But in the case of the private medical insurance sector, the amount of benefit that all customers receive has to be less than the amount that all customers pay. Solvency is evidence of net negative value, unless there are some other externalities. So, what could those be? Fire insurance can prevent disruptions to a city. But can private medical insurance prevent public health hazards? I don't see why it would be better suited to do so than a single-payer alternative.
It's hard to tell, because pricing is so opaque, but everywhere the incentives are misaligned.
Insurance companies are regulated on profit margins, which means it's actually in their interest for costs to rise, since their income is limited to a percentage of the costs. Administrative overhead at the insurance company is limited by percentage as well, but I don't think that includes the overhead at medical offices required to deal with insurance billing.
Users may be able to pick between different cost options, but at best they know the direct cost to them, not the overall cost. There's also a sense of wanting to get the most the insurance will cover, because that's why you paid for it.
Doctors' compensation is certain a factor, especially since there are effective rate limits on new doctors based on the number of slots for residencies, that aren't adjusted for population growth.
Employers (who are usually the ones selecting the insurance plans) may be cost aware, but might be selecting based on direct costs to the employer and not on total cost to the employer and employee combined.
Seems to be a huge reluctance for anyone in politics to place the blame on them. But I'm pretty sure they make far more in the US than anywhere else in the world.
From what I've read, doctors are also substantial owners of the malpractice insurance companies. Also, their premiums are paid by their employers. In fact, salaries don't tell the entire story for doctors, since they are heavily invested in their own industry. For instance, at one point my health insurance provider advertised itself as being doctor-owned.
As mentioned above, a problem is that the system is so opaque, seemingly by design. A potential benefit of a government run system is that there could simply be fewer business entities. For instance, doctors could just work for the government, for a decent salary.
> But I'm pretty sure they make far more in the US than anywhere else in the world.
Yea, but the opportunity cost of getting there is huge. At graduation, most doctors are in the ballpark of $1MM behind where they'd be if they went straight into a professional career.
Also, doctor's salaries only account for 8% to 20% of total healthcare costs.
that's not entirely true. There are nonprofit medical providers and they are equally expensive as for-profits; and there are also in the US a handful of "extreme for-profit" medical providers which are considerably cheaper (without sacrificing quality).
Non-profit doesn't mean "we don't pay our staff, partners and suppliers market rate". It's entirely possible that non-profits contribute towards rising medical costs through the same mechanisms that for-profit entities do.
According to a comprehensive study published in the New England Journal of Medicine, U.S. admin costs are double that of Canada.[1] More context in this NYT column, which features this quote: "'The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,' said Kevin Schulman, a co-author of [another] study and a professor of medicine at Duke. 'The high administrative costs are functions of the system’s complexity.'"[2]
Also, these studies don't take into account the time/opportunity cost to consumers of navigating this complicated system, which can be quite substantial.
> Would love to see a breakdown of real estate and admin costs for private insurance systems throughout the States to understand how much could be saved by eliminating redundancy.
I would love to see the same breakdown for the Netherlands, Germany, and Switzerland to see how they avoid it.
This does not take into account the fact that in most countries with an universal health care system, you will only contribute to it during your +/- 40 years career while you'll benefit from it during your whole life.
Effectively the same in the states. When you are a kid, you're on your parents health plan which brings up their cost and your future cost as a parent, and when you are old you do get universal healthcare through Medicare.
The difference is that your taxes go up as you earn more, but your health insurance premiums don’t. Lower middle class workers are getting screwed, but the top earners are doing great! It’s a feature, not a bug.
The international comparison is a bit eyebrow raising. It has two countries (Canada and the Netherlands), which are on the lower side in terms of overall taxation, on opposite sides of the scale. The Netherlands is listed as the highest tax jurisdiction, at 48%, despite having one of the lower tax burdens in Europe: https://en.wikipedia.org/wiki/List_of_countries_by_tax_reven.... Canada is listed as just 11%.
