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U.S. Life Expectancy Drops for Third Year in a Row (2018) (smithsonianmag.com)
280 points by EL_Loco 13 days ago | hide | past | web | favorite | 399 comments





The article says the drop is due to people in their 20s and 30s are dying but why? The article states there is a big increase in overdose deaths but in percentage terms. Is this significant? Are deaths from fentanyl up from 1,000 to 2,000 or 100,000 to 200,000?

I also didn't find the word "obesity" anywhere in this article and I have to wonder how much this is a factor too.

As much as people might take this as "see how much life is better in [country X]", you still see people desperate to come here. Even in the EU, legal and illegal immigrants are much more likely to be headed to the UK and Germany.

I'm Australian but I've now lived in the US coming up on 9 years. The reason? As a software engineer, you can squeeze what would be a lifetime of savings in Australia into 10 years or less and that's hard to ignore.

The US is a pretty terrible place to live if you're poor however. And that goes far beyond life expectancy (but it of course plays into it).


Actually, if you're poor enough in the US and you live in a state like California you'll qualify for the best free healthcare in the world via Kiaser. Zero copay, pick your own doctors, specialists, eye exams, medication, etc. at zero cost. Then as soon as you get another job and start earning more than $1,400 a month(IIRC) you'll be kicked back into the regular system where no amount of money will ever buy you back into that awesome top tier that you got with the free plan.

Kaiser is fine for acute issues, or prescription drugs. For chronic issues, you have to yell at them repeatedly to get a decent doctor. I left that mess long ago and never looked back. Insurance is more, but I actually get semi-competent doctors now.

If you have a rare disease, which is common, as 6-7% of the general population has one, you will very likely get profoundly screwed, one way or another, even with the "best" HMO plan.

In my case, I have a very rare autoimmune neurological disease that affects my peripheral nervous system. Even being able to properly diagnose the illness, in my particular situation, would be confounding for some of the most talented doctors out there.

There is a very unique and esoteric board specialty within the field of neurology that a handful (~40 neurologists in the US currently are board certified in it) of neurologists will have, which makes them more likely to be equipped for dealing with situations like mine.

Even then, you may have to see at least a few of them to figure out what is going on, and then figure out the proper treatment--which is more like an art than a science. That is what happened, in my case.

Anyways, there is a near-zero chance that an HMO plan has a proper selection of in-network doctors equipped for dealing with rare disease, just in general.

So, for all of the praises that HMOs may get, they are structurally unequipped to deal with rare disease in general--and it is actually common to have a rare disease--whether you want to believe it or not. Remember that.


That is unfortunate, your condition. Sorry to hear you are going through that.

What I was referring to wasn't even rare conditions. Kaiser have many junior doctors that in many cases were not trained by reputable schools. Furthermore, they are the insurance company, so they already know which things they are willing to and not willing to even test for. They already know who will live and who will not in some cases. In my case, I had a serious G.I. issue. They poked my belly and "diagnosed" it as a virus. I ended up self researching and treating my issue with a myriad of "shotgun" approaches. I was lucky to figure it out on my own. Two years later after having finally left Kaiser, a real doctor was able to confirm what I was lucky enough to figure out. I am still going through the healing process to this day.

Almost all of my coworkers have horror stories of Kaiser misdiagnosing serious issues, in some cases leading to fatal results. They also trick people into believing non arbitration applies to negligence.

All of this said, there is not a single doctor in the United States that knows how to treat high blood pressure. I am learning how to do that on my own. All doctors can do is throw BP drugs at people and those are more dangerous than heroine. i.e. You can safely stop taking heroine. Stopping BP drugs will induce life threatening rebound. It is a very dangerous dependency. There are simple lab tests that can be done to find some of the root causes, but it takes arguing and nagging to get even one or two of them because they are going to have to argue with the insurance company. I've even offered to pay cash. And then there is the issue of most of the labs having really shady network security practices and leaking customer data. It really feels like a whole new industry is needed, something a level above hospitals.


Part 2 (sorry for the length!)

I should have been tremendously happy. I do feel like I got a completely new lease on life, and a second chance to live life on my terms. My teen years were very rough, and my 20s were extremely rough. And all of the sudden, I am tremendously better, and I all of the sudden turned 30. Life has passed me by, and it has revolved mostly around trying to survive with constant, severe suffering involved for about 15-17 years. It invoked a crisis for me, and now I am trying to soul search and find out truly what I want in life, now that I actually can enjoy things in general.

Also, I properly vetted the situation, and there is a very, very high chance statistically that I will lose access to the only medication that has worked for me, that blood product, due to the Affordable Care Act Supreme Court Case (which will be released late June 2020). This is based off of ~8 or so rare circumstances where the Solicitor General does not defend a Supreme Court case, for the Department of Justice, at the Supreme Court level. Let's just say that statistically the odds of it going well are extremely bad, and I want to hope, but I cannot afford making any bad moves.

I happen to be a dual US|EU national, for which I am extremely grateful and fortunate to be.

This 4th of July is going to be very sentimental for me. This may be the last time I celebrate this holiday with my family, before I am forced to uproot my life in the US, due to potentially no longer being able to access the one medication I need to stay healthy.

I will have to go to Europe, if so, where I have a legal right to access healthcare. Trying to get my care set up properly is going to be an enduring process. I see several providers, and I am also on a lot of obscure and unusual medications. However, there is no country in the world that handles rare diseases better than Norway, so I do know where I am going to settle.

Basically turning 30 made me realize that I am going to have to uproot my life and make a new home, so I can stay alive. I have been in survival mode since I was 18. Plus, it is believed that the third leading cause of death in the US is preventable medical errors. I cannot take that risk when I have a ton of medical problems. It shouldn't have to be this way. It hurts, but I suspect things will be a lot better in Norway.

I know this post was wild, but maybe you got some beneficial insight out of it, that perhaps you can relate to. I hope so. Either way, I am sorry for rambling.


I really appreciate your thoughtful post. You really captured the situation well, and you were spot on in all regards. I totally agree with you! Also, thank you for the kind regards!

Sad but true: I do expect at least 33% of my medical data being leaked via security breaches, and a lot of it is extremely sensitive information.

Yeah, relying on junior doctors is a serious and insurmountable problem when you need actionable results and accurate diagnoses. I also have type 1 diabetes (autoimmune and insulin-dependent) and my endocrinologist (who is phenomenal yet only has a masters degree and is a nurse practitioner...) has always had my back, getting me out of some really bad situations, and has always referred me to the most amazing and reliable specialists. The thing is, all you really need is a link like that in an highly regarded academic medical center to get you to exceptional doctors. This is a strange thing to say, but she has been at this hospital for several years, and as a nurse practitioner, has climbed the hierarchical ranks of the healthcare institution, earning respect from her colleagues, so she has connections like these. I also have always had the impression that she gets a lot of enjoyment out of throwing her weight around at the hospital.

Yeah, I know what you mean about how the fox watches the henhouse. I receive a blood product, that literally costs over $300,000/year, at the contracted rate that insurance pays out, and I am forced to get it through a specialty pharmacy that is a subsidiary of UHC. It is extremely temperature sensitive, and it has been shipped to me hot, and I was told it was "OK". About 1/3 shipments, they leave out critical supplies that I need, too. There is a total disregard and/or sense of responsibility towards the situation, overall. It is beyond appalling. Plus, I have tried about 10 different treatments and/or medications, including in combinations, and this particular medication and route of administration, is literally the only thing that has ever worked, after over 6 years of trying with profound suffering, let alone has put and kept in in pharmaceutical remission. So, a lot is really on the line here.

Yeah, when I go to see my doctors, I do get the impression from them, out of amusement, amazement, and concern, "How on earth is she even alive?". Anyways, I have cheated death more than a few times.

Actually, the very rare autoimmune disease that I have was first diagnosed as "diabetes complications" in the form of "diabetic autonomic neuropathy" starting at age 18, even though it really started prior to the type 1 diabetes (T1D) diagnosis at age 5.

At age 18, it was diagnosed as a severe digestive disorder that causes chronic nausea and vomiting. Before that, I had been to several doctors, at least 10 in 6 months, including some very incompetent GI doctors. The nurse practitioner endocrinologist diagnosed it and put the bad situation to an end. Long story short, but I basically have a form of autoimmune autonomic nervous system failure that is pervasive, and affects bodily functions in general. Basically, my body cannot regulate its own bodily functions due to the antibodies I have, and it used to be very severe.

Long story short, this is never supposed to happen, and it never added up. But, I didn't know what to do with it, so I accepted it. Due to the severity of the autonomic neuropathy and the progressive nature of diabetes complications (and the lack of any sort of remedial treatment whatsoever for this particular diabetes complication), I accepted that I was going to die from my diabetes, at a young age, when I was 18 years old. I never had any prior warning signs (like terrible care or management) that would have signaled even something remotely of this severity to occur. So, I felt extremely jaded.

I am an electrical engineering student (senior, undergraduate), who is finally finishing up her degree, at age 30. Literally 10 days before I was diagnosed with the very rare disease (my blood had been sent off to the one lab in the US that did the antibody testing at that point) I actually had to decline a 6 month internship offer with Intel in Folsom, California, in mixed signal processing at their research and development campus. I was absolutely floored and honored, but I was in no position to take up the offer. I was very sick and I could not have worked, even if I wanted to.

Anyways, my training and education in electrical engineering, probably made the difference of the world, in my profoundly bad situation. I always wondered, even at age 18, if the autonomic neuropathy was actually due to my T1D in the first place. I would scavenge through peer-reviewed journal articles during the very little free time I had (I was studying engineering full time, plus working part time 15-20 hours a week, plus juggling around severe physical health problems that we all underestimated to an extreme). I literally did this for years. I certainly did not understand all of the articles conceptually, but due to being trained as an applied scientist, I could eliminate what was theoretically possible--and what wasn't.

At age 22, I was finally diagnosed with severe orthostatic hypotension (low blood pressure when standing up), that would get more and more severe every month I went to the cardiologist. My cardiologist is a great doctor, and is in charge of all of her colleagues in cardiology at a prominent academic medical center. My resting heart rate in general was around 130+ beats per minute whenever I was there, in addition to not being able to stand up without nearly passing out, every single time, at minimum.

You would hope that a cardiologist would not be hesitant to make bold or risky moves, or be intimidated by a particularly bad situation. However, because my heart rate was so high and there were very few appropriate medications available at the time to treat the heart conditions I have, I was prescribed a beta blocker.

Everything at the time had very much been going downhill, but this put it on the superhighway. I literally ended up being hospitalized for severe orthostatic hypotension every 1.5-2 weeks over 4 months, at like 2-3 days at a time. All they could do for me was pump me full of fluids and discharge me, only for it to happen again.

Anyways, I ended up coming across the name for what I had via Googling on my phone in the ER. My endocrinologist tested me for it, and I had it, and the rest is history.

My cardiologist said, looking back, that I had the worst orthostatic hypotension that she had ever seen in a diabetic. I was only 22 at the time. She came to the realization that it was a red flag.

But, engineering school has helped me come up with creative solutions to my health problems in general. Plus, I understand the scientific process in general well too, so it helps me make better and more informed decisions.

I was tested for a disease that I should have never had. It had an insidious onset and it looked just like diabetes related autonomic neuropathy. We believe that this disease caused the autoimmunity that led to me developing T1D too. We also have a hypothesis on how my autoimmune diseases are linked. There is no way that there are not others out there like me, which bothers me tremendously.

What if I never received proper diabetes education? What if I never pursued engineering? What if I was poor?...etc., etc. The fact is that this would have never been figured out, and this disease has only been discovered relatively recently in the history of medicine, too, under NIH grant funds.

I turned 30 a month ago, and celebrated my birthday with my fraternal twin brother, my best friend. I have been in pharmaceutical remission for nearly a year now (I basically have to take this medication for life, to hopefully stay in remission). It really was a milestone for me. I know I have cheated death more than a few times, and that I really should not be alive. I truly was never expecting to turn 30, ever.


If you're in the USA illegally and living in CA, beginning next year your health care is free regardless of income.

A lot of young adults are graduating and finding zero hope of getting a full time job with benefits. Also they have large amounts of non-dischargeable student loans. In addition if they have any health problems they are no longer on parent's insurance and suffering disproportionately. I'm not surprised to see issues with drug use and suicide bringing down life expectancies. I also don't expect the trend to get much better in the next few years.

The median student loan payment is $220 per month, for the minority of young people who even have student loans. (Only a third of millennials have any student loans, and the median amount is less than $25,000.) People are killing them selves over a car payments worth of debt? Or are you trying to shoe horn these mortality statistics into a pre-constructed narrative?

Probably the suicidal people are at the extremes, not the median.

The student loans and collections effectively give up when a borrower moves to Europe or leaves the country.

It's ~17,000 --> ~70,000 in the last twenty years.

Also, since a lot of these deaths happen early, they have a greater impact the life expectancy rate. One person dying 55 years earlier from a heroin OD has the same impact as 11 people dying 5 years earlier.


The number of deaths in 2017 was over 70k:

https://www.drugabuse.gov/related-topics/trends-statistics/o...

That's more than traffic fatalities.

you still see people desperate to come here.

Yes, mostly Mexicans, Chinese and Indians. If I hailed from such a country I would be desperate too.


> The US is a pretty terrible place to live if you're poor however.

That's simply not true. The poor in the US have one of the world's most expensive welfare states. It's the next ~20%-25% or so above the bottom 25%, that have it worst. Those people don't get free access to healthcare because they earn too much.

The US has a very advanced welfare state and safety net for the poor. The US spends more of its economy on its welfare state than either Canada or Australia, and is in the upper half of the OECD in that regard. The US welfare state is also rapidly growing, whereas most other developed nations are seeing their welfare states shrinking.

The US poverty and homelessness rates are both superior to Canada and France. The US provides free healthcare for the bottom 25%, along with countless other massive programs involving food and shelter for the poor.


You talk about absolute costs as if that means much.

Surely a conclusion can be reached where you’re spending more than any other country, yet so inefficient at distributing the wealth that you’re spending, or funnelling it into broken feedback loops that keep people in the welfare system.

surely if that were the case then it doesn’t matter how much you’re spending in absolute terms, you’d still not be enriching the lives of the poor or helping social mobility.


US social spending as a percentage of GDP (not absolute amounts) is about 18%, about the same as Canada and Australia, a bit higher than the Netherlands or Switzerland, and a smidge below the OECD average of 20%.

https://data.oecd.org/socialexp/social-spending.htm


I’m saying total spending doesn’t equate to effectiveness of spending. I too can “spend” a lot of money on a boat by throwing suitcases of money into the ocean, but it does nothing to improve the boat.

It would be interesting to see how nominal numbers will change if you recalculate them to take prices and per capita factors in consideration.

What poor in Canada can afford in terms of food, shelter and healthcare, and what poor in US can afford.


> The US poverty and homelessness rates are both superior to Canada and France.

Which figures for homelessness in the US and in France are you using please?


E.g. OECD: https://www.oecd.org/els/family/HC3-1-Homeless-population.pd...

0.18% in US, 0.22% in France, 0.44% in Canada. 0.36% in Sweden.


So you're comparing different things, because these countries count homelessness differently.

> There is no internationally agreed definition of homelessness. Therefore, this indicator presents a collection of available statistics on homelessness in OECD and EU countries in line with definitions used in national surveys (comparability issues on the data are discussed below). Some countries have different official definitions of homeless: they may use a definition for the purpose of data collection but use another one or several definitions for policy purposes, i.e. in the framework of policy measures aimed at tackling homelessness. In this indicator we refer only to the statistical definition used for data collection purposes.

[...]

> Definitional differences drive variations in the reported incidence of homelessness across countries and hamper international comparisons and the understanding real differences in homelessness rates and risks. Besides definitional differences, there are a number of flaws in the scope and methods of data collection which might affect measuring the real extent of homelessness. For instance, administrative data can provide good data on the users of homeless services but they leave out people who are not in contact with services providers or local authorities. Furthermore, geographical coverage of data collection often does not include the whole national territory but only municipalities with a certain number of inhabitants. A full description of methodological issues in homelessness data collection is beyond the scope of this indicator but more in-depth information can be found in Busch-Geertsema et al.,2014, and OECD, 2015.


Folks, the equation is quite simple: the US is a high-risk, high (financial) reward society. Unlike the EU, it's optimized for the upside: you have many opportunities to create wealth for yourself (and sometimes for others). The EU, conversely, is optimized for the downside: you may not have too many opportunities to climb high, but even if you are the bottom, life can still be relatively comfortable. So, for the averaghe person, the European system is likely (almost definitely) better. For risk-craving entrepreneurs, the US is better (although some other places may have even more and bigger high-risk opportunities nowadays). For you? You decide!

> So, for the averaghe person, the European system is likely (almost definitely) better.

I would strongly dispute this. According to the OECD, median household disposable income (adjusted for purchasing power) in the US is $10,000 per year, more than 20% higher than Germany, and $12,000 per year higher than the OECD average.

Health care and educational expenses don’t come close to wiping out that difference for the median person. The median American household has no student loan payment, and spends just a couple of thousand per year on out of pocket health care costs: https://www.kff.org/health-costs/press-release/interactive-c...

> For example, a person with employer coverage earning $50,000 annually spends on average $5,250, or roughly 11% of her income, on health care. This includes $800 per year in out-of-pocket costs, a $1,400 premium contribution, and $3,050 in state and federal taxes to fund health programs.

(The OECD disposable income statistic is after taxes, so the $3,050 in taxes above should be excluded from the comparison.)

