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US Workers Are Highly Taxed If You Count Premiums (peoplespolicyproject.org)
434 points by viburnum 16 days ago | hide | past | web | favorite | 498 comments



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.


That's odd. Dentists, unlike doctors, will in my experience just give you a price if you ask for it... Maybe this varies state to state?


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.


Bravo, perfectly succinct description of the ground truth.


> 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!

Its completely absurd.


> They can charge whatever BECAUSE OTHERWISE YOU'RE DEAD.

Just like when you buy food! Or heating! Or water!


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.


What do you recommend if it requires 2 months to get an appointment with a different specialist?


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.


That may be so-called "balance billing". It is illegal in some states.


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.


Dental insurance isn't insurance in the normal sense. It's more a way to prepay dental expenses with pre-tax dollars.


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.


In the US those estimates can often be wrong.


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.


As a point of comparison, in Austria:

- taking a kid to the ER costs nothing

- taking a kid to a GP or a pediatrician costs nothing

- staying a night at the hospital costs around 15€

- getting a prescription from the pharmacy costs 5€


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.


Yes - so you're worse off.


Based on US household income, 7.65% of 56,516 = $4,323/yr


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.


"Obama" care is a far cry from single payer.


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.


Employer’s share of premium is on your W-2 tax forms, box 12 code DD.

https://www.irs.gov/affordable-care-act/form-w-2-reporting-o...


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...


What the...? Almost a thousend a month? That's 12k a year, just paid by employers. Where is the money going?


To the USA's $9.5k/year per-capital healthcare spending.

Did my taxes and my family of four was well past the $30k mark for insurance, copays, dental, and optical this year.


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.


Employers can also negotiate for group rates that someone buying insurance on the individual market won't have access to.

Not only do employers pay for a portion of employee healthcare costs, they also get better coverage for less.


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.


> I imagine you can still pay $1000+ out of pocket to have a baby in a US hospital, even if you have great insurance.

I just got that bill, in fact, and we have about the lowest deductible insurance you can buy, at a cost of about $1500/month. It was still $6500.


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.


Note the figure in the article does not include income taxes, but rather only labor taxes and compulsory payments.


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.


If you're poor in the US, insurance is free. It's the lower middle class and middle class who are frequently bankrupted by these costs.


> If you're poor in the US, insurance is free

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.


Assuming you can find a doctor taking new Medicaid patients.


Hahaha. Sure.

Good luck finding a Medicaid provider.


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.


Can you imagine someone thinking that Obama, a neoliberal imperialist, was a socialist?

Or that socialism is a bad thing?


Oh yea but how many billionaires does your country have. Hah!


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!

correction - wow! the first ever audit has finally happened https://www.defensenews.com/pentagon/2018/11/15/heres-what-t... :

"But department officials were quick to note that was no expectation that the audit would be clean, given the size and scope of the project."


I always felt great to serve in the military and fight for freedom (of oil).

Next up: Venezuela.


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.


On the other hand, a typical state college is closer to $10,000.

Yes, it's not Ivy League, but it does the job.


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.


Move!

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.


I wonder if 10 thousand is a lot for undergraduate education to a German, or Austrian, or French person?

EDIT:

Doh! Just checked the cost of undergrad in some of those nations.

Umm, Yeah.

I guess if I were a German or French guy, I'd likely find tuition levels in the US a bit outrageous.


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. :)


Thats right. I had a similar experience as an american exchange student in london. The college didnt baby sit you and extra services cost money


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.


Do you have any idea if this causes grade inflation to protect below-to-average, but otherwise responsible, students?


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.


I know that German universities are generally free, while, for example, their UK counterparts charge around 10,000 GBP a year.


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.

https://www.moneysavingexpert.com/students/student-loans-tui...


That's sad though. This means that most students never earn more than 25k per year, even if they studied..


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.


Interest rates vary depending on how much you earn. https://www.gov.uk/repaying-your-student-loan/what-you-pay

It's basically inflation + 3% if you're earning more than £45k/yr+.


That makes a lot of sense, thanks.


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).


Some of the best state schools (with huge endowments) are also trending downward in effective tuition.


State colleges vary widely in quality, though.


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.


And if the insurance does not cover something the prices are reasonable and transparent.


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 have to offer HMOs.


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.


Source? I am not aware of any legislation requiring specifically an HMO option, at least in the states I do business in.


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.

https://www.thenation.com/article/thanks-koch-brothers-proof...

The problem, as always, is what do you do with all the redundant bullshit jobs that are eliminated in the process.