This article makes some good points up until the end. It criticizes private sector waste without evaluating waste in the public sector. I see how the taxpayer impact could possibly* be a wash, and do see problems in the private sector for sure. But my experiences with just about any US federal system does not cause me to see them as a bastion of efficiency. Without a profit incentive or really any incentive beyond occasional bad press, and with strict salary and firing controls they do not innovate or improve. Look at the VA for an example. Horror stories do exist for British and Canadian systems as well as others I’m sure.
* This article also ignores the fact that many of the countries listed also still have private insurance supplementals. Those may need to be added for a fair comparison.
In the end I don’t have good solution, but think the traditional arguments in both directions are generally hyperbolic and over simplified. Unless data shows conclusively otherwise, I lean toward free market solutions.
Individual US tax payers pay for most of the world's security. This is one tax of being the global super power, so it's not particularly surprising that when you include all things the US tax payer pays for privately that is taxed in other countries, you arrive at a number higher than other similar countries.
In reality, there is no country with which we can fairly compare US tax rates.
> Although the existence of the US military probably helps. As long as they don't do anything.
But the US has one of the largest all-volunteer armies in the world, with some of the most advanced technology, so it makes sense that it costs more. My comment is not a justification for America's military power, it is simply an observation that American tax payers pay for something the rest of the world gets to enjoy for free -- the threat that if another country attempts to upset the balance of power from which many countries profit (namely many of those in Western Europe), the United States (and only or mainly the United States) will stage an intervention.
For example, regardless of Norway's foreign policy, they benefit from American warfare (or threat of warfare) in the middle east which ultimately does lower the supply of oil. Same with Saudi Arabia. None of these countries contribute, which is why it makes sense that the american tax payer pays more.
Partially yea, it may be that using the word "security" in that first post was a wording error that caused a bunch of people to misunderstand you. But then, in this follow up, you've mentioned that Norway is benefiting from the US lowering the supply of oil (I assume via setting it, and the people who extract it, on fire)... I am not Norwegian and can't speak as to their preference, but given that Norway is currently scaling back their oil exploration efforts along with the general character of Norwegians that I've met, I'll make an effort. I'm going to assume that the Norwegian ethical stance is against the US starting wars in the middle east and killing people to make their oil a bit more valuable.
> Norwegian ethical stance is against the US starting wars in the middle east and killing people to make their oil a bit more valuable.
I mean the American ethical stance, as demonstrated numerous times by various popular votes, is also against war. However, that does not change the fact that countries benefit from it. Ultimately, while perhaps making some countries hypocritical, none of what you said changes the argument I put forth: namely that, by virtue of being the only country whose citizens are forced to pay for the status quo (which has the effect of subsidizing the economies of many of the countries to which the article attempts to compare the united states), there is no way to properly compare US tax policy to any other country.
> Partially yea, it may be that using the word "security" in that first post was a wording error that caused a bunch of people to misunderstand you
Indeed. For some reason, many people define security as not just security of the status quo but also some cosmic fight between good and evil.
Both countries do not benefit from it, otherwise they would view these wars as just and support them. The political machines in both countries support these wars and force the populace into them - in part (in the US at least) by being a two party system without any way to politically express a desire to not go to war, one party is more hawkish but both parties are full of hawks.
As an American I am happy to say, "Please, America, stop messing up the world for everyone with your endless economic wars." A bully cannot neutrally justify their own actions, they are biased in approving of the path they have chosen.
No, the point is that a subset of the populace benefiting monetarily isn't equivalent to a country benefiting. People can rationally say that acquisition of wealth is not the sole goal of existence.
Not so long ago it was nice to have a couple of tank divisions located in West Germany doing nothing. Doing nothing. Just looking at their Soviet colleagues stationed across the border.
I assume that's precisely what the parent comment meant, that the appearance of force was enough to keep people in line - it's only when America flexes their muscles that things move into the grey area.