The US system is optimized for the top 60%, and further optimized so the middle 40% doesn’t have to pay EU-level taxes to bankroll a safety net for the bottom 40%. It’s optimized at maximizing material comfort for the majority of people who never get seriously ill before they’re eligible for Medicare, as opposed to optimizing for raising the floor for people who get unlucky.


That's not actually true at all. The US has lower social mobility than most wealthy European countries. Thus, there are actually fewer opportunities for most people to create wealth for themselves compared to countries with more equality. It's hard to start a business, if, like the vast majority of people, you don't have a bunch of excess money sitting around.

https://www.forbes.com/sites/aparnamathur/2018/07/16/the-u-s...

https://www.economist.com/graphic-detail/2018/02/14/american...


Quintile graphs obscure absolute magnitudes. Most of the people that have a realistic chance of making it into the upper income/wealth quintiles come from relatively high social strata already (either within the U.S or, if they're an immigrant, within their home countries), but they want that high percentile to mean more in absolute terms.

In other words, if you come from the upper end of the distribution, income inequality is a feature not a bug.


The is a fatal flaw with the way they measure mobility in these studies because the income quintiles are skewed much higher in the US.

Take this scenario:

1. You go from 1st quintile (10K EUR) to 5th quintile (100K EUR) in Europe.

2. You go from 1st quintile ($10K) to 4th quintile ($110K) in the US.

By this measure, Europe has better mobility, but the person in the US ends up with a higher income.


I don't think using quintiles is unfair.

Consider thinking about it using an extreme: If I'm earning (and spending) in the top percentile in NYC or London, I assuredly have a very nice standard of living, but the effort (personal growth, career, etc) to move to that top percentile from anywhere else is far lower in London than it is in NYC.


Is that actually true? In refurb's example, you can move from the 4th quintile in the U.S. to the 5th quintile in London simply by moving from the U.S. to London and holding everything else constant.

In my career, the biggest bumps in compensation have been through events that I had little to do with. Pick the right industry and company, pass the hiring bar, have their wage-fixing cartel broken by Facebook, and let stock-price appreciation do the rest. I worked hard, but I worked hard mostly because what else am I going to do with my time?

I also feel like there's a difference in working models between your post (and by extension, most middle-class and lower people) and how people actually get to the top income & wealth percentiles. Most people believe it happens through hard work: put in the hours, learn the material, diligently do what you're told, get a steady stream of promotions, and you'll get rich. In practice, this usually results in a series of 6-7% wage increases that keep you roughly where you were within the relative distribution, because everybody else is doing the same thing. All really big fortunes are made through arbitrage: identify a problem that lots of people really want solved, present yourself as the solution to that problem, profit. Work is required for this, but the returns from it are highly non-linear: you might work a little more (or sometimes even less) than someone who slaves away at their career, but get orders of magnitude more return.


Moving simply to London is not an easy task though, even for a high earner.

How do you decide which country you get born in exactly?

You don't, but if the countries are different, you can at least relocate to your liking.

If all countries are the same then you're out of luck.


poor people can't relocate.

True, but life expectancy is declining here in the UK as well.

I think this has to do with the Great Recession. Prolonged economic insecurity is associated with a poor mental health. And that is in turn associated with self medication with things like alcohol and opioids.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4741013/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151244/


I'm curious why the broad result is also showing up in UK as another example (the opioid deaths in the US are making its situation even worse). There must be something in common occurring:

"Life expectancy progress in UK 'stops for first time'"

https://www.bbc.com/news/health-45638646

"Life expectancy falls by six months in biggest drop in UK forecasts"

https://www.theguardian.com/society/2019/mar/07/life-expecta...

"Why is life expectancy faltering?"

https://www.theguardian.com/society/2019/jun/23/why-is-life-...


The UK has "enjoyed" nearly 10 years of post 2008 austerity, destroying services, reducing spending on health, education, social care, everything really. Health waiting lists have risen to the highest levels for decades, mental health care has essentially become dysfunctional. The resultant effect on life expectancy isn't surprising.

For the UK at least, it's policy.

The main alternative political party spends more time making itself unpopular than opposing the government, or we may have voted in a change years ago.


That would be a quite a laggy effect at this point. The US has been having it’s longest continuous period of economic growth ever.

Growth on Wall Street isn't growth on main street, and huge corporate and big investor profits (and associated cash hordes) haven't meant economic recovery in the places and communities hardest hit by the opioid epidemic.

Growth on Wall Street isn't growth on main street

Of course it is. Where do you think main streets pensions and 401k are invested? Where do you think main street people work?


most equity is held by the richest americans, while others primarily depend on wages which haven't risen in decades, basically.

also most people aren't employed by large business.

https://www.pewresearch.org/fact-tank/2018/08/07/for-most-us...

https://www.huffpost.com/entry/five-big-myths-about-amer_b_8...


Wages are only one part of compensation. Total compensation has increased faster than inflation over the past decades.

Health insurance costs have increased faster than inflation for decades and is responsible for the total increase in compensation[1].

Workers are not getting more or better benefits. They're getting the same or worse benefits, it's just that health insurance costs for the same plans increase each year at a rate that vastly outpaces inflation.

[1] https://si.wsj.net/public/resources/images/BF-AU065A_INSUR_9...


That's true, but it also contradicts the claim that compensation isn't going up. Sure it's going towards ever more expensive healthcare, but it is going up.

you seem to have both shifted the frame from wages to compensation then defeated a non-existent claim about it, so that seems like a mighty straw man.

Only a third of Americans -have- a 401k, and only 13% have pensions.

> The US has been having it’s longest continuous period of economic growth ever.

Cost of living and healthcare costs are skyrocketing and have outpaced inflation for decades. Wages are stagnant, and benefits are rare for those who are working.

Yes, if you have significant investments, you're benefiting handsomely.

If you have thousands of dollars of student debt, can barely afford health insurance and are making much less than your parents did at your age, things don't look so good from that perspective.


> Benefits are rare for those who are working

~70% of employees receive health insurance benefits. [3] And unemployment has never been lower.

Since 2010 the unemployment rate for young workers has dropped steadily from nearly 20% to about 8%. The lowest ever recorded was 7.8%. [1]

Real median household income has also risen sharply since 2010. [2]

Please don’t move the goalposts to something like “the economy is perfect for everyone”. In the context of “is the Great Recession” responsible, I am merely stating a recession ending over 10 years ago followed by the longest period of economic growth the US has ever seen, just seems like an unlikely candidate as a potential cause.

[1] - https://tradingeconomics.com/united-states/youth-unemploymen...

[2] - https://fred.stlouisfed.org/series/MEHOINUSA672N

[3] - https://www.bls.gov/news.release/pdf/ebs2.pdf


Your second source is giving an error.

> ~70% of employees receive health insurance benefits.

From your third source:

> For part-time workers, access to medical care benefits was 21 percent and the take- up rate was 56 percent.

Post-2008 recession saw a restructuring of employment. I know plenty of college graduates who are saddled with debt and are scheduled to work slightly less than full-time hours in order to sidestep having to be offered benefits.

Nearly 80% of Americans are living paycheck to paycheck[1]. 40% of Americans can't cover a $400 emergency expense[2]. Wages have stagnated for most Americans since the 1970s[3].

[1] https://www.forbes.com/sites/zackfriedman/2019/01/11/live-pa...

[2] https://money.cnn.com/2018/05/22/pf/emergency-expenses-house...

[3] https://www.pewresearch.org/fact-tank/2018/08/07/for-most-us...


The BLS numbers break down the access, participation, and take-up rates for public and private workers, as well as union and non-union, full time and part-time. There’s a very handy table.

For all workers overall, access is 72%, take-up is 73%, so overall participation is 52%. Thats Table 1, Row 1.

Of course sub-populations like part-time workers have lower access and take-up, but they are included in the average for All Workers.

See Table 1 on Page 6 of the BLS numbers. The claim that “benefits are rare” is demonstrably false. Benefits are rare for certain sub-populations of US workers, but not rare overall.

Real wage are stagnant (not clear if those real wages are accounting for increased employer share of medical benefits) from the 1970s. Real household income is not stagnant, particularly since 2010.

(Edit: Household income vs individual wages — perhaps household income rising reflects mainly the participation rate increasing? Which would be a negative effect on individual wages.)

Again, the point is about recent increases in suicide rate in the context of a 2008 recession.


> There is no error.

Yes, there is. From your second source:

> Looking for Something?

> We're sorry, the page you were looking for cannot be found. Please feel free to contact us if the problem persists.


I misunderstood. Fixed.

It's quite possible that the people who are dying of overdoses and suicides are precisely the people for whom the economy sucks.

70K deaths is about 0.25% of the U.S. population. It would only take the economy being sucky enough to seem hopeless for a few percent of the population to produce a meaningful increase in deaths of despair for this number of people. The economy could be doing great for the majority of people, and this would only rub it in further for a marginalized group.


Well there is zero doubt that suicide rates are correlated with poverty rates! That isn’t quite the question though, is it?

If poverty rates explained the recent life expectancy drop and concomitant suicide rate and overdose spike, we are wasting a lot of time in this comment section.

Except the poverty rate is falling. [1]

Maybe the theory is that even though the economy has been getting better for almost a full decade, and the poverty rate has been falling, there is a segment of the population that is still in poverty or even coming out of poverty and yet still feeling more dreadfully helpless than past people in similar financial status.

[1] - https://www.census.gov/library/publications/2018/demo/p60-26...


Wages have not increased and inflation has made employment not measurable compared to 20-30 years ago where it represented economic growth. Friends out of university are being hired for jobs paying what the going rate was without a degree 10 years ago. Suicide rates are increasing for the youth and it's obvious because their parents had it better with homes, no student loans and more spending money.

I see some people talking about Germany and France offering far better and cheaper healthcare.

But can you afford to look only at Germany and France? They operate in a broader framework of EU.

If you are going to compare services/living standards then must also directly compare Romania or Bulgaria to the US because Germany and France are able to provide cheap healthcare because their healthcare staff are willing to accept lower prices and how does it work? By importing labor from cheaper European countries. Presently, many doctors and nurses from Romania work in Germany without them good luck being able to maintain "cheap" healthcare.

If you cut off Germany and France from rest of the EU, the healthcare cost will likely shoot up far more than what it costs in US now.

There is downward pressure on wages in whole EU and this is why Europeans come to states for better employment opportunities, and better pay which can and does buy you better living standards if you are willing to spend the money you make but it seems not many want to do that, they want free healthcare in addition to taking large proportion of their wages home.


I am from Portugal, a country that has many people working in richer EU countries, but I don't think this is true.

Romanian or Portuguese nurses and doctors working in France or Germany or any other country will have the same wages as a french nurse or doctor. Or most of the time at least.

My wife is a nurse and we did some research on this a few years ago.


I am not saying they are accept lower wages then their German or French counterparts, what I am claiming is that because they are available in the market, their availability puts downward pressure on the wages and that's why German or French doctor/nurses can't charge more than what they'd pay to a worker from any other country.

I don't know specifically wages but often there are re-certifications needed even within the EU (currently a friend's wife who is an M.D. is trying to switch from Estonia to the UK and has to jump through several administrative hoops and get certifications in English and a few other things)

There is still the possibility of increased worker availability reducing wages, you have less bargaining power if theres readily someone else to take your place.

Medical workers coming in from other countries can suppress wages, but enough to cause a significant price difference in cost of health care? We also don't know the dynamic effects of a labor shortage. Maybe Germans would switch jobs into the medical field and the wages won't rise that much?

German companies are bitching forever now that there are no workers available for them. I read that in news every other week.

and there is the converse too, where people go to eastern countries to get surgeries.

It's not like North America doesn't have its share of immigrant doctors. However, at least in Canada, their diplomas are often not accepted. I know a dentist operating a daycare, for example. Is it any different in the EU?

Lack of a stable career, terrible health insurance, high premiums, lack of community involvement, isolation from people, increased screen time and media consumption, hopelessness from always on sensational news, hopelessness in the face of global catastrophe to be coming near you due to ever worsening climate problem, student debt, not being able to afford a home, lack of healthy food options, diet and exercise misinformation, overprescribed medication, always on notifications never allowing you to relax, binge watching Netflix no time for brain to relax, shortened sleep cycles disrupting circadian rhythm.

I wonder what could possibly make people feel like shit and wanting to end it all...


I'm open the idea of various forms of drug legalization, but someone pointed out that the opioid epidemic (which is behind the decline in life expectancy) is arguably an experiment with legalizing heroin. The analogy isn't perfect, but that gave me pause.

Decriminalization (which is subtly different than legalization) of drugs isn't in conflict with preventing addiction and abuse by treating these as health problems, which is what they actually are.

The opioid epidemic was in significant part pushed forward by the unscrupulous marketing of prescription opioid manufacturers, and further catalyzed by the declining socioeconomic conditions in the areas most affected by the epidemic.


> Decriminalization (which is subtly different than legalization) of drugs isn't in conflict with preventing addiction and abuse by treating these as health problems, which is what they actually are.

It is when you hold the belief that addiction is a moral failing. Most parts of the US seem to be digging out from under that misconception, though. Finishing it off for good could be the one good thing to come out of the opioid epidemic.


Yes, if there's any benefit to the current opioid crisis, it's that American perceptions of addiction are changing as they see that anyone, not just poor/minorities can be affected by addiction and that it's absolutely not a moral failing

It isn't legalizing heroin, or else we'd have nationwide formal public health strategies for harm reduction. What we have is a strategy that seems like it was custom-built to maximize harm to public health.

We should hand over the reins of drug policy to the Public Health Service Commissioned Corps and task them with minimizing harm, instead of the abject failure we have now with police running the show.


The main point of drug legalization to me is to get people out jails and into proper support networks where they can get the medical treatment they need for an addiction without throwing their life away.

> I'm open the idea of various forms of drug legalization, but someone pointed out that the opioid epidemic (which is behind the decline in life expectancy) is arguably an experiment with legalizing heroin. The analogy isn't perfect, but that gave me pause.

Not in the slightest, because presumably heroin that you get from your pharmacist at Walgreens wouldn't be contaminated with fentanyl.


Heroin dealers are mixing in fentanyl because it’s extremely dense (in terms of doses per mass) and therefore easy to smuggle. People are ODing on fentanyl because those same properties make it hard to dose accurately. None of this would happen if opioids were legal.

No, it's not. Throwing addicts in prison does nothing to help addiction rates, and proper support systems to help addicts can't be created easily if heroin is illegal.

Two weeks, I had open heart surgery in my mid-20s in the US.

My main takeaway is this: those of us who work in tech or companies with decent health insurance are extremely fortunate.

In total (knock on wood that this doesn’t go up), I spent around $10k out of pocket.

This included more than surgery itself:

- multiple ER visits because of my deteriorating valve

- a LOT of dentist work (cleanings, fillings, wisdom teeth removal); these things increase your risk of stroke/heart attack after heart surgery.

- multiple visits with cardiologist and surgeon consultations

- pre-operation

- six days in the hospital recovering

To be honest, that’s a lot less than I expected to pay. However, I can’t help but think of people in less fortunate positions that would 1) get fucked by the bills if they had no insurance or 2) still go into debt despite having insurance. When you really think about it, all options are ridiculous for an operation that is literally do-or-die.

I’d also like to add a note on specialized vs ‘routine’ care here in the US. Or my experience with it, anyway.

All specialized treatment I received (dentist, heart surgery, cardiologist) was outstanding.

Routine cafe was awful, and ER visits were nothing short of ridiculous. I went in with chest pain/shortness of breath (that I now know was very serious). I waited for 6 hours. They gave me some blood work and an ekg and sent me on my way. I went again the next week, because my symptoms were getting progressively worse. Once again, I waited about 6 hours in the waiting room before getting an ekg and some blood work. Both visits were a complete waste of time. Luckily, I saw a cardiologist shortly after who gave me an echocardiogram and identified the valve issue.

This (the shortness of breath, dentist visits, surgery) was all done within the last two months. Were I in a less fortunate financial position, I probably would have hesitated to even go to the cardiologist. Especially after having thrown money at the ER for nothing.

It’s unfortunate how our healthcare system mirrors some sort of class-based hierarchy: If you can afford it, great! Else, get fucked.


Medicaid provides free healthcare for low-income Americans. It covers 23% of the population.

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


Medicaid is only expanded via the ACA in 36 states. In the remaining states that denied Medicaid expansion via the ACA, Medicaid is not available based on income at all.

In the states that expanded Medicaid, it is only available to individuals making less than 100-138% of the federal poverty level. The FPL for a single individual in 2019 is $12,490.

Individuals making more than 138% of the FPL, which is $17,236, are not eligible for Medicaid.

I'd argue that making slightly more than 138% of the FPL is still poverty level income, however Medicaid is not available to these individuals.


Did the ER send you on your way with a recommendation to see your PCP or a cardiologist?

Nope! Just told me to reach out to a cardiologist if things didn’t get better, and suggested it’s probably anxiety. I suppose I can’t blame them given my age, but it makes me wonder how many cardiac deaths (#1 source of deaths in the US [1]) are preventable.

[1] https://www.healthline.com/health/leading-causes-of-death#ca...


> It’s unfortunate how our healthcare system mirrors some sort of class-based hierarchy: If you can afford it, great! Else, get fucked.

It's not widely known in the upper/upper middle classes but healthcare is more or less free if you're poor in the US (even for major things like cancer treatment). It's really the middle class that has it the worst as they don't qualify for free health care.