$300 is a steal.


$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?


You probably don't live in the US, 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.


Probably better to withdraw and eat the penalty then, inflation will make it worth peanuts by the time I'm 65.


You can invest it in US or international mutual funds that historically have beaten inflation by 7% per annum.

If it's over a certain amount you can treat it like an IRA, otherwise you should get regular savings account interest, yeah.. I'm laughing too.


Fidelity has an HSA with zero fees that lets you invest just like an IRA. I don’t know if you can open one without being a US resident, however.


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.


The US, in general, is hell bent on forcing consumers to be experts in everything if they don't want to be screwed over on prices.


One ER visit. The surgeries we're both planned, and I went to an urgent care for triage of my strain, then to a regular orthopedist.

> Maybe consider that your experience is the exceptional, not the people you call hyperbolic.

I'm not saying I'm typical. I'm saying that four-figure Mexican bills aren't. If they were, then I'm an extreme outlier, which I don't accept.


I'm certain your visits were four figures, you just have good insurance.


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.


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"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.


In what way is your comment about price fixing relevant? I don't care if the lower price is because of price fixing or not.


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"you're completely ignorant"

Thanks. Very stylish.


mate, the health situation in the US is a joke. the US is less healthy than Oman and Slovenia.


$359 is an order of magnitude less than four figures.

It's also about what we paid for my wife's shoulder. Which, like I said, is bad enough on its own.


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.


Let me guess - your deductible is 6000$?


Is that really relevant though? That should never cost anywhere near that much.


It's relevant because the doctor probably charged EVEN MORE than $6,000, and mikeash only saw $6,000 of that because it was his entire deductible.


Did you pay the bill outright without negotiating?


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.


Normally you just call and say youd like to lower the bill


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.


Why would they respond with anything besides “fuck you, pay me”?

When I did ask, their response was basically a more nicely worded version of that.


In my experience that doesn't work.


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.


I really don't understand this 'labor theory of value' thinking.

Just because there wasn't anything wrong doesn't mean you don't have to pay a person for their services.


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.


True. One thing I have noticed about dental though is that they give reasonable upfront estimates which is something most other doctors don’t do.


They do that to keep insurance away. Dentists have it much easier.


A basic non-complication natural child birth will cost at least a couple of thousand out of pocket for most insurances.


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).


Over a million for 10 weeks in nicu? Who sets these rates?


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.


To be "fair" that also includes the c-section delivery...


Wife passed out on the way out of the hospital after getting an IUD put in.

With insurance we paid $800 for her to lay in the Er for 3 hours.


My 6yo son went to the ER with blue lips and we ended up with a $1400 bill for a glorified strep test.


It happens with high deductible plans.

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.


> It happens with high deductible plans.

I never said it doesn't happen, which seems to be the strawman most people are responding to. However, there is a huge gap between "it happens" and

> happy if your cost for seeing a doctor is less than 4 digits

which I indicates this is common and typical.


It depends on who you are and what you do. My health insurance costs more than what a typical minimum wage workers gross compensation.


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?


In fairness, the US typically does not cost $1k+ for a simple doctor visit.


> 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.


This is missing a few important points.

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.

EDIT: more clear wording.


> Also, only 7.5% comes out of your paycheck, the employer pays the other half.

That distinction is imaginary. It all comes out of your total cost for employer, which either goes to you or to (possibly earmarked) taxes.

This doesn't mean the amount is not fair (it very well might be). But it's important to realize it all comes from your paycheck.


> 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.


Meanwhile, US governments pay more per capita for healthcare than other "socialized medicine countries", but with terrible clinical outcomes.

https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...


I wouldn’t say that the govts of socialized systems negotiate rates down, it’s more of “this is what you will get paid”.

Salaries for doctors are the highest in the US. If we want to move to a single payer system they will have to take significant pay cuts.


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:

https://correctiv.org/en/latest-stories/super-bugs/2017/01/1...


>>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 US is the only place I know of where someone with good insurance coverage could expect to pay that much for a basic visit.


An emergency room is not a "basic visit".


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".


That’s what urgent care is for. You shouldn’t be going to the ER for a typical fever or a cut requiring stitches.


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.


We have some 24 hr ones here, but yes, if it’s not an emergency, but you need immediate attention, the ER might be your only option.


You don't need an ER for any of those things. We already solved this problem with Urgent Care.


Where I am, urgent care closes at 8PM and only takes two of the several insurance providers that are common.