Europe collectively twiddled their thumbs, "waiting for diplomacy to work" while Milosevic slaughtered Muslims. It took US initiative to step in and stop that.
Individual US tax payers pay for the largest military budget in the world - I think stating that the US's military budget equates world security isn't a fair jump.
Also, bear in mind that a good chunk of that money just gets cycled into politicians via the DOD -> defense contractors -> lobbying.
No. The amount that gets donated to politicians is peanuts compared to the DOD budget. Even if you counted all lobbying by defense contractors, it still would be peanuts.
You do have half a point, though, because the lobbying leads Congress to fund projects that, if one were trying to efficiently run a military, one would not fund.
I think there was a time not too long ago where you could say, "the US spends more on it's military than all other countries of the world combined." That's no longer true (thanks China!) but it's still not too far off.
For all the situations in which you feel like the US was not justified in its actions, have you considered all the ramifications of alternative actions? And what about all the situations where its actions were justified but would not have been possible had the US military not been funded as it has been historically?
How would the USSR have evolved without the US security presence in Europe since WWII?
How would China have evolved without the US deep-water navel presence in the Pacific? Without the US support for Taiwan?
How do you value the success of South Korea in the presence of US troops?
What would have happened in the Middle East if the the US hadn't supported Israel or pushed back on Saddam Hussein in Iraq?
I'm not trying to justify any or all US actions, just trying to point out that any evaluation of the US military's impact over the last 100 years is going to be more complex than suggested by your comment.
The Mafia also provides security. Since I've written the same thing to like three different comments. I'll say it again: Arguments that attack the morality of US action do not counter my claim that US action benefits many foreign countries, corporations, and individuals, who do not contribute anything to the funds that allow such action to take place. Depending on your point of view, this makes the rest of the world either calves sucking from the teats of a benevolent, but ignorant cow, or bats sucking blood from an undead vampire. But regardless of how you slice it, the non-American countries are basically sucking from someone.
So as a counter to that, and dialing my language back to patton-y style, America is going around stirring up shit that the rest of the world needs to shovel. Why is it that after Syria and ISIS have emerged and created a refugee crisis the US is miraculously missing (on a per-GDP basis) in the aide efforts. While America is fueling economic growth beyond the ability for the earth to sustain it why has it refused to help people fleeing desertification in Africa. Oh, the situation in El Salvador, yea... America never did anything to turn central and south america into a dumpster fire...
America is the vampire, trying to suck all the resources and productivity into a machine that feeds itself - with little regard for the rest of the world.
Oh wait, that was too reductionist... maybe the US does a lot of good by sending food aide around the world but also causes problems... maybe the rest of the world is the same, being good sometimes and bad others, and no one nation is some beacon of light and purity that all others are constantly sucking[1] the productivity out of.
[1] The analogies used above were pretty weird and awkward,
> Oh wait, that was too reductionist... maybe the US does a lot of good by sending food aide around the world but also causes problems... maybe the rest of the world is the same, being good sometimes and bad others, and no one nation is some beacon of light and purity that all others are constantly sucking[1] the productivity out of.
I never claimed America was a beacon of light. I merely claimed that many non-American countries benefit from American global hegemony. That is an observation (which perhaps you think is wrong, but I don't see any generalized counter claim), not a value judgement.
> [1] The analogies used above were pretty weird and awkward,
Perhaps, but that doesn't take away anything from the main argument.....
And many non-American countries have suffered from American hegemony. The US used concentration camps in the Phillipines and overthrew the Honduran government so we could have cheap fruit. Are you absolutely sure that the US provides a net benefit to other countries via its military?
> Are you absolutely sure that the US provides a net benefit to other countries via its military?
Yes, the issue at hand isn't whether the US provides a net benefit to every country, because 'every country' is rarely used as a metric against which to measure the US. Instead, America is typically measured against western European countries and 'developed' countries (so, ex-colonies, essentially). The article in question in this HN thread compares the US to Europe.