Edit:

Some additional information to back up my assertion:

72.5 million people are covered by Medicaid: https://www.medicaid.gov/medicaid/eligibility/index.html

The vast majority of medical services are available for free to Medicaid members: https://www.medicaid.gov/medicaid/benefits/index.html


> healthcare is more or less free if you're poor in the US

If you qualify for Medicaid, you have government-provided insurance available, but that doesn't mean care is free even then, because Medicaid rules allow state plans to incorporate either or both of premiums and beneficiary cost sharing as part of the state Medicaid plans.

Also note that many people (particularly adults) that would meet many definitions of poor are not qualified for Medicaid, because several states don't cover adults (especially non-parents) with Medicaid above a small fraction of the federal poverty level (and sometimes not at all for non-parents).

See, https://www.kff.org/health-reform/state-indicator/medicaid-i...


I was on Medicaid just a few years ago. It was definitely a lifesend, but the network is very tiny and, as a result, scheduling visits with specialists (in my experience, so anecdotally) took about three months.

I am very grateful I was not on Medicaid during the past few months. But I am happy it’s an option.


scheduling visits with specialists (in my experience, so anecdotally) took about three months.

From my own experience, that's approximately what it takes to schedule a specialist visit in the UK.

Unless (surprise!) you have a private insurance.


Emergency healthcare is free. Cancer treatment might be free, but good luck seeing the specialists needed to get that treatment without some very explicit charity.

This is incorrect. You can see specialists for free as well. There are no restrictions on treatment.

Maybe if they already know you have cancer, but just some symptoms? The emergency room typically isn’t going to make a cancer diagnosis.

A lot of healthcare is simply best effort, and you won’t typically get that best effort if you aren’t paying.


Medicade is full blown health coverage, it's not just for emergency room visits: https://www.medicaid.gov/

> Medicade is full blown health coverage,

Medicaid is (1) not available to anywhere close to all poor people in the US (though it would have been for a particular poverty definition had ACA expansion been universal), and (2) doesn't provide free care to all the poor people to whom it is available (both premiums and cost sharing—effectively, deductibles—are allowed in State Medicaid plans), and (3) very often does have limits on available services, so while Medicaid exists, it does not meet the description made of healthcare being free in the US if you are poor without treatment restrictions that has been made.


> You can see specialists for free as well

What specific program are you talking about? Because you're wrong when you state this as an unqualified generality about poor people in the US, but identifying the exact error requires knowing what program you think is involved.

> There are no restrictions on treatment.

There is no program for low income healthcare for which this is true.


I was expecting the cause to be obesity - just imagine how much healthcare costs would go down if the 40% of Americans who are obese, weren’t.

I’d imagine life expectancy would go up a bit too.


Free or reduced cost stuff is all the rage these days. Yet we refuse to look in the mirror, where at least a partial explanation for the costs may be found. Quite unfortunate.

There are some other interesting tweaks that can be done as well, sin taxes on things like sugar, tobacco, and booze are all likely to have major impacts on increasing the overall life expectancy

In this week's UK news: https://www.bbc.com/news/health-48826850

"Cancer Research UK says bowel, kidney, ovarian and liver cancers are more likely to have been caused by being overweight than by smoking tobacco. It says millions are at risk of cancer because of their weight and that obese people outnumber smokers two to one. But its new billboard campaign highlighting the obesity-cancer risk has been criticised for fat-shaming."

[..] "NHS England chief executive Simon Stevens said: "The NHS can't win the 'battle against the bulge' on its own. "Families, food businesses and government all need to play their part if we're to avoid copying America's damaging and costly example.""


We continue paying more for demonstrably worse care and outcomes than our global peers.

Single payer needs to happen, now. Medicare for All.


You do realize that Medicare Part D is entirely run by private companies and thus is no "single payer".

That's true, but it only covers prescription drugs. The rest of the system is single-payer.

Not that we need single-payer, just more controls on costs and benefits. Germany and Switzerland do fine without single-payer.


Medicare Advantage includes Parts A,B,D and are run by private insurers as well.

It just irks me when people call for "Medicare for all", but clearly don't understand what Medicare actually is.


Not accurate. Part A and B are paid directly to medicare.

Part C plans offer Part A and B through private insurers.

You do realize that Medicare Part D is an optional program that is separate from the rest of Medicare?

Optional, but one that 70%+ accept because it's free gov't money. The ones that don't have their own health care coverage on the side.

Or are you suggesting when people say "Medicare for all", it wouldn't include prescription coverage?

robbintt 12 days ago [flagged]

Medicare part D provides prescription coverage for a fee. It's a negotiating block for cost averaging and leveraging with a pool of participants.

You clearly don't know anything about this and I recommend you just delete your comments.


Please don't violate the site guidelines regardless of how wrong or annoying other comments are: https://news.ycombinator.com/newsguidelines.html.

Your comment would be fine without the last sentence.

refurb 12 days ago [flagged]

You’re pretty angry for someone who has limited knowledge on this topic!

It’s highly subsidized by the gov’t so the fee is trivial compared to the benefit. 2019 budget is $99B. Monthly cost is a little over $200 if you pay full freight.

Unless you’ve got other insurance, you’d be stupid not to go with Part D. You’d pay more with a private plan.

Medicare Part D plans (private insurers) compete for customers and get money from CMS for offering coverage that confirms to CMS standards.

It’s far more than “negotiating block and cost averaging”.


Please don't violate the site guidelines regardless of how wrong or annoying other comments are: https://news.ycombinator.com/newsguidelines.html.

Your comment would be fine without the first sentence.


Has there been comparison of urban to rural areas with this? Are young people in rural areas dying faster than urban areas?

I found this from 2017: https://www.cdc.gov/media/releases/2017/p1019-rural-overdose...

My sense is that rural areas are harder to change, and probably far more prone to monopolies from service providers. The combination of higher costs of monopoly with higher rates of drug use might lead to more deaths.

Or, in another way, in the US, is being poor in a rural area better/worse/similar to being homeless in an urban one?


Unless I'm missing a parent reference you're referring to, the article explicitly mentioned this:

>In terms of deaths from suicide, Bernstein writes that there is a huge disparity between urban and rural Americans. The suicide rate amongst urban residents is 11.1 per 100,000 people, as opposed to rural residents’ 20 per 100,000.


I'm just wondering if there's ways to link the timelines of the main article (last 3 years) and the rural vs urban comparison (which was from 2017, but cites data much earlier)

Glad to live in Canada. As of 2016, life expectancy was nearly four years ahead of the US, and trending in the right direction.

Huh?

"Life expectancy in Canada has stopped increasing for the first time in more than four decades, due largely to soaring overdose deaths in the Western provinces."[1]

[1]https://www.theglobeandmail.com/canada/british-columbia/arti...


My bad, there's a drop two years after the source I looked at. Seems like the problem is international. So I guess the question is: what can we do about it?

[Nit] Show me 4 embedded ads but not a single chart when talking about trends. Also 2018.

This is a good starting point. This is all open access, and funded through the Bill and Melinda Gates Foundation. This is done at the University of Washington Medical School, which is basically "as good as it gets" for a public medical school in the US. UW also has solid allied health departments. Their statistics department (even outside of the realm of health) is solid too: http://www.healthdata.org/us-health/publications

one of the side affects of google's search monopoly is the entire news/info media has been frozen in a textual model. facebook "helped" a little bit by requiring at least one good image to get shared, but that was in like 2012.

we get the content we get because of the algorithms, not because its a good way to present information.


> Also 2018.

Good catch. Added above.


Interesting quotes from the article:

> Speaking with NPR, disease prevention expert William Dietz of George Washington University stressed the links between overdoses and suicides. Both may occur amongst people “less connected to each other in communities” and are tied to a “sense of hopelessness, which in turn could lead to an increase in rates of suicide and certainly addictive behaviors.”

> McHugh echoes Dietz, concluding, “There's a tremendous amount of overlap between the two that isn't talked about nearly enough.”


Meanwhile, I was informed yesterday that my health insurance premium is going up by 12%.

Anecdotal Comments < Hard Evidence. US is indeed in relative decline.

The writing is on the wall: the US has to fix is healthcare system.

Quick googling shows suicide deaths increasing 24% over 15 years, to 45,000 in 2014.

I heard an interview on Sam Harris’ podcast where the contention was teenage suicide rates are dramatically increasing.

Overdose deaths are at around 70,000 for 2017.

Overdose deaths and suicide are very connected, insofar as they can be traced to a feeling of hopelessness or meaninglessness.

Alcoholics are at a very high risk for suicide, for example.

There may be many other related causes of death: homicides, car crashes, and other destructive behaviors can still be viewed through a lens of lack of self worth or hope.

I think it is a huge mistake to treat it as a priori that economic factors drive this situation.

You can argue that even though we are all materially much more well off than 100 years ago, the awareness of relative status still has a profound psychological impact.

But I think looking at possible non-economic factors relating to psychological, philosophical, and spiritual health might provide alternate hypothesis that could help. I think policy makers and pundits avoid that because it seems much harder to address those issues via policy.

To me, though, the data implies a widespread crisis in sense of meaning.


US population is up 15% over those same 15 years. The increase in suicides is a lot less dramatic when normalized per-capita.

Even in a country where people were well educated, the average life expectancy rising beyond some point wouldn't be a good thing. No idea where that optimum average life expectancy is, but it's entirely possible that we exceeded it and the drop noted here is actually a positive thing.

What is your rationale for capping average life expectancy? I hope not some reasoning based on costs due to old age since that is not a logical consequence. Advances leading to increased life expectancy could also lead to healthier / more productive old age.

Not capping life expectancy artificially and not artificially working to extend it for everyone. The world got along fine from 1800-1900 with the world average life expectancy existing at less than 50, but there's no guarantee of the same being true at a global average of 100. IRL everyone alive now exists in a tenuous situation where one of the key constraints is Earth's finite resources. Everyone can't have everything everywhere at the same time while living to 100 unless the population stays artificially low.

*https://ourworldindata.org/life-expectancy


If you live in the US and plan on staying alive in the long run, then you better spend a lot of time consulting HealthData.org--and analyzing the data there--to fit your particular situation.

The third leading cause of death--or at least what is believed to be the third leading cause of death--is preventable medical errors: https://www.npr.org/sections/health-shots/2016/05/03/4766361...

Let's not even get in to how much health care actually costs in the US. But, if you want a completely solid read on that matter, get the book CASINO HEALTHCARE via Amazon. You will not be disappointed.

That being said, both me and my fraternal twin brother turned 30 a month ago. Unlike for most people, turning 30, together with my brother, was a very special milestone that I never expected to reach in life.

I have 2 rare autoimmune neurological diseases, that affect my peripheral nervous system (with one of them being very rare, with only case reports and cohorts published in the medical literature...and it was discovered relatively recently in the medical world...in the past 20 years via NIH research grants to physician-scientists) plus type 1 diabetes. It is all connected, but that is another story for another time.

The US health care system is unequipped to properly deal with people who have rare diseases. 6-7% of the general population has a rare disease, so having one, diagnosed or not, is actually common, and is even more common than the prevalence of ADHD in adults! This too is another story for another time, but I ended up self diagnosing the very rare one correctly, even though in my case the whole situation is beyond confounding, even compared to others with the same very rare condition that I have.

The issue is that for people with rare disease, the situation can be desperate, dismal, and even hopeless. In the case of rare disease, the social support structures in place within a society are literally just as important as the medical aspects of care.

We really do need highly specific plans and approaches for, rare diseases in general, for dealing with our unique situations. Compared the the United States, the European Union excels at this, and is the only world superpower that has a practical, pragmatic, and winning approach on the matter. For access to orphan drugs, Germany is the clear winner worldwide. For societal supports, Norway (which is not part of the EU but it is kind of part of the EU for the purposes here) is phenomenal and no other country compares, worldwide. Their government has extremely well developed programs, offices, and "medical homes" (go to contacts that are teams that coordinate all care) for rare disease patients, and for them only.

Remember, our situations are unique and different compared to other more common chronic illnesses, whether you want to believe this or not.

In fact, probably the biggest threat to my well being as somebody with rare disease: a government that does not reform, regulation wise, with the rapidly changing pace of technology. (And yes, all technology in general needs to be regulated, to varying degrees, whether you want to agree or not.)

Sorry to go off on a tangent. If I told the whole story, which would take quite awhile, you would be shocked, amazed, stunned, and impressed, all at the same time. I have cheated death many times, and I really shouldn't be alive. Both my doctors and I very much are aware of that. I certainly do not know why I am here, however I have purpose and I have meaning in my life.

I would love to go into more specifics, but I cannot without effectively writing a novel here.

The point is, on my 30th birthday, I came to the realization that I basically have to go to the EU (I am a dual US|EU citizen) to not only stay alive in the long term, but to potentially avoid having to suffer profoundly for the rest of my life. I cannot go in to the specifics here, though. But, trust me, the US health care system is not equipped to deal with rare disease properly, at all.

So, instead of celebrating the remarkable accomplishment of my 30th birthday with my best friend (I really shouldn't be alive), I was realizing that I had to leave the US for good, to stay alive. I cannot go in to specifics here, but this is not an exaggeration at all. It was profoundly sad for me, because I have to leave my family, who mostly live int he US, and basically start a new life.


I moved from the EU to the US...

Toddler had a seizure (first and last ever). Called 911. $1300 for a 1.5 mile (per Google Maps) ambulance ride to the hospital plus a $300 bill just towards "medical care" for the ride (none actually given).

Then $800 for the ER, and a seperate $400 bill for the doctor (who sent us home after telling us to come back if more occurred but otherwise give child's tylenol and go see the child's pediatrician on Monday).

Did I mention that both the ambulance company and the hospital have a local monopoly? There's no price competition, no choice to be made, nor could there be in a medical emergency.

The problem with all of these is: If it happened again, I'm genuinely going to think "is this an emergency enough to justify a $2K medical bill?" That shouldn't be how medical treatment is decided.

The whole "capitalism will solve it" thing just isn't working. I cannot shop around for medical care, I cannot see prices, and insurance is $1300/month for essentially no benefit (except to turn prices from bonkers to incredibly high).


Nowhere near as close - I had what I thought was food poisoning and went to the ER. Deeply aware of US ER fees and was already questioning my choice. I go there and was made to wait 30 minutes in excruciating pain. But it got better and I felt good enough that I decided to leave - specifically because I’m scared of the costs. I informed them and left. Did not see the doctor or anyone. Except the nurse who took my weight and height. Got a bill for $1000. Literally for stepping into the ER.

It’a no coincidence that US has such high opioid addiction and homelessness. Even in third world countries these people would have gotten treatment that didn’t bankrupt them.


one reason ERs are so expensive is they are required to provide medical services for people who can't pay. so you are paying a subsidized price. also those fees are negotiable if you are patient and can spend a bunch of time on the phone.

This is a bit of a feedback loop - jack up prices to cover those who can't pay, now more people with bad/no insurance can't afford to pay, rinse and repeat. And it's not just ER prices, the whole medical industry in the US is overpriced - even offices whose patients all have good insurance will still charge large amounts, and of course drug makers still raise prices well after recouping R&D.

This is empirically the least efficient way in the world to systematically handle medical services and payment for them.

With that theory, the prices would be just as high in countries with mandatory and regulated medical insurance, yet they aren't.

The theory is that if the people that couldn’t pay also got lower level services in the first place they wouldn’t be straining the ER rooms.

This is especially a problem in SF with the homeless population. They obviously have no normal healthcare, but the hospital I went to was inundated with them (my own 5 day stay there was billed at over $80k; no surgery).


>people who can't pay

How does it work? Do you need to apply somewhere that and get certified for "cannot pay" status? Do you need to do it before the bill? What if you can pay 1000$ but cannot pay 2500$? What if you can pay but after paying it your life standards lower significantly? What if you have some money and you were about to go to college but an appendix happened and now you cannot affor college?


You're imagining this to be more friendly than it is -- "can't pay for emergency medical care" in the US is a euphemism for "got a bill from the hospital, couldn't pay it, so the hospital sold the debt to a collections agency and wrote the account off as a loss", not a reference to a forgiveness program.

Since the hospital takes a loss in those cases (and has to, since they have to treat everyone), everyone else's cost of care goes up to subsidize the loss.


> You're imagining this to be more friendly than it is -- "can't pay for emergency medical care" in the US is a euphemism for "got a bill from the hospital, couldn't pay it, so the hospital sold the debt to a collections agency and wrote the account off as a loss", not a reference to a forgiveness program.

As someone who's family has been in that situation before, not it is not. We had a $35,000 bill forgiven entirely because we couldn't afford it. The process was certainly stressful, distressing, and we shouldn't have a system where it happened in the first place. That doesn't change the fact that the end result was forgiveness.


If the patient is a destitute homeless person they literally cannot pay. The bill can get sent to collections, but it's not like they have an address to collect from, or a good credit score to ruin, so it's uncollectable.

You can typically try to work out a deal with the billing department which might be a payment plan, cash payment in exchange for a discount (easier to get if you have bad or no insurance), or a combination of both. But once they send it to collections, good luck.

You can negotiate with collections too. If they bought the debt for 5 cents on the dollar (typical) and you make it clear they can accept 50 cents on the dollar or call you for the next 7 years because you just don't care, they may accept.

You just don't pay. They send a bill, you ignore it.

That's about it.


How can a private business be required to perform a public service at its own cost? If the service is public, the public should pay for it; if it's not, each pays his own.