ER is open 24/7 and doesn't turn people away even if they don't accept their insurance plan.


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.


It wasn't worth the cost in Toronto, either, but you didn't care because it wasn't you who paid the cost.


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.


Ouch. Sorry to hear that :/


While technically true, that's disingenuous. You paid no additional marginal cost. The incentive structures matter.


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"


GP is not the one being disingenuous.


Who do you think is being disingenuous?


Interestingly, in the UK they had a large "this is not an emergency" campaign trying to make people to choose GPs over emergency services.


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.


Taking a kid with fever to the ER is about as basic as you get.


Doesn't the US have out-of-hours pharmacies, or out of hours doctors, or urgent but not emergency treatment centres?


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.


Depends on where you are. Some places have 24-hour Urgent Care centers that can handle the basic stuff that doesn't need a real ER.

But many places don't have any kind of Urgent Care centers, much less one that is open 24 hours a day.


Yes, that's why I said "usually" and "often".


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.


Yep. Usually the rule of thumb is:

* Potentially life-threatening emergency: ER

* Something like a broken bone or fever that needs to be fixed asap, but not life-threatening: Urgent Care

* Everything else that can wait a bit: regular doctor appt


Yes, kind of. They can handle a few things (ear aches, something that requires anti biotics, basic pain relief) with a nurse practitioner.


Not really. I live in Queens, NYC and there's no 24 hour urgent cares I'm aware of within a 30 minute drive.


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)).


Can confirm in Australia "emergency" does mean the department with the giant red emergency sign at your local hospital.

We have late-night general practitioner services here (at least in the city), which I have used for less-urgent stuff.


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.


I'd say that it applies even more to an emergency room.


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.


Just to be clear, $300 was only our share of the bill. Insurance also picked up more than that, and there were insurance "discounts" applied.


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).


It's not always an option, but if it's possible -- consider Urgent Care if that's offered in your area.


We were told specifically to take her to the emergency room by the on call pediatrician.


You don't go to ER for a high fever.


High fevers in infants can be quite serious, even fatal, so yes you do go to the ER for a high fever in that case.


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?


Good question! I wondered the same.

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.


NB: in most states minors can drink alcohol if served by a parent.

I'm not encouraging underage binge drinking, but if you want to have a quick pint with your high school senior, that's absolutely legal.


Yeah and with their 21 yo alcohol law tied to road funds... sure. Lets play.

I live in Indiana. Lets shut down the interstates for non-Indiana citizens. Yes, that means the I69, I65, I70, I90 corridors.

The feds would have came to a 'deal', in new speak.


Hahaha you think that people can drink under 21 in the military. I assure you that nobody under 21 is officially getting served at a base club.

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.


But inefficiency can't get rid of $5,000 when less than that is left after simple transfers.


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.


The SALT deduction is not gone, it is capped at $10,000.


our cities are filled with bums, and have absolutely no money to either give them jobs or make new programs.

New York City spends about $30k per homeless and you still cannot walk a block without seeing one.

It's not about the money...


If New York was more efficient with that money and took half the homeless people off the streets, they'd be paying about 60k per homeless person.


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.)


> or more and our states soo soo sooooo much less

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.

0: https://taxfoundation.org/state-and-local-sales-tax-rates-20...

1: https://www.thebalance.com/best-and-worst-states-for-propert...

2: https://en.wikipedia.org/wiki/List_of_toll_roads_in_Texas#Op...


But then the tax shelter states wouldn't be able to mooch off of federal programs.


There's going to be a lot of buts I get it. I want someone that can figure this out and move it forward.


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.


and yet the first group of states votes in politicians that raise taxes and the second group votes in politicians that cut taxes?


Those states also pay more to the federal government than they get back.


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.


Except the voters who don't need any of those things, and who feel that those programs should be eliminated in their entirety.

Now, consider how the above is impacted in the wake of Citizens United where $1 == 1 vote, and Corporations are People Too.


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.

See Robert Peston's WTF? for details.


>This doesn't seem to be a major problem for the EU

Are you serious?

https://en.wikipedia.org/wiki/European_migrant_crisis


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.

[1] https://www.unhcr.org/1951-refugee-convention.html


This is in fact a major problem for the EU.

>and the high earners are going to move away.

Expand your timeline.

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.


See for instance, the flood of high earners moving from NY and California to Wyoming.


The poorest in the US do not have the resources to simply pick up and move.


This is a cornerstone of traditionally "conservative" viewpoints in the US. I am now in favor as well.


This.


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