Pretty much every 'developed' country benefits from US hegemony. That is one reason why they are considered 'developed'.
How many times do I have to say that I am in no way justifying American military action or even saying it's a good and ethical thing. I am just making a very obvious observation that American tax payers pay for the current Pax Americana (evil or not) that many countries often contrasted with the US benefit greatly from.
> Except that the the US gains tremendous advantages from having such a large military and projecting it's power globally.
Correct, further supporting my claim that there is no other country that can be properly compared to the United States, since no other country has corresponding military might and it is unclear how to value such a thing fairly.
This can't be right. The bulk of US defense expenses in the last 2 decades for instance have been in needless middle east wars that destroyed those countries, killed millions and enriched US corporations and their employees. It created power vacuums and destabilized entire regions that allowed the rise of ISIS and other extremist groups. There is now slave trade in Libya which was one of the most advanced countries in Africa before the US intervention. Massive immigration caused by these actions is taking a toll in Europe. How does this help global security?
A country's defense expenses are for its own benefit providing easy global market access for its companies, leverage, favorable terms and markets for arms for its own defense industry. All these benefit the US and its citizens.
There is a well documented history of military intervention under pretexts driven by business interests going back centuries with the latest being Venezuela. A country is being openly destabilized, millions will suffer, there will be increased immigration leading to more right wing extremism against immigrants, and more business opportunities for US companies with access to the largest deposits of oil in the world. How does this help global security, this seems to transparently benefit US interests at the cost of everyone else. [1]
Because, in general, maintaining the status quo (regardless of whether the status quo is good or bad) is good for perceptions of stability and security. Saying that American military might preserves the status quo of Western European / American global hegemony is not particularly controversial. Neither is pointing out that many many countries benefit from maintaining the status quo while contributing nothing to the force that maintains it.
This is not a justification of American military maneuvering, but simply an observation that many countries, individuals, and businesses benefit from it, while contributing nothing.
Your evil specter of big business is ultimately a distraction from the issue, because many non-American companies also got pretty good paychecks from American military involvement, despite them or their employees contributing anything to the United States's actions that gave them that money.
I'm unsure how an argument that attacks the ethics or morality of US action can at all counter an argument that US action maintains a status quo that benefits many people who do not pay for it.
"They have pillaged the world: when the land has nothing left for men who ravage everything, they scour the sea. If an enemy is rich, they are greedy, if he is poor, they crave glory. Neither East nor West can sate their appetite. They are the only people on earth to covet wealth and poverty with equal craving. They plunder, they butcher, they ravish, and call it by the lying name of 'empire'. They make a desolation and call it 'peace'."
You can't be bankrupted with full coverage (except by the cost of premiums), but very few, proportionately, Americans have anything like full coverage.
My understanding is that in the US there are even companies which can be hired by hospitals and other care centers to "optimize" the codes before the final submission to the insurance. I take this to mean that they can ensure that you're using the right codes and also probably try to maximize the payout.
Markets such as the US health care market, characterized by ineslastic demand and secret prices, should never, ever be tolerated under any circumstances. This arrangement is here to benefit the supply side and screw the demand side and it has to be stopped. The only pathway out of this crisis starts with the federal government replacing private insurers, relegating them to selling supplemental coverage. Such companies also should be legally compelled to run as mutual insurance companies, where any profit deriving from good risk management is sent back to policyholders. It is long past time everybody in the US admitted that markets have completely failed in US health care.
I think I'm privileged to live in Australia where I do not need to pay for my visits to the hospital and for my operation when I had appendicitis. Whereas in the US I've seen it is 30-70k. It's also interesting that there is a range of prices depending on the hospital. Would this be representative of treatment quality? How much one can pay shouldn't be the determinant of the optimal treatment that one deserves to receive.
I actually spoke to someone today who is hiring a guy from a FANG in SV to go and work in Denmark. He told me taxes are high enough over there it isn't all that different.