Consider this: a public service is financed by taxes that are proportional to one's income. The way it works now, both a minimum wage worker and Jeff Bezos are asked to pay $1k to walk into a ER, to "subsidize" what is effectively a public service.


In the US you pay just as much as us in the EU from your taxes towards healthcare as well. You are being double dipped for the privilege of having portions of the population not able to afford actual care.

Possibly, on average. Some pay (vastly) more, some less.

I don't see the double-dipping in the math though. EU has populations of people who aren't contributing in taxes much or at all.


We’re talking about total sum per head. Not average.

So saying some people pay less and some more is ignoring the fact that you are actually as a whole paying much more.

It’s arrogantly individualistic to assume that “others might pay more therefore I should continue to support this horrid system”


You're putting words in my mouth, complete with quotation marks. I never said anything about what anyone should do. I didn't even say that on the whole people in the USA pay less.

In the EU, people pay a varying amount (overall a greater fraction of their income) in taxes. In the US, people pay a varying amount (overall a greater fraction of their income) in healthcare. I think these are widely accepted facts.

The US healthcare system has endless problems, I was only commenting on the "double-dipping" part of my parent comment, not writing an essay.


The 'Double dipping' is referring to the average US citizen having to contribute just as much as western europeans from taxes towards healthcare, and then on top of that having to spend just as much privately from personal or employers insurance, and cash. US healthcare costs are about double that of other nations and tax contributions at the same level.

Are you saying that taxes in the US don't vary by income?


I think I misunderstood your original comment. I heard "paying for one's own expenses plus for those who can't afford it" (which is same in the US and the EU), where it seems you mean "paying from taxes plus out of pocket".

My uninformed impression is that in the US one does not pay proportionately the same amount of taxes towards healthcare (maybe you have citations to the contrary?).

I would (only from experience and anecdotes) guess that you're right about it costing double, however.


> My uninformed impression is that in the US one does not pay proportionately the same amount of taxes towards healthcare (maybe you have citations to the contrary?).

Each and every report of US healthcare costs and funding. I'll just grab from the wikipedia article [0] for now.

> Public spending accounts for between 45% and 56.1% of U.S. health care spending.

And one of the pretty handy graphs [1]

Worth noting that this is with a lot of people unable to afford treatment.

[0] https://en.wikipedia.org/wiki/Health_care_finance_in_the_Uni...

[1] https://upload.wikimedia.org/wikipedia/commons/thumb/f/f7/OE...

Edit: Has to be coupled with public spending in other nations to be complete. There is another article related to the graph [2] with another easy to understand graph [3]

[2] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

[3] https://upload.wikimedia.org/wikipedia/commons/thumb/0/0b/OE...


Your citations seem roughly in line with what I said and expected: Americans pay double overall, with a similar dollar amount of public healthcare.

Proportionately speaking, that means Americans are not taxed the same (higher incomes). Interestingly, based on what I'm seeing re: incomes, the /total/ healthcare expenditure is, as a proportion of income, the same between the US and western Europe.

Overall this seems quite unsurprising: healthcare is expensive, the US pays more and the government spreads it around less. Worth noting that health and lifestyle in the US is also "worse" (more cultural than healthcare related).


You know that ERs also provide service to the poor in the civilized world, right? And we don't bankrupt the poor for the privilege of living.

"subsidized price" for heath care is the most horrible and obnoxious shit yet.


That would buy you 5 days of ICU stay in most of the third world countries :)

You can call your doctor's triage line if they have one and they can usually diagnose food poisoning over the phone and call in a prescription if you need one. Otherwise there is urgent care which is cheaper than the ER.

Similar story. Came from Europe to US to go to college. Got a terrible strep throat. Went to the nearest emergency room. Waited for almost an hour. Saw some intern for 10 minutes who prescribed me a codeine pill and later charged me $400. That was in early 2000s money. The funny thing is I already had insurance through the university, but this doctor wasn't "in-network" apparently.

Even if there wasn't a monopoly I can only imagine the insurance company advising clients to use specific hand signals to indicate which network they belong to so the ambulance driver knows where to drive if you're incapacitated and can't speak. "Raise and wiggle three fingers for Blue Cross Blue Shield, and two for Anthem". Or maybe have everyone get tattoos on their arms with their insurance network details.


How did an intern prescribe something to you? That should not be possible. Also, codeine isn't a treatment for strep. They should have given you antibiotics after diagnosing a throat swab.

I was in pain and I guess after checking that my throat wasn't going to close completely he gave me something for the "pain".

> How did an intern prescribe something to you?

He seemed young enough to be intern. I didn't specifically check his age or credentials.


Perhaps a young doctor. :-) They should have advised against you leaving until they did a throat culture. It's rare, but strep can develop into a life threatening condition.

This does not make sense on several levels:

1) strep throat is not an appropriate use of the ER.

2) codeine is not a course of treatment for strep or any other communicable disease. A course of antibiotics is mandatory.

3) strep infection cannot be diagnosed at first sight. Culturing is required.


1) I had no idea what it was, I was just thinking my throat was going to close. They never did a culture. I was sent out in 10-15 minutes after I was seen.

2) I was expecting some antibiotics. But because I said I was in pain they gave me a "pain" pill I guess and sent me on my way.

3) For sure. I was expecting them to do some better diagnostics. Certainly after charging $400 (in early 2000's money, I would probably be more now).


Well my family moved to Germany and this was our experience with German healthcare:

1. Mom goes to doctor because of shoulder pain

2. Doctor prescribes "health spa" (wtf?) to see if the pain will go away. Apparently "spa time" is a common default prescription because the healthcare system is overrun with people that come in with sniffles and aches that go away in a few days?

3. Spa Time does nothing (as predicted); doctor orders xrays

4. Process/analysis/??? is taking forever; in the meantime we have moved back to USA

5. US doctor correctly diagnoses problem same day as initial visit and orders specialized PT that actually helps


I'd wager that you just went to an 'allgemeinarzt'... they're doctors for general illnesses, which usually go away within a few days. practically just to get an AU so you can get a few days of paid leave[1].

If you're having an actual issue, you'd have to go to a specialized doctor or a hospital which has the equipment to actually diagnose your issue... such as an xray machine in your case. diagnosis is done right after taking the image, so you'd have had a similar experience if you went to an actual clinic

[1] according to the Finanzamt (german IRS) the average worker takes an additional 12 days of paid leave like that... additional to the normal 20-30 days.


> because the healthcare system is overrun with people that come in with sniffles and aches that go away in a few days

I have a family member who's working in ER in a public hospital in France, she told us that there's a lot of people who come in for nothing, often abusing the free ambulance service. And apparently whenever it's raining there's less people coming in, all things being equal.


The problem is, there's no price caps on anything, so these profit seeking monopolistic predatory hospitals can charge whatever they want. Medical emergencies are the number 1 cause of bankrupcy in the US. The US spends 19% of GDP on medical with worse service and outcomes. this is more than twice the Euro average.

In the US, you need to be very careful with medical care. You should never ever go to a hospital unless you're absolutely sure that your life is in danger, and even then, you should research your condition first.

Also, don't have kids. The medical insurance premiums in the US are extremely high, if your employer isn't paying for it.


> Medical emergencies are the number 1 cause of bankrupcy in the US.

Nit:

Medical expenses are the top cause, not medical emergencies. Not that this is much better.


What about the 60% of Americans who have health insurance through their employers? The median American spends about $3,000 a year on premiums + out of pocket expenses: https://www.commonwealthfund.org/publications/issue-briefs/2.... That's less than what most would pay in mandatory social insurance taxes in Europe.

> That's less than what most would pay in mandatory social insurance taxes in Europe.

Yeah, it might be. But you also pay that in the US, to the same degree.

Why is it so common to think that US citizens don't pay taxes towards healthcare? They do, and just as much as western europeans. The europeans just don't have to pay those extra $3k. US healthcare costs twice as much per person as healthcare in other western nations.


Same here.. $1300/mo for family of 4. 10k deductible. Another $2k/year for dental.

And then it barely seems to cover any normal stuff.. physical therapy for son, still get $1k bill. Dental work for kids, another $1k.

And you are totally right all it does is make you think "is my kid really doing that bad that I should take him in?". Fuck having to get down to that mentality... I hate it, but it's the reality of the situation I'm in.

If someone is lurking outside our house, we don't think to ourselves.. "Hmm, should I call the police? I don't see a gun, he probably isn't too dangerous.. I'll just wait it out". No, you freakin call the police when you need it and don't have to worry about going bankrupt because of it.

Really sick of this backwards ass country we live in with regards to healthcare. I can afford it.. sort of.. but I have no idea how people below my income deal with day to day medical stuff. It's horrifying.


I agree with your points, however, many Americans do indeed have to think twice about calling the police in that situation and all probably should. Should you call the police because there's someone outside the house and risk them arresting or shooting you? That's a real question for many Americans. Healthcare isn't the only thing that's broken in this backwards ass country, that's for sure.

“If someone is lurking outside our house, we don't think to ourselves.. "Hmm, should I call the police? I don't see a gun, he probably isn't too dangerous.. I'll just wait it out".”

I’d actually just grab my gun and wait it out, assuming I wasn’t already carrying it.


In the US, you only call the cops if someone is likely going to die anyway, and you want a better chance of it not being you or one of your friends.

The current training regimes generally do not emphasize de-escalation. Adrenaline-fueled escalations end up killing people that have not committed capital crimes, and likely never would.

There is, of course, also the possibility that the cops don't show up in a timely fashion, or don't do anything to help you when they do arrive, or even turn their investigation onto you, and that is not independent of cultural background or apparent skin color.

There are reasons for owning and carrying guns in the US beyond hoplophilia.


it's very naive to think that Europeans don't pay for their healthcare. Germans make monthly payments for insurance, etc. Are they that much lower than 1300 a month?

according to posters here, basic insurance is 800 dollars a month. Average net disposable income in Germany is 34K.3 a year http://www.oecdbetterlifeindex.org/countries/germany/

In the US, it's roughly 45K. So, Germans pay less for insurance, but not that much less, considering it as a % of disposable income. And this is for the basic public option. Many Germans pay for private insurance.


They are much lower, think in the 100 to 150 range. And that's without company discounts if you have a job. On top of that, there is a fixed limited amount you have to pay yourself per year if you actually use it, and everything else is covered.

But they get much better healthcare for that though.

In Germany you make your monthly payments and if you ever need anything, it is very cheap or free. In the US you make the same payments and still pay thousands whenever you need care.

So what is being paid for in the US? In the German system you pay your money, you get your healthcare, in the US system you pay your money so you get the pleasure of being less over-charged when you need your healthcare?


> In the US you make the same payments and still pay thousands whenever you need care.

That's an exaggeration. You make it sound like a definite whenever you go to the doctor here. That's far from accurate. It can happen, and way too often does, though.


in Germany after tax disposable income is lower than in the US and prices for things are generally the same or higher.

naive calculation from an estimated 8% effective rate[0] says a german family making 60,000 would pay 400/month. Additionally however, no deductibles.

[0] https://www.npr.org/templates/story/story.php?storyId=919714...


Does that include the employer contribution?

They have Google where I live so we can find out.

https://www.howtogermany.com/pages/healthinsurance.html#gkv

The public opinion which covers you and non working dependants is a reasonable 720 euros or aprox 800 usd or aprox 15% of wages whichever is less.


720 euros a month as a % of after tax income is higher in Germany than 1300 in the US ? also, not clear what that public option covers exactly and how many people buy additional private insurance because public option is inadequate? https://www.handelsblatt.com/today/politics/handelsblatt-exp...

720 euros or 15% whichever is less. As I type I'm paying 38% of my income before taxes in health care related expenses. I'd take the German option in a second.

The US system is worse than "capitalism will solve it." It combines everything that is bad about socialized medicine (regulatory red tape, bureaucratic overhead, slowed advancement, state-enforced moribund monopolies) with everything that is bad about privatized medicine (predatory pricing behavior, regressive cost burden, non-universal coverage).

It's a remarkably bad system, a kind of "pessimum" solution that benefits only insurance companies as far as I can tell. I've also heard that it's run as a kind of jobs program that's designed to employ massive numbers of middle-tier management, clerical, and bureaucratic types.

The US has a lot of these worst possible outcome systems. We seem to like to take all the worst ideas from the left and combine them with all the worst ideas from the right. Another example of the worst ideas of both sides is zoning and urban planning in California.


Yet people blame Obamacare for the prices you just mentioned :).

That . after the smiley is making me go bonkers, lol.

State granted monopolies aren't capitalism. What the US has is literally the worst of capitalism and socialism mixed together in some sort of corrupt, inept, admin heavy hybrid system. It's like pick a team already, but you can't do both; create healthy markets through regulations, or get rid of the markets, but right now the regulations just create incredibly unhealthy markets.

> The whole "capitalism will solve it" thing just isn't working. I cannot shop around for medical care, I cannot see prices, and insurance is $1300/month for essentially no benefit (except to turn prices from bonkers to incredibly high).

Considering that, for the services you mentioned, in the US it is often a government itself sending the rhetorical you those bills, I think it is a bit more complicated than merely blaming capitalism.

Edit: does someone mind telling me why I am wrong?


You're certainly correct it's more complicated than that, so the downvotes aren't due to being wrong. shrug

Healthcare in the US is neither free market nor socialized. It's an absurd mess of both worlds combined into a singular nightmare.


It's essentially the worst of both worlds. Just enough socialism for a selected class of businesses to capture the profits of necessary services. Made worse by the fact that sometimes those "businesses" include local governments.

I didn't downvote you since legitimate opinions shouldn't be downvoted but the reason I think you're wrong is that US is a particularly chronic case of the government serving the needs of capitalism above and beyond the population at large.

It's like saying don't blame Catholicism, blame the Vatican. One is a direct expression of the other.


> I didn't downvote you since legitimate opinions shouldn't be downvoted but the reason I think you're wrong is that US is a particularly chronic case of the government serving the needs of capitalism above and beyond the population at large.

I think it's more a problem of local governments often acting as quasi-capitalist entities themselves. If charging people $1000 for a ride in a fire department ambulance reduces property taxes, why not?

> It's like saying don't blame Catholicism, blame the Vatican. One is a direct expression of the other.

Eh, I don't think that is accurate because the Vatican is Catholicism, not merely an expression of it.

Also, my point was that you can't blame one idea or entity for the state of health care in the US. There are a number of sociological factors that need to be addressed, including but not limited to extreme capitalist beliefs, belief in "rugged individualism", moralism, and xenophobia.


You’re not wrong. However, given the facts that most of the people on HN are from the Bay Area and that Socialism is the soup du jour, the down votes shouldn’t be surprising.

About 10% of HN users are in the Bay Area.

Perceptions of ideological bias on HN are in the eye of the beholder. Opposite ideologues see opposite bias, I assure you.


I think what we've got in the US cannot be described as capitalism either. The market is way too regulated to be a well functioning market. I think we've just got the right mix of capitalism, regulation and complexity for the average consumer to be confused to get the perfect crony capitalism. The US health Care system is a Rube Goldberg machine made out of grifters.

Edit: of course there are great people working in health care, but they get ground to pieces by the grifting machine.


FWIW, according to this list[0], U.S. median household income is about $10k/year higher than Germany.

[0]: https://en.wikipedia.org/wiki/Median_income#Gross_median_hou...


I agree that is outrageous. The problem is that people think it is capitalism. When there is no price transparency, there is no capitalism, period.

Hopefully the US is on the way to government healthcare, but for now it would be great to just achieve price transparency so people can shop around.

Without price there is no competition. Without competition there is no capitalism.


Kenneth Arrow did a great analysis on efficient markets and the US healthcare industry. Basically it doesn't work the way it works in most free markets because of information asymmetry (he got the Nobel for it). Even if you had price transparency, you aren't in a position to decide what treatment to buy because you're not the doctor and don't have the necessary knowledge to make that decision. The whole process is misaligned because the recipient is not knowledgable enough to make the decision, the decision maker (doctor) is not the payor, and the actual payor (insurance) is often neither of those. Efficient markets require certain preconditions to be met to work. It's true in many situations but there are some well known edge cases.

I would welcome a link to the analysis you point if you wish, but this is very reductive.

There are a million markets with information asymmetry and work just fine, and there are plenty of examples of cash-pay systems that work reasonably well for healthcare.

I disagree with OP that the problem is price transparency, but the healthcare market in the us is intervened in ways that prevent the classic workings of a market.


I think you are right but I still think two steps would make the system much saner:

- Price transparency

- One price for the same service. The practice of charging $500 to the insurance but $10000 to the uninsured needs to stop. Maybe it's fine to vary by a few percent but there is no other market where the same product costs 20x more depending on who pays. If the excuse is that this is to compensate for non payers then let's pay for this from a separate pot.


None of this addresses the point- even if you have price transparency and one price for the same service, you are not educated enough to select services you need. Doubly so if an emergency happens.

There are plenty of situations where you know what you need and you could shop for prices if it was possible to get any reliable prices. At a minimum transparency would make it obvious to the public how crazy the pricing practices are.

I agree about emergency situations.


If I go for routine bloodwork do I know exactly what bloodwork to order for, or the codes to request? Do I know when to discern between MRI, Xray, or ultrasound diagnostic? I find this hard to believe.

Often your doctor tells you what tests they want and then you go to some center where they perform the tests. It's pretty predictable in many cases.

"Often your doctor tells you what tests they want"

This is the exact point- you do not have the education to shop because you don't even know what you need to be shopping for.