Plus like many Americans he was curious about living in Denmark. Cycling everywhere, laid back lifestyle, that sort of thing.
That budget seems to be always nonnegotiable, despite the occasional media outrage. Realistically, how can US voters change this?
As an aside, the US is the only country I've seen give military personnel priority boarding for civilian flights. With all due respect to veterans, it seems so strange to do this sort of worshiping in what is effectively peacetime.
It isn't worship. It is gratitude for their service. Your implication that military service should only be valued during wartime seems odd to me but I'm guessing that your perspective on the proper role of the military in society is probably very different than mine.
I think we could stand to do significantly less worshipping of our soldiers, but a lot of the ones boarding commercial flights are on their way to places like Afghanistan where groups of unfriendly armed crazy people will attempt to kill them.
I agree with you in principle, but calling people you've never met from another country and culture "unfriendly armed crazy people" is a big, sad reason why we even need militaries in the first place. I imagine many of those "crazy people" in Afghanistan consider the US military to be invaders who won't leave them alone.
It's of course all not that simple, but... why the need for unnecessary name-calling? It just perpetuates the "us vs. them" mentality that seems to be at the root of many of society's ills.
Unfortunately all that waste creates millions of jobs. If military and healthcare costs were brought under control too quickly, it would literally destroy the economy.
Military yes, that's millions of jobs for people that would struggle to be employed otherwise.
The health insurance industry, however, needs to die. The sooner the better. The resulting boom in people actually receiving healthcare in the US will cover the job losses over time.
The only problem with the ‘Medicare for all’ system is that it won’t reduce that insanely high ‘stealth’ taxation - it will just add to it... However, at least with efforts like Oklahoma’s Surgery Center etc one stands a chance to escape the compulsory racket through market efficiency. Potentially.
I never understood why people are against some form of universal healthcare. The idea of "socialism" or "communism" scare many conservatives, but it just doesn't make sense here.
How universal healthcare sorta works - we all put money in a pot, and use it to pay for healthcare.
How health insurance works - we put money into a company, who uses it to pay for healthcare, while taking a significant cut as it's a private entity.
With the correct organization (which the government is notoriously terrible at) it would seem to me that it could only be cheaper to have taxpaid healthcare?
Someone else beat me to it, but being Canadian who moved to the US, I can kind of see where some people are coming from.
If you're young healthy, have a good job and are a bit short sighted, you're way better off in the US (with little to no insurance or a crappy high deductible plan) in term of take home pay.
Even if you're not healthy, if you have a lot of money, you're also way better off since wait times in affluent cities are way, WAAAAAY, _WAAAAAY_ better.
When I lived up north, getting an apointment with my family doctor was a 3+ month deal, most people didn't even have a family doctor because almost none took new patients, wait times for surgeries were so high my grandma almost died while waiting for hers (and did end up dying because of lack of care in the end). And i think in some places they're talking about no longer covering some services like regular check ups?
I had a bunch of lingering non-critical conditions I never got checked until I moved to the US, because it just wasn't worth the trouble, and was able to get everything squared away in record time since I did.
Something that isn't always brought up too is things like dental, which wasn't covered up there so you needed private insurance anyway, and very few of my employers offered compared to my US employers.
It's completely messed up and only benefit people who don't think far enough or have money up the wazoo, but for those, the socialized system would be worse.
To provide a contrasting experience, in Canada I had a family doctor who would see me with a couple day's notice, and 99% of people in the community had a family doctor. However, it was a relatively affluent suburb, which means a lot of doctors lived there.
Dental coverage is a valid point, I was surprised at how many things weren't covered under my company plan.
Fair point. That is from good old Quebec, and friends from Ontario do tell me it's better over there. My anecdotes do match with numbers and stats I've seen at the time (but it's been a while since I've lived up north).
>Something that isn't always brought up too is things like dental, which wasn't covered up there so you needed private insurance anyway, and very few of my employers offered compared to my US employers.
Most employer provided dental plans have a $1,000 or $2,000 cap.
Or you could socialize the costs, cut out the massive waste involved by the private system and realize a healthcare cost that nears that paid by similar first world countries.
Plus I think(/hope) that people in the US have fully embraced their hatred of pre-existing condition exclusion in health care that came through with the ACA. The GOP keeps saying they'll drop it and they keep shying away due to the popularity.
Not sure what the down voting is for. While I don't condone anything the Nazis did, it is true that eliminating "expensive sick people" would lower the cost of care. Whether that's something we would want to do and were you draw the line is a different story.
Why do you stop there? The chain goes on. Employer will have to listen to the employees or they will be on a lookout for better place to work. It's not uncommon at all for employers to tout benefits as a way to attract new hires.
That only works if you’re in high demand, and your health problems don’t preclude getting a new job. Very few workers can rely on that being true at any point in their lives, much less all the way until retirement.
I cannot pick my own health insurance company. My choices are:
- Whatever my employer wants
- Something on the exchange for quadruple the price (particularly without my employer's share of premiums)
How does the market decide when it isn't a competitive market? Why are employers allowed to pick their employee's health insurance? Why are employed people at large companies paying less than employed people at startups?
What is the market, here? What good or service do you get from insurance?
For their real value prop (covering the unlikely need for catastrophic healthcare), you 1. most likely won't ever use it. 2. have no idea how good their service is until you have no other option but to exercise your coverage.
Market-based capitalism works best when consumers can shop around, and take their money elsewhere when the good or service is not a good value. This is absolutely not the case with health insurance.
Meanwhile, medicare is pretty beloved in this country. And the public options in other industrialized nations outperforms US healthcare in most respects for significantly less money.
I grew up in Canada so I totally understand why people are against universal health care... Check out the wait times for MRI scans that are published by the various Canadian provinces. 90 days' wait is not uncommon.
Meanwhile in the US it can be had in 3 days or so in every decent sized suburb or city.
As someone who grew up in Canada and actually paid attention, this common line is mostly BS.
If you have an emergency, you essentially have no wait time for an MRI. If you have a condition that can wait, you go into the line and potentially wait for a long time. When the wait times become too long, it becomes a scandal and then improves. Every scandal then gets reported in the USA as stories about how horrible Canadian healthcare is.
Yes, this is the same as in NZ - the thing is if there are not queues for expensive resources (be they surgeons, MRIs etc) then there must be expensive resources sitting idle.
Queues are a good thing in that regard, they indicate efficiency of use, what we mostly argue about in countries with socialised medicine is "how long the queues should be?".
Ideally they are on average just long enough so that they never become empty when the usual various peaks/troughs of demand occur, plus have the capacity to handle all the life threatening cases on an urgent basis
An MRI that you can book in 3 days, if you have the money. I know people with health care insurance that had to postpone imaging for months in order to be able to afford the cost.
I find it ironic that you stated the answer to your own question and didn't notice.
That is, how notoriously terrible the government is at organization is a major reason for why people are against universal healthcare. Whether their concerns are overblown or not I leave to opinion. But that is a major fear for many.
> how notoriously terrible the government is at organization is a major reason
A major propaganda point, not a reason based on data. It’s really hard to find a first-world country which has a medical system which doesn’t compare favorably with American insurance companies on either cost or quality — the baked-in conflicts of interest are too powerful.
Insurance companies are also not exactly....paragons of good customer service themselves. I was camping with a friend when he managed to slice off the tip of his finger. The insurance company fought him tooth and..err...nail to avoid paying out for not having the ER visit “pre-approved”
That was my point: I’ve known a fair number of people from other countries and I’ve never heard any reaction other than stunned disbelief when they experienced the American private insurance system — up to and including giving up jobs here just to avoid the stress of not knowing whether you really will get treated or not.