Our current system is completely fueled by legalized price gouging. It's insane how much the medical industry is allowed to exploit these regulations.

"When there is no price transparency, there is no capitalism, period."

Capitalists are perfectly fine with lack of price transparency or other tricks as long as it makes them money. They don't like competition.

What you are talking about is functioning markets.


There's a lot of equivocation in the term "capitalists". Using the term to mean "people who want to take the capitalist system and turn it into a non-capitalist system that permanently writes their own benefit into it" is, well, I'll go with "not the path to clear thinking about the problem". I'm not comfortable calling it wrong, I mean, such people exist and in quantity, but it's definitely asking for muddled thinking on the topic to call someone deliberately tearing a system apart a name that implies them to be an advocate of that system.

Capitalists can mean ideological believers in capitalism, or it can mean those who own capital. The former may be interested in efficient markets; the latter generally only want to maximize returns.

Both will eventually merge into the same thing, so I struggle to see a real difference.

In a free market, the assumption is that everyone is a rational actor that will work in their own self-interest. People that want to maximize returns are behaving as you'd expect; someone not wanting to maximize profit in a free market would be considered an irrational actor.

Which, well, there lies the problem. For a lot of markets, maximizing profit comes at a very human cost. For healthcare the profit incentive is to have as many barriers to avoid paying individuals as possible because their profiteering is orthogonal to your well-being in most cases.

This is also why many markets can be considered short-sighted because it's easier to make returns now than it is to gamble on long term growth, which results in smash-and-grab style of corporate takeovers.

Ultimately even if we did have price transparency for healthcare all of the issues would still remain. It just can't work as a free market and going further in that direction is just pouring salt on a rotting wound.


No, they do not merge into the same thing. If you already have capital it is to your advantage to create a system where nobody new can compete with those who do - lest someone who doesn't have capital comes along and undercuts you.

Yes, and that was my point. Staunch supporters of capitalism often own capital. A great example is home ownership, which people use as an investment platform. Using your home as an investment platform means you have an interest in maintaining the value of your investment, which leads to things like NIMBYism or voting against measures that might help the city, but devalue your property.

The only way you could possibly maintain free market capitalism is by, ironically, putting in rules preventing people from using the free market in their own rational self interest. Which is why I believe healthcare can't be fixed by making it free-er, simply because the rational self-interest of insurance companies is against that of the insured.


that's why I want a clear distinction between the two. A lot of the second type of capitalist disguise themselves as the first type.

Theories about efficient market/exchange is _liberalism_. Capitalism is an ideology about who own the means of production: in this case, the person who own the capital. When the state OR a "commune" owns the mean of production, this is communism. But you can definitively have a "free market communism", except WTO will probably disagree on whether product issued by a state controlled industry really respect its rules.

You can also the two, like in the nordic countries (or germany) where employee actually have voting power about the strtegic orientation of the company (actually i think employees are considered "owning" 30% of the issued shares or something like that). From a (weird) point of view, this is 70% capitalism, 30% communism.


Look at the health system. There are a lot of capitalists who make a lot of money on their capital and don't seem very interested in change because most changes will cost profits. But from a market point of view the system is inefficient and lacks transparency .

No true capitalism.


> "is this an emergency enough to justify a $2K medical bill?"

Yep, that's how you think about medical problems as an American. Get used to it.


not being able to see prices ahead of time is probably the biggest problem... but it also stinks that with or without insurance, you appear to pay about the same total cost.

“Capitalism will solve it” is not at fault here. What you’re describing is crony capitalism. It sounds as if your local politicians are not doing a great job at creating TRUE competition along with a TRUE free market. In other words your local monopoly should not even exist it should be broken up.

> The whole "capitalism will solve it" thing just isn't working.

There's no capitalism in US health care system - you alluded to it yourself with lack of price transparency example. The key issue is medical cartel with AMA at the core who lobby hard to restrict supply of physicians as well as narrow scope of practice for everybody else. As a result you have people having to go through a gatekeeping 500k-a-year dermatologist to get a prescription for $250 creams which you can buy over the counter in the UK for 10 pounds.

Nobody really talks about medical cartel in politics because doctors are popular with average Joe - unlike insurance and drug companies.


> There's no capitalism in US health care system - you alluded to it yourself with lack of price transparency example.

This is true.

> The key issue is medical cartel with AMA at the core,

The AMA has basically zero power over any of the issues you describe.

> AMA lobbies hard to restrict supply of physicians as well as narrow scope of practice for everybody else.

No, the number of physicians is limited by the number of residency programs, which is determined by how much funding there is. Residency programs are not self-sustaining, so they're funded by Medicare.

> As a result you have people having to go through a gatekeeping 500k-a-year dermatologist

Most physicians take home a lot less than you'd think. The gross salary is misleading, because physicians also have high licensing, insurance, equipment, and continuing education costs. The gross pay does not take these expenses into account, and furthermore, these expenses are typically not tax-deductible for most physicians.

It varies heavily by region and specialty, but the average (not top - average) physician in a city like New York or San Francisco actually has a lower take-home pay than a mid-level FAANG engineer[0] in either city.

[0] e.g. an L4 engineer at Google.


"It varies heavily by region and specialty, but the average (not top - average) physician in a city like New York or San Francisco actually has a lower take-home pay than a mid-level FAANG engineer in either city. "

That's a pretty high bar though.


> That's a pretty high bar though.

Depends on what your reference point is. I think most people on HN would be surprised to learn that their doctor likely makes less take-home pay than the second-lowest level of engineer - L4, "SWE III" - at Google.


I’m of the opinion that is how we should assess medical treatment, by cost. People get a ton of unnecessary treatment. Depending where you live $2k for a hospital trip via an ambulance may also be fair. Think about how many people saw your son, drove you, the bed he took. In SF a bed in a hotel is $400 - $500. That’s just a bed, not anything else.

Your take home salary in the U.S. is typically 80% after tax (effective tax rate). In the EU it’s closer to 50% (or less). It’s much more expensive in the EU just not all at one time. That’s perception.

I do think we should have competition though and open pricing. Can’t decide to do something or not unless pricing is clear.

Also if you are upset about medicinal costs be upset at the medical schools. They limit the number of doctors intentionally to inflate salaries.


Comparing a hospital stay with a pricy hotel stay is deceptive. The 2 types of services are by no means related. It's an utterly meaningless comparison.

Having seen a seizure I would definitely call an ambulance if my kid had one for the first time.

Since you picked SF let's talk about that. You may take home 80% but then you pay state income tax, sales tax, real estate taxes etc.

In SF you are more apt to be paying 40% than 20 in total.

Then your premiums for health insurance for a family. The average family pays 5,714 in premiums not including actual health care costs.

Then you have to consider the situation of those who are less fortunate. In Europe it's a slide down a slope. Here it's a drop off a cliff.


>In the EU it’s closer to 50% (or less) It’s much more expensive in the EU just not all at one time

Not really, procedures and the drugs themselves are much cheaper as they are usually negotiated on a national level. Personnel salaries are also not that high. If everything is cheaper you cannot argue that the total cost is higher.


The personal salaries is really messed up because of they are barely graduating more doctors now than the 90’s that’s an intentional inflation of salaries.

US government spending is 38% (2018) resulting in a net tax rate of you guessed it 38%.

UK government with it’s well known free public healthcare and similar culture spends an excessive 38.5% (2018).

PS: Government debt has the net effect of increasing the cost of government spending over time, which somewhat underestimates these figures.


You're wrong.

Can you please stop posting unsubstantive comments to Hacker News? If someone is wrong, it's great to provide correct information in a factual way. If you can't or don't want to do that, it's fine to post nothing.

https://news.ycombinator.com/newsguidelines.html


Might be off-topic, but in general, US is very harsh on poor people.

Apart from healthcare, Two more things that are harsh on people that don't have money (like students) are:

1. You need a car, which costs thousands of dollars (depending on how much reliability you need). Then, if your car breaks down and you're poor, you're really fucked.

2. Eating out is a big expense (e.g. tip makes it worse). It's ridiculous that eating out every day in a month could cost as much as a round-trip flight to Thailand. You could also buy a macbook with that money.

Back, in Thailand, when I was a college student, my allowance was $15 USD a week, and I ate out pretty much every meal. Most of semi-poor/average-income people in Thailand eat out. Granted, the food safety standard is way worse. But I'd still prefer that than spending time doing the cooking myself.


I know it doesn't compare to Thailand/Asia, but in general eating out in the US is much cheaper than in Europe.

In some cases, you need a car. But there are also many cases where people perceive that they need a car, but really don't. It is indeed a problem that so many are willing to overspend on a car to avoid the horror of sitting on a bus or riding a bicycle.

If you live in a city, a car is much less needed, anywhere else, you're correct, it's a big expense. When I was poor my car always caused me money troubles. Insurance, tags, gas, breakdowns. If any of that goes out you pay more in fines.

Eating out is a luxury. It's much much cheaper to buy groceries. Groceries are cheaper in the US than any country I've been to, including Thailand. I didn't try to eat natively though (bought cheese/beef/milk imported from Australia)

When we eat out it's usually fast food or pick-up, we don't like eating in public. It's between $15-30 for both of us. Thailand it was cut in half, but we used Grab to deliver it to us. Japan we spend upwards of $50 for half the portions.

You're comparing being poor in US vs Thailand. I'm sure you know the standard of poor is very different. Being poor in the US would be middleclass living at least in Thailand.

tl;dr I disagree, being poor in America is a much more pleasant experience than being poor in many other countries.


> Eating out is a luxury.

This would be one difference. In Thailand, we eat out to fill our stomach. We usually don't consider it a luxury. We also don't care much about services.

If anything, I am a bit annoyed about the high-touch service here.

> It's between $15-30 for both of us. Thailand it was cut in half

Half is still too expensive for Thais. A dish in an average air-conditioned mall (e.g. Tesco Lotus) would cost $1-$2 USD per dish. These dishes taste great as well.

> tl;dr I disagree, being poor in America is a much more pleasant experience than being poor in many other countries.

I agree with this statement.

However, this pushes toward the all-or-nothing situation. You either have good experience or are screwed. There's nothing in between.

Restaurants having high safety standard is great. But then there's no cheaper restaurant. Then, poor folks have to spend time cooking, which is gonna waste time and taste worse.

One of my tidbits that illustrates the different quality of life between US and Thailand is that: I live in US for 6 years now, and I've never seen a cockroach here. In Thailand, I'd see one on the first day I arrive. This happens even if I stay in a high-end condo.


> This would be one difference. In Thailand, we eat out to fill our stomach. We usually don't consider it a luxury. We also don't care much about services.

Wages are higher in America, so the getting service is going to be more expensive. However, food is very very very cheap compared to most countries. So yeah, it may not be a luxury in Thailand, but eating out is a luxury in the US because you're not paying for the food, you're paying for the service. Fast food is an option though if you really don't want to cook, but some people don't like that.

I actually prefer home cooked meals, I think they taste better, but I'm lucky that my wife loves to cook. When I was single I was content heating up food. Food was the last thing I was worried about at the lowest point in my life. I ate corn dogs nearly every day because it took a minute to cook and a minute to eat and I could buy a 50 pack for next to nothing.


Who are you to decide that?

People can decide whatever they want, but if they're wasting money on eating out when they don't have much money, I don't feel bad for them.

I thought it was a common sentiment that eating out is something you do as a special occasion.

I'm not here to tell people how to live their lives, but I've been on both sides of the poverty line. Eating in is a great way to save money. The exception is certain fast food places that are close to the same expense (value menu at McDonalds or Taco Bell)

I'm beginning to think I'm an outlier here though. I don't really like food. I just want to not be hungry. I could eat the same thing for weeks. I usually skip lunch, I eat cheese and jerky every morning for breakfast, and one big homecooked meal for dinner.


Are you seriously complaining about the cost of eating out in the US compared to a developed country? Talk about an insignificant problem.

I wanted to point out how the cost of eating out compared to other expenses and income within a country.

Thailand's cost of eating out is quite small compared to other expenses and income in Thailand.

As the other comment explains it, eating out in US is seen as a luxury. In Thailand, not so much.

I hope this helps clarify it.


I would imagine it's a necessity in Thailand because you're significantly less likely to have access to a kitchen and you're much closer to a "communal kitchen" in the form of street food or a canteen. In the US because of strict zoning regulations restaurants are not usually allowed within walking distance of the communities they serve, and so any use of a restaurant must be treated as a special occasion. And because of similar zoning rules and apartment design standards the vast majority of living arrangements will come with a kitchen that is large enough to allow someone to prepare meals for at least themselves.

You're actually pointing out a side-effect of how the US as a whole generally designs for sprawl and social isolation rather than for tight-knit communities like in Thailand.


I agree with every point here. And, wow, you did explain it very well!

Leaving your 20s and 30s with a career you enjoy, basic benefits such as health insurance, retirement funding, and paid time off, and the ability to afford a reasonably sized home without falling into tremendous amounts of debt seems less and less likely each year. I have a lot of family who have moved from the EU to the US and back to the EU, I have also lived there myself, and I'm intimately familiar with their day-to-day. If the average American knew what the benefits and lifestyle are like for a middle-class German family, all those totally disconnected accolades about job and GDP growth that our oligarchs like to shower upon us would do nothing to prevent work strikes and riots in the streets.

You can also arbitrage different strengths and weaknesses of countries to improve your quality of life.

I was born in EU where I got access to all the benefits you're mentioning, such as free health care, free computer engineering BS+MS degree for myself, and social security providing for my aging parents. However, job opportunities as a software engineer there were ridiculously bad, both in terms of quality of work, and compensation (99% of my college mates ended up, and are still, working in mind-numbing boring consultancy shops paying less than an average skilled blue-collar job).

So, as a single, young, healthy and educated person I immigrated to the US, where a massive world of opportunities, not possible in EU, opened up to me. I'm blessed to be earning way more than the EU economy, with all its safety nets, would be able to support. And I'm doing very interesting work.

Once I get tired of this, or if a major health catastrophe happens, I will go back to EU with significant 7 figures savings, and keep enjoying the EU benefits.

All I'm saying is: I have lived in EU for 23 years and in the US for 10, and the opportunities for personal growth that the US provides are simply unseen anywhere else, so don't automatically discount the US system as bad, romanticizing the lifestyle abroad. Every individual has their own dreams and expectations for their lives, so to each their own.


Kinda similar thing here. But ironically, this is eroding the country away. Once you get a considerable amount of job seekers that got free education elsewhere and can retreat back for major healthcare issues, the inflation-adjusted salary levels drop to a point where you can't afford those things off your regular paycheck. So North America is becoming a rather weird place that attracts the brightest people from all over the world only to offer them the conditions where they will likely not afford having a family and will not pass their knowledge and traits to the next generation.

From an Individualistic perspective, as you loosely outlined, the US is unparalleled. However, from a collectivist perspective, which we are discussing in this thread, the US is empirically and emphatically bad.

Do you ever question your moral integrity? You’re in the US taking advantage of a society that doesn’t have good social systems and which is why the wage in the US is high for skilled work. Then whenever you get sick you’ll return to a society with good social support but at the cost of lowering high wages. Seems you’re taking advantage of everything with ignorance and or desire. Whatever the case may be, I’m curious to your thoughts on this and I assume you’ve thought of it before.

I don't see it that way.

I am very committed to this country (US) and in fact I am also pursuing the citizenship process as a sign of long term commitment to it. The option of going back to EU is certainly something I keep in mind considering my European citizenship, but I don't necessarily look forward to it, at least not more than, say, all the hundreds of thousands (if not millions) of people planning to move abroad or to a different state when they want to retire and/or switch gears in life. I hope to be a productive member of this society for many decades.

Also, I am paying a massive amount of taxes to the US (effective tax rate in a coastal city can easily get to 40%+ on a tech salary), so I'm not taking advantage of anything at all.

By your logic, I should also question my moral integrity because I am not planning to ever have kids (personal reasons), so I am effectively relying on others to spend their own money/time to raise new human beings that will provide services to me and pay for my social security when I'll be old, which doesn't make any sense.


A single person making $200k/year in San Francisco will pay an effective rate of 34% in federal, state, and payroll taxes. Only your marginal rate is above 40%, but income taxes are of course graduated.

You don’t hit 40% until about $400k (in SF at least). So ya, if you are paying 40%, you are definitely in the 1%.


Yes, 400-500k is about the right range of compensation in SF for a senior software engineer working at FAANG, and that's about my number. Also, I'm single and renter so I get no tax benefits at all. But I'm not complaining about having to pay those taxes, it's a very reasonable price to pay for the massive opportunity being given to me, which I appreciate even more coming from EU, as I was saying before.

Got it, people often mistake their marginal rates for their effective rates and think they are paying much more than they really are. The jump of only 6% seems a bit small actually for an extra $200k in income, but thats America.

It likely won't work.

As soon as he gets US citizenship, exit tax will be placed on him and now if he wants to quit US citizenship he pays a big exit tax and US citizens are taxed on their global income, so whenever he works next, he also pays taxes to the US.


The exit tax is not some wealth/estate tax that will make a huge dent in your assets, it's simply making capital gains tax due on the date of leaving US, not on the date of the sale of capital asset. It's extremely easy to pay zero exit tax when you leave US: just liquidate all your positions, so that you only own cash. This way, you'll just pay capital gains tax instead of exit tax. Of course, there's no reason to do that, because both are equal.

Curious to hear more details on this, but this is my current understanding:

First, exit tax is not just contingent on citizenship, but also on long term permanent residency, so I am effectively already under that rule, citizenship or not. Also, while the exit tax is for sure draconian, it doesn't mean you'll have to necessarily pay a huge amount, it merely depends on the unrealized gains you have in your assets. In my case that's relatively small since I'm not a homeowner and I've been paying capital gain taxes all along.

Second, most countries in the world (including the one where I have EU citizenship) have tax treaties with the US so that individuals who pay income or other taxes in a foreign country where they are resident for fiscal purposes will effectively obtain a foreign tax credit against the US taxes, avoiding double taxation. Since taxes in EU are higher than US, one wouldn't have to pay anything at all to the US. I've been dabbling with the US foreign tax for years myself due to some passive income generated in my home country, and I've always been able to claim full credit for it when filing my US taxes.

Third, my plan would not be to "work next" somewhere in EU. When/if I decide to leave (which may be never), with 7 figures in assets I should be able to live a modest lifestyle out of passive income in my original EU country (very cheap cost of living), so taxes would be minimal, if any at all.


Hate the game, not the player.

If it becomes a big enough problem, then EU countries could change their laws to make government-funded medical care conditional on paying certain amounts of taxes in-country.


> Hate the game, not the player.

That's a lame excuse for anti-social behavior. "Somebody has to get those kids addicted".

Read some Kant, then ask yourself what would happen if everybody acted that way, taking all the benefits and then silently stepping out when it's time to give something back.


I know about the categorical imperative, but people aren’t saints. They follow incentives. The fix is to create incentives that make it easier to behave better, not chastise people for doing what benefits them.

That said, I fail to see how his behavior is antisocial. He’s creating far more wealth in his current job than he could in the EU. If he ever moves back, he’ll bring millions of dollars with him and inject it into the local economy.


> I know about the categorical imperative, but people aren’t saints

It's not about sainthood, it's about ethics.

> The fix is to create incentives that make it easier to behave better, not chastise people for doing what benefits them.

Breaking the rules will always give him more benefit, unless we "chastise" (that is: punish) that behavior. There's little we can do to make not murdering people that stand between him and riches "better" but making him believe that we will punish him.

Clearly, relying on ethics and/or rational acting won't work with that kind of people.

> That said, I fail to see how his behavior is antisocial.

There would be no society if everybody acted like him.

> If he ever moves back, he’ll bring millions of dollars with him and inject it into the local economy.

He will, as he stated, only move back if he gets seriously ill and requires the social net to catch him. He will only come back if he's going to cost money.


I am curious, how would you have acted in my shoes? A few alternative options I can think of:

1) Not even try to move to the US to pursue the dream of a world-class tech career (dream I had since I was 12), stay in my own EU country with a mind-numbing consultancy job (which again, it's the only kind of employment available since the country is mostly rural with a limited software industry) to be fully consistent with morals. This also means I won't be able to financially help my parents as a sign of gratitude for all they've done for me, since my salary will be barely enough to keep me afloat.

2) Move to the US and completely renounce to my EU citizenship, so I won't ever have a way to go back and "take advantage" of my EU country (meaning I wouldn't even be able to see parents and family without an immigration visa).

3) Move to the US, keep the EU citizenship, but completely deny to myself the option of eventually moving back if needed. So, if I get a massive debilitating cancer that will force me to quit my job and lose my health insurance in the US, I'll die without treatment and all alone (loving family is all in EU) but with morals.

4) Move to the US, keep the EU citizenship, keep the possibility of eventually moving to EU, but to be consistent with morals find a way to donate to my EU government a few hundreds/thousands a month to keep contributing to the social safety net even if I'm not a resident there (I don't believe that's even physically possible?). But certainly that wouldn't be enough to cover the expenses my government paid for my education, so I should also find a way to refund that?

5) Move to the US, keep the EU citizenship, and start a countdown mandating that in exactly N years (where N cannot be certainly changed!) I will move back to EU regardless of where I am in my career or health status, so I won't be able to just move to the EU at the most convenient time.

I'm asking because it's easy to talk about problems at a philosophical level, but please try to step down from your judging pedestal and come back to the real world with real problems, thinking what YOU would have done in practice.


I have empathy for your situation if your dream was from the age of 12 to be in the tech career and only obtainable in USA. I had a dream that wasn't work-related and I wasn't able to obtain it. Yes, dreams are worth a lot and makes me find your situation exceptional compared to someone just in it for the money. Myself, I chose to move away from the USA because being a software engineer could be done in Canada and it had nothing to do for my dream. Heck, even if money would have financed my dream, I wouldn't have wanted to work in the US for financing my dream because I've seen too much dread before graduating that was rooted by how US culture only cares about themselves. Anyway I guess you're okay morally if your dream has good merits as well. Like whatever you're making isn't just some mindless product for socially conditioning certain demographics and into buying a product that has no real extension to life in a positive way.

> 1) Not move to the US to pursue a world-class tech career, stay in EU with a mind-numbing consultancy job to be fully consistent with morals.

I know plenty of people in the EU that work in IT, get paid very well (compared to their peers) and do not work in a consulting company. Especially for very talented people, I haven't heard of any stories about not finding interesting, fulfilling work.

> 3) Move to the US, keep the EU citizenship, but completely deny to myself the option of eventually moving back, so if I get a massive debilitating cancer that will force me to quit my job and lose my insurance in the US, I'll die with morals.

Since you renounce your duties to the society that gave you your free education and upbringing, renouncing the benefits sounds fair, yes. Living and dying by your personal convictions is what I respect in people. Living by them only while it's convenient and stopping to do so when they get tested just means that you don't actually have any.

> 4) Move to the US, keep the EU citizenship, keep the possibility of eventually moving to EU, but to be consistent with my morals find a way to donate to my EU government a few hundreds/thousands a month to keep contributing to the social safety net (I don't believe that's even possible for non-residents).

That's another option, I'm sure you can find a way if you want to.

I don't mind the emigration part at all, it's the reasoning I dislike. Saying "I don't like the bureaucracy" or "I don't like the population density" or "I don't like the language/food/culture/tv program" etc, that's perfectly fine in my book. But saying "I've taken all I can, it's time to move on, otherwise I'd have to give back. Oh well, I might come back if I ever get needy again and there's more to take" is not in my book. Living in a society that finances your education and catches you if you fall comes at a cost. Ducking out when the bill comes isn't what I'd do.


>Since you renounce your duties to the society that gave you your free education and upbringing, renouncing the benefits sounds fair, yes. Living and dying by your personal convictions is what I respect in people. Living by them only while it's convenient and stopping to do so when they get tested just means that you don't actually have any.

Why not formalize it by saying one should lose citizenship automatically under these circumstances? If you don't agree with that, then realize you are drawing a line somewhere, and deanmoriarty is merely drawing the line in a different place. Both of you are the same, and are merely quibbling with the degree by which you are the same.


> Why not formalize it by saying one should lose citizenship automatically under these circumstances?

For practical reasons. It's hard to formalize and having people be stripped of any citizenship is shit. I don't mind the idea of losing your previous citizenship once you acquire a new one, that's fine.

I'd much prefer a system where education etc is fundamentally free but is converted into a loan if you emigrate. Society X invests into you, you want to jump ship to Y so you pay back what X invested into you, possibly in multiple installments or an additional income tax.


Thanks for your reply.

One more question for you, to understand the scope of your philosophy: I don't plan on having kids ever, and to be honest my reasoning is partially driven by the fact that I see them as an unnecessary financial and time burden on me and my partner (she agrees).

Does that mean that in your world view we don't deserve a place in society at all, because if everyone was like us we wouldn't have a society at all in a few decades, so once again I am living by exploiting all the financial and time commitments spent by other people in raising other humans for my benefit?


No.

I'm also not against suicide, even though society would end if everybody did it. It's about your interaction with others where your morality matters. Whether you have children or not is your personal decision and is up to you, similarly to burning your possessions. It's when you're contemplating to burn other people's possessions that the do/don't questions arise.


>Read some Kant, then ask yourself what would happen if everybody acted that way, taking all the benefits and then silently stepping out when it's time to give something back.

I know this comment will trigger a bunch of people, but for me a sign of maturity is when people realize the categorical imperative isn't all it's hyped up to be.

I was a big believer of the categorical imperative since my teens - years before I had heard the phrase or heard of Kant. But the more I understood statistics and its role in the world, the more I realized the categorical imperative is only a first order way of looking at things. Once you take into account human psychology, and its inevitable spread statistically, you realize that in many cases, viewing things with a categorical imperative lens is not only futile, but counterproductive. One needs to take that spread into account (i.e. realize that all people will not behave as you do) to get an optimal solution. The question to ask is "What behavior/policy will get the best outcomes given the differing behaviors you will see in society?"

Personally, I realized I was dodging difficult issues by invoking the categorical imperative.

That's my thought on the categorical imperative in general. Regarding this specific case: Various commenters have already mentioned that some countries do indeed make it hard for you to use their healthcare if you've not been paying into the system all these years. I know one guy who ran into this - he spent most of his career outside making big bucks, and then retired in his country which provides socialized medicine. They told him they will not cover conditions he developed while he was not paying into the system (essentially, pre-existing conditions when he moved back). He has to pay full cost to get treatment for those services.

deanmoriarty is not the sole actor here. The US, as well as his country of citizenship are quite capable of ensuring they don't get exploited. If either country thinks this is abuse, they are welcome to modify their policies.

And BTW, yes, part of the reason people in the US get paid high salaries may be due to the lack of socialized health care. However, there is no implicit social contract in the US to spend that money for medical care in the US. In fact, I'd argue the social contract is quite the opposite. The US is making the message clear: "We will not provide you with socialized healthcare. You are free to pursue whatever medical care as you wish." Which includes going abroad.


> One needs to take that spread into account (i.e. realize that all people will not behave as you do) to get an optimal solution. The question to ask is "What behavior/policy will get the best outcomes given the differing behaviors you will see in society?"

The categorical imperative isn't about "is it likely that everybody will act like me" but "would it be good if everybody acted like me". You'll likely not end humanity if you start murdering your neighbors, because most people will not follow your example. Your murder might not even get noticed, so even the statistics won't change - and yet you'll probably agree that there's an ethical problem involved in murdering your neighbors.

I do agree with you that we shouldn't use Kant as the one-size-fits-all solution. Don't rely on telling people (or people understanding!) not to throw their trash everywhere, just put up a trash can so they can throw it in there. It is a solid framework for judging acts, but has it's weaknesses of course. The whole "the murderer is coming for your friend who is hiding in your bedroom, are you allowed to lie to him to save your friend" thing is something where I don't agree for example.

> The US is making the message clear: "We will not provide you with socialized healthcare. You are free to pursue whatever medical care as you wish." Which includes going abroad.

Sure, externalizing costs will provide advantages.


>The categorical imperative isn't about "is it likely that everybody will act like me" but "would it be good if everybody acted like me".

I know what it's about. My point is that in many tough situations, following it leads to suboptimal solutions (not just for me, but for society). It is not a good way to decide the morality of many things.

>You'll likely not end humanity if you start murdering your neighbors, because most people will not follow your example. Your murder might not even get noticed, so even the statistics won't change - and yet you'll probably agree that there's an ethical problem involved in murdering your neighbors.

I would agree, but I don't need the categorical imperative to decide this. It's not as if this is a tough scenario that the categorical imperative made a lot easier to analyze.


> Hate the game, not the player.

I agree with this, I'm not sure why I'm being downvoted for asking though because I think anyone would be curious to read personal testimony of their own situation. I would question myself if taking advantage of being in a country that strips social programs for keeping wages high for skilled employees. It's not like paying taxes negates that reality.


I would encourage you to read the comment at https://news.ycombinator.com/item?id=20346775 and answer that.

Done, also thanks for writing your views. It's nice to read reasoning and more so from tech people because it's somewhat relatable being the same field as myself.

That's already how it is and has been for a long time in many EU countries, e.g. Poland, when you need to pay NFZ premiums to qualify for NFZ (i.e. state) health insurance.

As a south american living in the EU, I grew up hearing people saying "ah, in the US..." and while probably they were thinking back to a time when the US wasn't as terrible as it is now, it's a bit irritating for me to hear that kind of stuff considering that I graduated in the top university of my country with a masters in engineering and had to pay nothing because university is free and for everyone. I've met so many american expats in Europe who basically fled their student debt by emigrating. And that's just one thing, the fact that healthcare isn't free, people avoid calling for ambulances because they cost money, and people are jailed because the prision system has become a very profitable business.

In my experience "free" healthcare stops being a thing once you get above certain income level as the service provided by the public healthcare facilities is subpar (waiting lists huge, best specialists often work at private clinics, etc.) so you end up going private but you still end up paying a huge chunk of your income in tax.

Eg. impressions of Germany is that it's a nice place and all but they insist on paperwork/formalisms too much (for example apartment rental process is ridiculous) and it doesn't seem to be very upwardly mobile (you get taxed a lot so it's hard to accumulate capital when starting from mid level income for eg.).


In my experience "free" healthcare stops being a thing once you get above certain income level as the service provided by the public healthcare facilities is subpar (waiting lists huge, best specialists often work at private clinics, etc.) so you end up going private but you still end up paying a huge chunk of your income in tax.

That's not true here in the UK. People do use private healthcare but they're in the minority and it's usually for expediency rather than quality. Many very rich people still get treatment on the NHS. It's very, very good.


In fact most private healthcare delegates back to the NHS anyway.

My experience is completely different. I'm in Canada and the ER wait lists are usually a couple of hours. I'm also seeing a specialist in Toronto for procedures requiring image guided sclerotherapy. I bet I'd be fighting tooth and nail with insurance companies to cover that sort of procedure, which would likely run in the 100s of thousands of dollars, yet here I am getting it for "free" no questions asked.

I've never once even thought about money or insurance at all when receiving healthcare and I couldn't imagine thinking about costs when I'm already worried about my health. Americans are delusional if they think their system is better.


What makes you think Canadians don't need to battle for coverage?

"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."[1]

[1]https://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-...


It's not a perfect system, and of course cutting edge drugs take longer to get approved for coverage under pharmacare. This is an election issue, and it's very possible that we get national pharmacare coverage over the next few years, and cases like these are the driving force.

The difference is that we as a country are willing to pay more taxes so that every single person gets drug coverage, and it's reasonable to expect that this will happen in the near future, even for expensive cutting edge drugs.


" it doesn't seem to be very upwardly mobile (you get taxed a lot so it's hard to accumulate capital when starting from mid level income for eg.)."

I don't think that's true. You can get free/cheap schooling and health care is always there for you. I would agree it's easier to move upward than in the US where it seems one of the big secrets for success is to have wealthy parents. Coming from Germany and now living in the US I am also not sure if the taxation in the US is that much lower when you add all taxes together. And if you or your partner has any serious health issue it's very likely that this will cost way more than any taxes you pay less.


This reflects my experience in Canada. It's really hard to figure out how much of your taxes goes specifically towards health care, but we put a significant amount of effort into a calculation a few years ago and came up with a number in the same ballpark as the premiums for a very good private plan in the US. The problem is then trying to compare the composition; there are lots of aspects of the Canadian public plan that are superior to the USA, notably access to frontline services and certain widely used drugs (in the news: cheap insulin w/o a prescription). There are also many components that are vastly inferior, like timely access to diagnostics or procedures that seem "quality of life" related but really are not (ex: delayed hip replacements lead to major health issues).

So it's not just free vs. pay, but also what exactly you're buying. Unfortunately the single public payer in Canada system is a sacred cow, much like the idea of "socialized medicine" in the US is a non-starter. Everyone just digs their heels in and holds to the extremes, so the idea of small experiments of change never gets much traction...


> It's really hard to figure out how much of your taxes goes specifically towards health care, but we put a significant amount of effort into a calculation a few years ago and came up with a number in the same ballpark as the premiums for a very good private plan in the US.

The magic is that everyone gets this healthcare. Not only those able to afford the premiums for a very good private plan. On the one hand this is straight socialism. On the other it prevents bankruptcy (and downward economic mobility) due to serious health issues and allows access to quality healthcare to students, entrepreneurs, those between jobs, etc.

I don't understand how someone in the US can consider themselves more "free" than in more socialist countries when they're deeply beholden to their employers for basics like medical care.


Medicaid provides free health care to 74 million low income Americans: https://en.wikipedia.org/wiki/Medicaid.

Not everyone qualifies for Medicaid, and those who do must regularly jump through hoops in most states. It's obvious some states are trying to push people off Medicaid even if they don't have other insurance.

> In my experience "free" healthcare stops being a thing once you get above certain income level as the service provided by the public healthcare facilities is subpar (waiting lists huge, best specialists often work at private clinics, etc.) so you end up going private but you still end up paying a huge chunk of your income in tax.

My impression is that this varies a lot by country. For example that might be true in Australia and Canada, but not France or Germany. There are many different ways to implement universal healthcare.


>In my experience "free" healthcare stops being a thing once you get above certain income level as the service provided by the public healthcare facilities is subpar (waiting lists huge, best specialists often work at private clinics, etc.) so you end up going private but you still end up paying a huge chunk of your income in tax.

This is true, but this is not that bad. The basic social security indeed stop being a thing once you earn enough. But if you earn that much, your work will provide you with an insurance that start at 50€/month to 250€/month that will cover A LOT of what you would have to pay in a private care clinic. You will still have to pay for the surgeon (especially if he is well known), but not the full cost.


Really? Can you give some ballpark estimatives?

I’m really interested on how much of your salary can you save after paying not just taxes but kindergarten, health insurance, unemployment insurance, pension plan, 25-ish paid vacation days etc.