I've always found it slightly amusing that the mostly unchallenged conventional wisdom is that private enterprise is more efficient and better organized that the government. Sometimes I wonder if the people who really believe that have ever worked for a large corporation.
I also think people forget that, in any case, the gov't is not a private enterprise and efficiency is actually not their first mandate, it's effectiveness.
You might find a more sophisticated version of that conventional wisdom to be less amusing and more worthy of food for thought.
It comes from Ronald Coase's theory about the natural size of companies. Companies exist at the tradeoff where the costs of transactions between multiple companies equal the internal inefficiency of a large organization. The larger the organization, the more it tends towards inefficiency. Anything that decreases transaction costs, decreases the size of organizations. And vice versa.
From that you expect large organizations of all kinds to be inefficient. Which fits your observation. Now note that government organizations tend to be are large organizations with a tendency towards complexity and no incentives for efficiency. How do you predict that will work out?
Again, whether or not this is a compelling argument is a matter of opinion. But if you want to understand the views of those who don't like government healthcare, this is a key point to keep in mind.
Are corporations really that much better though when it comes to organization?
We've just offloaded all of the terrible organization to large corporations like ISPs or health insurers, which don't actually have the consumers best interests in mind. I've worked for a government contractor in the past and I can tell you that private companies will do everything they can to drag their feet or siphon money while creating bureaucracy on the level of any government agency.
I can sort of understand someone thinking that the government is bad at organizing large projects. What I don’t get is how so many people think that while simultaneously thinking that the government is the right tool for carrying out gigantic projects like completely reimagining the government of a foreign country that doesn’t want it.
If you don't do something, comparing tax rates between countries is meaningless when you get different things for those tax dollars.
I think the developed world (minus us here in the US, of course) has finally realized that access to health care is a basic human right and should be included.
The primary reason that some people push back against this notion of health care as a "basic human right" is that it is an example of a "right" that can only be provided by force. And by force I mean that the only way it can be "guaranteed" by the government is for the government to forcibly collect taxes to pay for the services. Forceable redistribution is required. Perhaps even forcible job assignments (nurses, doctors, technicians, etc) if you really want to make sure the right is provided equally to everyone (ratio of patients to doctors, etc.).
In contrast rights such as freedom of speech, assembly, press, religion and so on can be guaranteed through inaction of the government. Nothing needs to be taken away from anyone to guarantee these rights. Basically this is the difference between positive rights and negative rights.
One large problem with bucketing positive and negative rights together as "basic rights" and insisting that the government must guarantee these basic rights is that it becomes difficult to identify a limiting principle. If health care is a "basic right", then why isn't "food" or "shelter" or "clothing"? How would we go about guaranteeing those things?
Please don't interpret my comments as suggesting that reasonably priced health insurance and accessible health care services aren't important. They are, but there are ways of structuring those services and socializing some of the costs that don't require that they be considered "basic rights".
It is interesting that you qualify your claim that health care is a "basic human right" to the "developed world". Does that mean that it is not a "basic human right" in other parts of the world? Why not? If it is a basic human right, shouldn't it be protected universally? And if you think it should be provided universally who should be responsible for providing that right outside the developed world? And if it there is some complex economic conditions that are pre-requisites then is it really a "basic human right"?
> It is interesting that you qualify your claim that health care is a "basic human right" to the "developed world". Does that mean that it is not a "basic human right" in other parts of the world?
You misunderstand. I personally believe that everyone has a right to access to healthcare. My point was that the developed world has finally decided (for the most part) to recognize and codify that into law and taxation, whereas much of the less-developed world has not (to be fair, a decent amount of it has, though).
But even that doesn't include the real sting on the tail of US medicine. You pay a fairly high health insurance premium, but if you actually need health services you then pay again through the nose even with insurance "discounts."
For example my under one year old needed to go to the emergency room due to a high fever for several hours, we paid over $300 on top of paying over a thousand in combined employer/employee premiums each month. That's with insurance picking up at least that much.