Living in Germany I manage to get around 45% of take home money after fixed costs and taxes, from this I manage to save around 35% and could probably push a little bit more if I wanted to have a more miserable life and didn’t travel that much on vacations.


I agree, but this isn't the issue here. The issue is that poor people can't even access basic healthcare (can't even call an ambulance) without falling into massive debt. Free healthcare > no healthcare at all.

Healthcare in the US used to be a lot simpler and cheaper. But costs continue to rise faster than the rate of inflation for decade after decade and the price started becoming an issue so people had to start complicating and reducing the quality their plans to save money, but those were short term fixes because the costs continue to rise faster than inflation and now we're stuck with plans that are complex and have limited offering and are still unaffordable.

Worse, all of the complexity has its own costs which are now just compounding the problem.

At this point any sane person should be saying that our private market approach to healthcare is an experiment that unfortunately failed, but the gravy train is too big and too fast to stop quickly. Nobody in Washington or even the state legislatures can get traction on a replacement without drawing the ire of extremely well funded political interests.


The Argentinian government has collected taxes from its 50% child-poverty rate to fund your education so you could leave the country.

That is not an example of successful policy.


If the argentinian government wasn't riddled with corruption and people who literally stole most of public money then there wouldn't be a child poverty rate of 50% and engineers like myself wouldn't dream of emigrating.

Nevermind that I was one of those poor children.

But yes, the "policy" is the problem. Not the big heads stealing money.


The true act of corruption is that the poor pay for the rich.

4% of the national budget goes to public universities, and IVA is half the taxes levied by the federal government. There are no doubts of who is the giving and who is the receiving in this case. IVA is collected 60% on the bottom 50% of the population meaning its slightly regressive.

The first thing you can do to help the poor is to stop giving money to the rich: you can lower IVA by 1% if public universities were self funded.


Every day I see headlines like this and I think "surely soon enough it will get bad enough that people will support universal healthcare" or really any "socialist" policy. Every day I am mistaken.

If people actually did the research they'd see that these policies are just good common sense for them, but too many of our voters are lied to by the media they consume, so I worry things will never change.


Assuming the trend continues, at some future time there will reach a tipping point. Historically, once a population becomes so oppressed by those in power that it starts pushing into fundamental needs (food, shelter, etc), the population finally revolts and it's usually not a pretty picture.

Unfortunately (or perhaps fortunately in most other contexts), those revolution level standards of living are tremendously lower than what your average citizen has now even though we complain about home ownership and health care we still have places to live and emergency rooms. I'm not saying I'm willing to accept this level of modern indentured servitude, I'm saying most are.

For awhile, we had a generally progressive labor movement in the states where average citizens demanded improvement and progress. It seems to have reached a sort of stagnant state of complacency at some point and began to decline with much of that culture and momentum dying off in the process (not being passed on to future generations). Now, people just shake their heads and accept things the way they are instead of fighting for improvement in their lives. How do you educate the general population and convince them to support movements to continue to increase US workers' standards of living? I don't know the answer to that question.

I see an additional problem with the sort of bifurcation trend we're seeing in the middle class where people seem to be shifting to either upper middle or lower middle. The upper middle are typically more educated and so hammered in the rat race trying to salvage what remains for themselves, they can't find the time to support everyone else's rights. The lower middle typically aren't as educated: college is absurdly expensive and cultural + economic trends lead many of our most talented away from teaching (where many should be). This leaves the lower middle to be more susceptible to adopting media manipulation/ideology trends that aren't in their interests. I have a very bright and good friend who recently retired who told me if he was my age, he'd seriously consider migrating out of the country but he's retired and has a family. I hate to say it but sometimes I feel a tendency to agree with his evaluation and that's sad in one of the wealthiest countries in the world that has been a beacon of democracy and growth for many years.


I am from the same country as the commenter: there is a free public system of healthcare. I'm not using it. There is private insurance as well: I'm not using it either. Im doing cash pay for visits and they cost 20U$S each.

The universal care works against my usage in the case of Argentina, but I can still handle myself privately without hassles. The problem in the US is NOT that it lacks a public option.


Sure, healthcare can be super cheap as long as you stay healthy. What are you going to do if you get cancer? What if you break your leg in 5 places and need months of rehab? Just because you aren't sick now doesn't mean that healthcare is irrelevant.

I don't have specific statistics but in argentina the public hospitals that deal with cancer are decaying institutions and the people that I know have cancer use private insurance.

So didn't solve it either.

Im contesting the idea that public healthcare is what 1) lowers cost 2) guarantees good care


As a Brit I'm bewildered by the poor state of the basic working conditions Americans put up with. It's more similar to what my relatives in China get than the base line benefits and conditions in Europe.

On the flipside, I am amazed that Brits put up with going to college for 4 years to be a developer and living in a very high cost of living place like London, to make $50-65k a year after 10 years of experience.

Many differences for many different people / lifestyles.


I’ll probably get downvoted for this, but a strong argument can be made that the European welfare state has only been made possible due to massive US defense subsidies and economic stimulus during the post WWII/Cold War. This doesn’t mean that the US has a good excuse for relatively poor domestic social services vis a vi many European states, but let’s also be real about what allows Germany, France, etc to provide “free” healthcare and other social subsidies.

In the particular case of Germany, defense spending is only 1.2% (this stat is easily found via google). I’d rather have Pax Americana (which arguably is in decline) over the past 70 years providing stability in Europe, helping to lift hundreds of millions of East Asians out of agrarian subsistence, etc than slightly cheaper healthcare. Although, tell that fact to someone who receives huge, opaque medical bills for simple procedures in the US and they probably wouldn’t take too kindly to that line of reasoning...


What's the strong argument?

Germany spends 11.14% of GDP on healthcare or 442B. The US by contrast spends 17.07% of GDP on healthcare or 3498B. Therefore the US spends more and still lacks a comparable system.

Additionally the amount Germany saves by under-spending on defensive wouldn't offset the cost of the wealthfare state for example if Germany spent 3% (the US spends 3.5% on defense) of its GDP on defense instead of the current 1.2% they go from spending 47B to 119B. That extra 72B is less than 17% of their total healthcare costs, which again, are much lower than the US'.

This whole argument is a US Conservative talking point that has little to no basis in fact. When you look at the underlying data, it simply doesn't hold up, the cost of medical care and defense are orders of magnitude different and the US's system is so inefficient, even with the savings after decreasing defense spending from 3.5% of GDP to 1.2% (extra 472B/year) it wouldn't function well.


Just that. And at least in Germany health care isn't even paid for by the government. Rather the government defines minimum things to be covered and sets limits for non-private health insurance premiums in % of gross salary.

You say 17% like that is a small amount. That could easily break their welfare system if they had to extract that shortfall via more taxes or contract their healthcare system.

Also the military is not the only way the European healthcare system is subsidized by the US. Americans finance the drug research that pushes the world forward. If the US adopted European healthcare regulations the incentives for drug research would plummet, and healthcare innovation would slow to a crawl


They spend 11 and the us spends 17%. Do you think German health care somehow gets more expensive if they spend more on their military?

By the way, compare EU military spending to the US, not that of one country.

> The combined military expenditure of the member states amounts to just over is €192.5 billion. This represents 1.55% of European Union GDP and is second only to the €503 billion military expenditure of the United States. The US figure represents 4.66% of United States GDP.

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

Unless the EU wants to have military places all over the world like the US and equally extraordinary military expenses, for whatever strange reason, far outspending anyone located near Europe, that sounds like plenty enough money for the military. Of course, it seems to me the US uses much of that money for what elsewhere might be called "socialism" and "central economic planning" because doing so directly would never fly with the American public. So it's labeled "defense" and then it's fine.

> Americans finance the drug research that pushes the world forward.

I see claims like that a lot because for some reason some (few but vocal) Americans seem to take personal offense at any suggestion something might not be "the best", I have yet to see even a bad source for it, never mind a good one.

I can tell you German health care is shit too in so many ways that I'd be hard pressed to recommend it as a model to any nation, but according to the actual data it seems it's still better than the US system. Disclosure: I'm German but lived and worked in the US for a decade.

I also think cost alone is not a good path of argument. Costs on an economy level are circular - they are somebody else's income. Also, much of health care is "optional", whatever level people want. The more important point is what does that money flow achieve. According to the analysis I am aware of it achieves less, in the US, on average.

And US military spending since WWII wasn't and isn't high out of the goodness of American's hearts either. The US spend that much because it was beneficial at least from the point of view of those who got to make those spending decisions, and I'm sure they didn't have "foreigners" interests in mind but their own.


Drug companies also spend more on marketing than R&D, and given that marketing drugs is largely banned in other nations, the bulk of it is also spent in the US.

Further, that R&D is often more production development of drugs or drug families first identified in public research efforts. The pipeline for which has been drying up in recent years because of gov't austerity - and in response the billions per drug brought to market number has been going up for the commercial drug company efforts.


Last time I checked the Swizz, Germans and Brits were major players in drug and medical R and D.

Most of the important deep tech happens in university done by post grads, not by for-profit companies.

Drug development in the US is expensive due to the dysfunctionality that exists within the FDA.


> Last time I checked the Swizz, Germans and Brits were major players in drug and medical R and D.

Where do you think those European drug companies get the bulk of their revenues from to do that R&D in the first place?

They make their money off the U.S market!

> Drug development in the US is expensive due to the dysfunctionality that exists within the FDA.

No, drug development is expensive because it's expensive. The EMA & co. are not substantially different in their requirements and expense than the FDA is. Regardless, even still, half of the R&D conducted in the entire world is funded directly by the US.


Yes and those Swizz Germans and Brits are making the majority of their money from the US

I’m not arguing that the US healthcare system is more efficient (it definitely isn’t). I’m arguing the political and economic conditions present in post-91, EU-integrated, unified Germany were only made possible in part by constant military and political deterrence provided in part by US defense spending. US military power also increased the politician and diplomatic leverage of the West during the Cold War (the most obvious example being NATO).

Sure, but the "if it wasn't for our military you'd all be speaking Russian/German" angle is about as relevant to arguments that European countries are better than the US at promoting public health as "if it wasn't for our colonialism you'd all be speaking Native American" is to arguments that Silicon Valley is better than Europe at promoting VC-led innovation and growth. US military spending is not the reason the US politicians and political culture has chosen to prioritise tax cuts and healthcare middleman profits over citizens dying of preventable diseases over the last half century

The US could have been a Great Power and built a better public healthcare system.


That’s quite BS knowing France has a much better healthcare system compared to the US and also can nuke any country to death. Defense spending and healthcare are clearly unrelated.

I read somewhere France still has colonies somewhere in Africa.

Might want to factor in what the US defense gets out of that continued military presence, especially as a relay for operations in the Middle East.

US military spending makes us considerably less safe.

> US military spending makes us considerably less safe.

I see you're based in the UK. In that case, you might want to contact Parliament and let them know, because the UK is currently engaged in most of the same war efforts in the middle east that the US is.


Per capita amounts are more relevant here:

442B in Germany is 5K per capita. 3498B in the US is 11K per capita.

So the spending difference is even more in US's favour.


I somewhat agree with your point, but defense spending in the U.S. is only 3.1% of GDP. It's likely that we could have both Pax Americana and universal health care if the public/private divide were allocated differently. Medicare spending is roughly on par with defense and covers the most expensive patients; the government already pays for 64% of healthcare spending. Bump spending up to about $1T (5% of GDP) and you've got universal health care.

If you look at what Germans actually give up in exchange for the social safety net, it's the ability to get fabulously wealthy. If you're say a high-achieving software engineer or surgeon, it's possible to make roughly 10x more in the U.S. than in Germany - and that's saying nothing about startup founders or CEOs. Hence, people who fit into those categories tend to emigrate.

Your personal value system will determine whether you value the ability to get fabulously wealthy over the ability to know that you'll always have health care and education for your kids. There's a pretty strong selection bias within countries though: many people in America moved there (or their ancestors did) because of the ability to get fabulously wealthy, while the people left behind in the Old World tended to stay because they valued stability. That's perhaps why proposals for a strong social safety net haven't gotten much traction, particularly in the post-80s boom.


> let’s also be real about what allows Germany, France, etc to provide “free” healthcare

Germany doesn't provide free healthcare, it has a compulsory insurance purchase system. Both Germany and France spend less on both a per capita and per GDP basis on health than the US does, so they need no subsidy; in fact, their more efficient healthcare systems are a vastly larger subsidy to the rest of their welfare system than US’s defense spending is. (Moving defense spending from their current levels up to US levels would cost them 1-2% of GDP, moving healthcare spending from current levels up to US levels would cost 8-9% of GDP.)

The reason the US can't afford the rest of a European-style welfare system isn't the (huge, but still not a big deal in this instance) amount the US spends on defense, but the mind-bogglingly enormous amount the US wastes on the most wasteful and inefficient healthcare system in the world, which would be fairly in line, in per GDP costs, with many universal healthcare systems if you considered only the public expenditures, and not the (slightly larger) private share of health spending.


There's also the issue that there is not a "US health system". There are 50 slightly different health systems. Health insurance is still a state-level thing with different state-level requirements. We can't create a German-style compulsory insurance system until something is done about that.

Of course, nothing except political will is stopping individual states from doing so.


> We can't create a German-style compulsory insurance system until something is done about that.

Germany also has, IIRC, a mix of federal (including the basic mandate and baseline standards) and state-level rules for health insurance.


Oh, maybe there is something of a model in Germany then.

I think the US defense subsidy is underrated, as is generational wealth in Europe accumulated over hundreds of years by plundering, enslaving, and colonizing the rest of the world.

Europeans don't want to hear that though, they like to imagine they're just simply more civilized than barbaric Americans.


The US defense budget is more than that of the rest of the top 10 combined. There are many things that could be said about it, but underrated is a bit of a stretch, to say the least. You could cut it by two thirds and the so-called pax americana people like to mention wouldn't be threatened in the least.

>hundreds of years by plundering, enslaving, and colonizing the rest of the world.

This has got to be the most egregous case of pot calling the kettle black I've read in a while.


> The US defense budget is more than that of the rest of the top 10 combined.

Not quite. It's slightly less than the next 8.[1] Also, that number appears to include the $79B spent by the Department of Veterans Affairs[2], which is exclusively used to support post-service personnel.

There's a lot of shit we can and should cut, but let's not distort the facts.

[1] https://sipri.org/sites/default/files/2019-04/fs_1904_milex_...

[2] https://en.wikipedia.org/wiki/2018_United_States_federal_bud...


>This has got to be the most egregous case of pot calling the kettle black I've read in a while.

I know Britain extracted lots of wealth from India tho, the European continent became quite rich through colonisation efforts and once they had enough stimulus to fuel their economies, they became industrial powerhouses.

Not all country have such dynamics, Europeans really need think it through. Why Europe is rich and India is not? Why US can't offer free healthcare when Europe can.


India is rich though? There are also plenty of non-European countries offering free healthcare?

>This has got to be the most egregous case of pot calling the kettle black I've read in a while.

Both countries have terrible histories in these respects, but I think a fair case can be made for Europe having a longer period of this sort of method of wealth accumulation(/theft?) opposed to the US. The US shouldn't be cast as some sort of bystander in that same context--just a younger protege.


> but I think a fair case can be made for Europe having a longer period of this sort of method of wealth accumulation

The US territory itself was conquered using exactly those European advantages you speak of. US history is not separate, it's a spin-off from the European one. The US history without Europe ended with the settlers and their expansion, and they brought "Europe" with them. You can't claim a US history that is separate and didn't benefit from European history, given what actually happened there and by whom it was done.


>You can't claim a US history that is separate and didn't benefit from European history, given what actually happened there and by whom it was done.

I agree and wouldn't claim such, but you also cannot claim all the wealth was inherited through past practices from European colonialism. Much wealth was obtained under policy and practice by a sovereign US government and population. Once the US declared independence and became an independent nation, anything thereafter was conducted on its own accord under its own independent governmental system, free of the history of Europe with respect to responsibilities of practices. I wouldn't claim people instantaneously dropped their past inherited cultural beliefs or acquired wealth that kickstarted the process, but from them on, responsibility falls on the US.

Several wars, atrocities and theft of land from native Americans during continued expansion (trail of tears comes to mind), african american slavery used for production, exploitation of various other immigrant populations for wealth production--those practices fall squarely on the shoulders of the US and, in many cases, led to increased wealth and land in US. It is an offshoot of European history but when it comes to pointing fingers, the separation can certainly be made.

Such practices could have been abandoned by the US but continued onward, largely due to the tightly interwoven history you mentioned. Again, neither group can claim a rosey history but I would argue Europe had a headstart (if nothing else, just due to the arrow of time...).


European countries wouldn't be as wealthy in a world which hadn't seen colonialism, but they would exist...

The word underrated in the context means that it is not given sufficient credit for enabling European countries to spend more of their wealth on social services, not that it is less large than in it is.

> This has got to be the most egregous case of pot calling the kettle black I've read in a while.

The point remains that the kettle is black, regardless of who calls it so.


The apple doesn't fall far from the tree.

It is exactly those plunderers, enslavers, and colonizers that, well, colonized the new world and built their economies on top of slavery which eventually became independent countries.


Let’s try to consider the arguments in isolation without resorting to ad hominem.

Germany spends a bit over 10% of its GDP on healthcare. Even the US are only spending 3.2% of their GDP on defense. So even if Germany or some other European country did decide to raise their military spending and (for some reason) decided to pull the money for that out of their healthcare budget, it'd only make a relatively minor dent. It'd be painful, but it's certainly no either-or thing.

30%+ of all medical spending in the U.S. is wasted, so one doesn't really have anything to do with the other.

And then on top of that doctors in America kill somewhere between a quarter and a half million people per year[1].

[1] https://www.cnbc.com/2018/02/22/medical-errors-third-leading...


Do you have a source for that?


The US government spends more than many other OECD governments on health care. Not enough Americans know this basic fact.

Your argument is based on a faulty premise: Germany actually spends just a small bit more on government health care. Meanwhile the US spends vastly more on health in total when you add private spending.

https://www.healthsystemtracker.org/chart-collection/health-...


Some of the reasons for exorbitant health costs are not due to budget. The legislature actively attempts to obscure market conditions by allowing insurance companies to not publish prices. Remember that the US spends more as a percentage of GDP on health care than any other country.

Totally agreed + upvoted.

Having military bases in Europe (if that's what you're referring to) is mutually beneficial to the the U.S and Europe but I wouldn't call it a subsidy. It's done primarily to preserve America's global sphere of influence.

The economic stimulus ended in the 50's, the cold war 30yrs ago.

You can have free healthcare as well as Pax Americana. If anything I believe that free healthcare (and a better education system) would keep Pax Americana around a lot longer.


Agreed with your last point.

The US didn’t fund European security due to its kind nature. Rather, it was due to realpolitik concerns that there would rise another violent, genocidal European hegemon bent on world domination which would invariably threaten US security.


> I’ll probably get downvoted for this, but a strong argument can be made that the European welfare state has only been made possible due to massive US defense subsidies and economic stimulus during the post WWII/Cold War. This doesn’t mean that the US has a good excuse for relatively poor domestic social services vis a vi many European states, but let’s also be real about what allows Germany, France, etc to provide “free” healthcare and other social subsidies.

> In the particular case of Germany, defense spending is only 1.2% (this stat is easily found via google). I’d rather have Pax Americana (which arguably is in decline) over the past 70 years providing stability in Europe, helping to lift hundreds of millions of East Asians out of agrarian subsistence, etc than slightly cheaper healthcare. Although, tell that fact to someone who receives huge, opaque medical bills for simple procedures in the US and they probably wouldn’t take too kindly to that line of reasoning...

I may be misunderstanding your point, but are you attributing European stability to American military power?


I don't think you misunderstood. That commenter was definitely making that argument. Do you have thoughts on that?

I found it amusing to hear the American military occupation of Germany described as a subsidy.

It worked out better than the Russian military occupation of Germany.

I don’t think it’s much of a stretch to say that the only thing keeping Russian tanks out of Berlin is the US military/nuclear umbrella.

It is much of a stretch. Of a total lunacy variety.

I think this is a bit of a stretch now, but it was absolutely true - for West Berlin, at least - from 1945 through 1989.

There may be some truth to this, but I also think we choose to spend exorbitantly on military of our own accord. It is not the EU lobby that has kept us from massively reducing our military spending. Charitably, it is our own fear and uncertainty about what would happen if we massively reduced our military footprint. More cynically, the military is a big money maker for defense contractors and am entrenched jobs program. I think there is truth to both things: I certainly fear what would happen if we decided to stop investing in overwhelming force, but I'm also frustrated by the entrenched interests that seem to make it politically impossible to reconsider our posture. But I don't think it has much to do with propping up the European welfare state.

Agreed on your first point.

Although I think massive US defense spending during the Cold War was the primary factor in deterring the Soviets from tank rushing the Fulda Gap (and Soviet domination of Europe in general). I think it’s pretty clear that the Soviets were aggressively opportunistic in expanding their political and military influence (Hungary in 1956, etc)


This is pretty much wrong, Germany's welfare state in particular goes back to _1883_ (https://en.wikipedia.org/wiki/Healthcare_in_Germany#History).

Using military spending as a percentage of GDP is a huge oversimplification, and ignores many other huge factors.

For one thing, those countries tend to have higher taxes, especially on higher incomes.

More importantly, they spend Much less than the US per-capita on healthcare despite better overall outcomes [1], which is the real indictment of the US healthcare system, and the reason, as you point out, that the US has little excuse for it's healthcare conundrum.

1. https://www.healthsystemtracker.org/chart-collection/health-...


Interesting angle, but the US war machine has also trampled on the rights and freedoms of thousands. Look no further than Operation Menu in Cambodia, or the countless regime changes we funded in South America.

Surely we could have our cake and eat it too, in this case? Bear the brunt of defense spending but also not waste time on needless wars and coups, and put that towards a welfare state?


The thing is we don't really know what the world would look like today without post WW2 USA hegemony. Before that, the world was far more violent under what was essentially European hegemony than it is today. Instead of plundering at will, arbitrarily breaking countries up, and colonizing - the USA has taken an approach of world police. And yes, lots of mess ups and greed fueled wars. But the USA has carried the brunt of this policing and the world is safer than it has ever been in the post industrialized period. for the record, Europeans generally thought of themselves as more civilized and sophisticated than the people they were colonizing and the crude Americans. This is not a new perception Europeans have of themselves and is perhaps part of general European identity.

So, we don't know how many of these wars and coups have been "needless" to maintain the peace we have. Perhaps many of them have led to less peaceful times globally, but we can't go back and A/B test this hypothesis. But we shouldn't just assume the world would be peaceful or even more peaceful without continued USA intervention into the affairs of others. Perhaps it would, but history does not suggest so.


> But the USA has carried the brunt of this policing and the world is safer than it has ever been in the post industrialized period.

Maybe since 1989 or so. But if we're talking post-WW2, the Cuban missile crisis nearly erupted into global nuclear war. There were also a number of other near-misses up until the collapse of the USSR. That doesn't seem very safe to me.


I'm not even at odds with the idea that the US playing world police has done good for the world. I'm merely pointing out that when you allow anyone to be world police, you can't do that without some form of accountability. You simply cannot trust people to do good things and hope they won't abuse their power, because with no accountability, they will.

And that's what's happening right now. We have detention camps on the border because there's no accountability for power abuse, we have an entirely unnecessary campaign of bombing that murders children in Yemen because nobody will put their foot down and hold Saudi Arabia accountable. China has detention centers (disguised as "vocational schools") because nobody will hold them accountable. Pharmaceutical companies can jack up the price of insulin 700% over 20 years (FTR, inflation over the 1996-2016 time period was 53%) because there is no accountability.

We'll always need someone to watch the watchers, basically. Because if we don't, they'll abuse their power and trample on the rights of others. And I know the original post was about healthcare, but this still holds true. All of these things are happening at the cost of the standard of living of the average person, because those in power are not accountable to those they represent.


Well I think the exercise of power inherently will result in killing people, manipulation, lies, and general suffering inflicted on some group of unfortunate people.

Not sure it’s as easy as taking a dollar from funding Western Hemisphere coups and putting it towards health care. I think it’s also important to try to appreciate the security concerns of politicians and policy makers during the Cold War when attempting to prevent Soviet/Russian influence from creeping into the hemisphere (Monroe Doctrine).


It's hard to tell if a war is going to be "needless" until it's over.

Was Vietnam a needless war?

How about the Korean war? Was that needless too?


The Korean War is universally and intentionally ignored in such discussions, because to bring it up as an example of a needless war when eg discussing Vietnam is to proclaim the South Koreans should be living like the North Koreans right now. That is, it's to say that they should be enslaved under Communism and living at the very bottom of third-world style conditions. So nobody will dare to say that, they'll just ignore the Korea outcome and focus on Vietnam as the example instead.

The US spends an enormous amount on healthcare, we just get less for every dollar...

You could have your Pax Americana, equivalent healthcare, and more money in your pocket!


A first class surgeon earns in Spain around lets say 3000-5000 Euro/month (minus taxes).

The same first class surgeon in USA doing exactly the same job would earn... dunno, 25000 dollars? Probably more.


"I’ll probably get downvoted for this, but a strong argument can be made that the European welfare state has only been made possible due to massive US defense subsidies and economic stimulus during the post WWII/Cold War. "

As a German that's actually something I agree about with Trump. Europe lets the Americans often do the dirty work for them (an example would be Yugoslavia in the 90s where nothing happened until the Americans started doing something). Europe should be paying more for its own defense.

But that shouldn't be an excuse for a lot of dysfunctional policies in the US. The health care system is expensive and bad. Mass incarceration is very expensive and disenfranchises large population groups. A lot of low income workers are being exploited without recourse.

I also question if the US really needs to spend as much on military as it does.


I have the same sentiment but that was more or less part of the US strategy for maintaining peace in the world during the Cold War. As someone once said the purpose of NATO is to "keep in the US in, the Russians out, and the Germans down". It's a bit unfair to the Germans to blame both wars on them but the strategy of extending American protection over the Western European powers means they won't have to be too heavily armed as long as there is guarantee that the US can come rescue them in case of an invasion. I think the system stayed in place after the war and without a threat of invasion, why wouldn't the Germans and other Western allies dial down the defense budget even more?

" I think the system stayed in place after the war and without a threat of invasion, why wouldn't the Germans and other Western allies dial down the defense budget even more?"

I think it's time for Europe to grow up and stand on their own feet.


I don't necessarily disagree with this, but I can understand why Germany would be reluctant to significantly expand its military, and I can understand even better why the entire rest of Europe (especially, but not only, Russia) would prefer to have Germany protected by American nukes and not German nukes.

What about Canada? The United States has traded with us to great profit for both parties, but you could hardly call that a subsidy.

I think this is actually a great point. To expand on it a bit further, imagine that the US ceased to exist tomorrow. Europe would have to massively increase its own defense spending, or else risk that China or Russia would decide to walk right in.

That massive increase would have to come at the cost of social services, or else further increase their already considerable debt-to-gdp ratio.


Do you have much experience with middle class life in the U.S. outside certain dysfunctional big cities?

For a household with employer-covered health insurance, which is most households, out-of-pocket spending (employee contributions + cost sharing) is about $3,000: https://www.commonwealthfund.org/publications/issue-briefs/2.... For a median household, the German health insurance tax of 7.5% (employee portion) would be more than that.

Most people in both countries don't go to college. In the U.S., the ones who do have a median monthly payment of $220: https://studentloanhero.com/student-loan-debt-statistics. That's about 5.5% of median income for college graduates 0-5 years out.

As to housing, the median new house in the U.S. is twice as big as the median new house in Germany: http://demographia.com/db-intlhouse.htm.

As to retirement, the German pension system is not particularly if at all more generous than Social Security.

Offsetting those benefits is the fact that Americans make a lot more money at the median. Adjusted for purchasing power, the median American makes about $5,000 per year more than the median German. That's enough to pay for the extra out-of-pocket health insurance and student loans, and that's not even accounting for the American's much lower taxes.


I'm glad you pointed this out as the voice of reason. I can't believe all of the anti-American sentiment in this thread. I still firmly believe that any American who is willing to work hard and avoid drugs can have an amazing life. I'm not even that hard working and do fine. Every super hard working person I've known is doing well, most better than me. I have two cousins who became pipefitters, and both make in the 150-200k range per year. I know a family friend who works package handling part time, and part time he drives a truck and trailer doing hauling, oddjobs, moving, etc. He is nearly a millionaire at this point. None are college educated. The biggest problem USA has is people who expect/demand that since they went to college, they deserve a job and money. Or folks who think that working at all should provide them a nice lifestyle. It may have been that way at one point, but not in a long time. Unfortunately, those are a lot of vocal voices.

That reminds me of this twitter thread about our healthcare system. There are absolutely heartbreaking stories on there. The one that really sticks in my mind is the parents who were paying off and earlier ER trip and were literally waiting in the parking lot of the ER again with a fevered child, waiting to see if seizures started or the fever broke.

https://twitter.com/AllOnMedicare/status/1124042436345569286


I don't look at insurance in that way at all. Insurance is just another way for the government to tax me as far as I am concerned. If something goes wrong they will find a way to not help me, whatever it takes, they will find a way. They force me to have it and I just assume that money goes directly into their employees pockets and into campaign contributions. The US is incredibly corrupt and if you want to live hear you need to understand that you can't get sick. If you do get seriously sick or injured you are better off blowing your own brains out.

> If the average American knew what the benefits and lifestyle are like for a middle-class German family

In a pure numbers comparison, you tend to get higher salary in the US. I guess an American making $100k in the US would not easily consider a $70k job in Europe, because it immediately seems like a downgrade.

Not everyone bothers to go into details, like cost of healthcare, pension, daycare, school fees when applicable, tax rates and whether there is property tax or not, cost of commute, typical cost of a home, groceries etc.


> I guess an American making $100k in the US would not easily consider a $70k job in Europe, because it immediately seems like a downgrade. ... Not everyone bothers to go into details, like cost of healthcare

If you're making $100,000 at a job in the US your healthcare is being covered - often entirely - by the company you're working for.

Somehow this point is routinely ignored on HN in these discussions. Good paying jobs in the US almost always come with great healthcare coverage. Employers cover half the people in the US with health insurance. On average the higher your pay, the more of your insurance cost is likely to be paid for by your employer.

That style of higher income healthcare coverage and its tremendous qualities, like very expeditious access that embarrasses countries like Canada (which have superior overall systems), is why the US healthcare system still exists as it does. Higher income voters that don't want to give up what they have.


> If you're making $100,000 at a job in the US your healthcare is being covered - often entirely - by the company you're working for.

Zero deductible, zero copayments for you and your family?

Well, if you have an insurance where the yearly out-of-pocket that you pay in deductibles and copayments is capped in say $3000, it's not a big dent on that $100k.


Especially since a lot of us Ameticans are already in the streets

I'd have to disagree about work strikes and riots, given how conditioned this country has been to lick the boots of the powerful, as a large chunk of this country sees itself as "temporarily displaced rich". Hacker News comments are frequently hyper individualist in a way that, outside a few coastal bubbles, makes up the political view of a majority of people in this country, including plenty of self-described liberals. This is only going to change after the massive inverted-pyramid generational demographics of this country shifts, and giving our increasingly anti-immigration policies and a below-replacement birthrate, I honestly believe this country is trapped in a death spiral. Or maybe I'm just in a bad mood...

> "temporarily displaced rich"

So many people in America believe this, that they would be rich or successful if it weren't for X. X is different based on race, gender, and geographic location but the sentiment is the same.

The reason politicians like Trump are so popular right now is that they're successfully speaking to that shared sentiment and not to any one specific issue.

The political parties are basically comprised of groups with non-conflicting sentiments who are willing to support each other's ideologies.


I don't think you're recognizing the effective tradeoffs that exist between the German and US economies. In Germany per capita average individual consumption is more than 30% lower than the US. ($25,000 thousand per capita vs. $36,000)

That translates into some major differences in material living conditions. The average German home is about 50% smaller than the average American home. Germans have 30% fewer cars per capita. Meat consumption is 20% lower.

Many German homes don't have common household appliances that Americans take for granted. 30% of Germans don't own microwaves. Same for dishwashers. Most Germans don't have air conditioners. Only 42% of German homes have clothes dryers. Only 50% have freezers.

It's not just an issue of America being stupid. Things like strong social safety nets, universal healthcare, and free university all come with major major economic tradeoffs. Europeans do sacrifice a lot in terms of middle-class luxuries to enjoy those benefits.

You may say that things like bigger houses, fancy appliances and steak dinners aren't worth the stress and struggle, you need to recognize that that's a personal preference. One that many Americans are unlikely to agree with you on.

The reality is that Germany is a fundamentally different culture than America. And most Americans wouldn't choose to sacrifice their creature comforts for a Western European lifestyle. I'd be shocked if any more than a small percent of Americans would move into a house half with half their current square footage, even in exchange for free healthcare and eight weeks of vacation.

[1]https://en.wikipedia.org/wiki/List_of_countries_by_household... [2]https://www.elledecor.com/life-culture/fun-at-home/news/a765... [3]https://en.wikipedia.org/wiki/List_of_countries_by_vehicles_... [4]https://www.homeappliancesworld.com/2018/09/18/the-growth-of...


You should also check the average savings per person in Germany vs USA (both total and percentage). Not buying tons of random shit doesn't always mean you can't afford it.

But you are right, it largely comes down to the mentality/preference on how to spend your money.

I had just some medical issues that resulted in me being hospitalized for a month (while receiving tons of care in terms of specialists, MRIs, X-Rays, CT scans, ultrasounds, drugs).

I can imagine this kind of random thing ruining somebody financially or at the very least eating heavily into their savings. I received majority of my salary during that time and the final bill was $0.30 for 3 months worth of new expensive drugs I have to take.

So yes, choose between safety nets or fancy appliances / larger houses / steak dinners (all of which people with decent jobs can still afford any time of course)


Americans are a prideful people that share commonalities such as fear of an unknown and distrust of governing institutions.

As such, you cant really gain consensus with them by talking about other countries and what Americans are missing. You have to flatter their ego and avoid bruising it, make ideas seem homegrown.

I’ve reintroduced legislative changes in the US modeled after the exact laws that I helped pass in European area countries. In America it absolutely has to appear as an original idea that Americans came up with first and independently.

There really is an art to consensus.

edit since I am rate-limited for the next two hours: I am referring to the people in power that matter for the next decade


FWIW, half of this country desperately wants to be more European in our approach to government, so I'm not sure where your generalizations are coming from. And this site has a healthy population of Europeans who clearly have a chip on their shoulder about American geo-political dominance, so, you know, "both sides..." and all that.

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