It's often said that health is a highly profitable business in America. And yet it is astonishing how feverishly the average Joe will fight against free healthcare because those who make the profits have convinced them it's bad for them. Look at any country with nationalised healthcare; none of us in the UK have a bad word to say about paying for the NHS through National Insurance if it means we can walk into any GP's surgery or hospital and never need to worry about money or insurance.
In the best possible way I hope the system breaks completely and it has to be rebuilt from the ground up. Maybe then some semblance of fairness can creep in.
Insurance is only really necessary to avoid large up-front cash payments - the healthcare provider will treat you with the expectation that they'll negotiate some amount of payment from your insurance provider. Past that, it's fully legal and completely possible to set up your retirement finances so that healthcare providers have to make you pay in advance to get any money out of you whatsoever.
For example: move to Texas to get your IRA 100% exempt. Buy a duplex that's also 100% exempt, live in half, and rent out the other half for cash or physical checks. Whenever you get money from your tenant, immediately convert it to cash and use the money to pay off credit card bills - if you're spending via debt, they can't seize the cash accounts you're using to make purchases.
More generally, there are plenty of ways to acquire bankruptcy-exempt assets with your non-exempt retirement savings. Delaying social security is the easiest of these.
That's a big thing that breaks my heart to see happen. People have a giant pile of medical bills, and a large 401(k), and decide to raid their retirement funds to pay off the bills when there's neither a legal nor moral obligation to do so.
>if you're retired in a state that isn't protective of your primary residence (and lots of people have retired to places that aren't Texas) then what?
My standard advice is to limit your home equity via a mortgage or line-of-credit. Losing a $300k house to creditors sucks, losing the $60k in home equity on a $300k house sucks a lot less.
>and what if your mind is deteriorating, then it's on your inattentive descendants to make sure all of this is running as it should be?
You should have a well-documented financial plan anyhow, especially if you want to make it easy for your heirs to deal with your financial assets.
We can’t act like Americans not wanting universal healthcare is such a head-scratcher when the vast majority of those in power are fighting to prevent it.
In my family's case, it was a difficult pregnancy and delivery, and pretty soon you were getting bills from 20 odd providers with different names, many out of network, who happened to participate in some capacity or another.
I regularly heard comments like "I dont want to change things, I have great insurance!" and I think to myself...yeah just hope you don't experience the reality of it.
Apathy is baked into our individualistic political ideologies. It’s a feature, not a bug.
Hospital treatement was the #1 cause of bankruptcy.
Then, 30 years ago, our universal healthcare system was introduced.
Problem solved. There is a levy on our taxes each year to pay for it, a bit like a private health insurance premium. But its worth it. It also covers people who can't pay, like the unemployed/disabled.
We have a similar levy in the USA, except it's mostly paid by people that can pay for healthcare, so an aspirin costs $100 when administered by a hospital.
And since insurance companies are smart, they negotiate down those exorbitant rates to something more reasonable, so much of the burden lies on those stuck in the middle -- they don't have enough income to pay for health insurance, but have enough assets to pay for healthcare so they end up paying the exhorbitant rates because most people don't have time to rationally evaluate and price out their healthcare and choose the most cost effective provider, and even if they do have the time, the hospital can't tell you how much it's going to cost until the work is done and they bill you.
Even when you are insured and have a procedure done by a doctor that's covered by your healthcare plan, sometimes another provider (like an anesthesiologist) will do part of the procedure and you end up paying $10,000 or more out of pocket for his services.
Our system is broken in so many ways.
But in countries that are “for corporations, by corporations” regular people can’t lobby their way into getting what they want or need. Only the wants and needs of a certain few that pay for their laws are considered.
> And since insurance companies are smart, they negotiate down those exorbitant rates to something more reasonable
This is just absurd, though. The market value of aspirin administered by a hospital is not 100$, but closer to what the insurance company negotiates it to.
This is one of the worst parts of USA healthcare -- why are uninsured patients charged more than insured patients? (sometimes much more, like 10 times more )
You're not describing health insurance firms here. They constantly innovate new reasons to delay, diminish, and forget about payments to providers. For small procedures, many providers charge cash patients less because they know they'll get paid when the service is provided. They do this even though it often violates contracts they've signed with insurance firms.
(Having said that, I don't think the pathological cost divergences in US healthcare are mostly explained by this)
Which means you need the big guns (health insurance company or your own millions for legal fees) on your side, or else be destitute and have nothing for them to go after. But if you’re in that sweet spot where they can make up a bill since you signed a paper that says you’ll pay whatever you need to keep you alive, then you’re screwed.
And unlike, say, choosing between buying a $250k Lamborghini vs a $20k Toyota, the patient has to choose the $250k bypass surgery or he'll die. Which is why this can't fairly be judged purely in business terms, customers have little choice in whether or not they purchase healthcare services.
Because I’m not a sociopath, and I don’t think of healthcare as a product just like kitcat bars, and I don’t think a civilized country should allow this to happen.
The moment you accept framing it like people are buying and selling kitcat bars, you accept misery and death that are completely avoidable in economically advanced countries.
"Wait, you mean I pay nearly $5000 a year for healthcare insurance, but they won't pay for healthcare until I reach a $5000 deductible!? And if I don't ask each and every doctor at the hospital if they take my insurance, they may not be covered at all?"
That's one way to discover a giant out-of-network bill, when you went in for surgery at an in-network hospital, performed by an in-network surgeon, with an in-network anesthesiologist... And an out-of-network nurse, whose job consists of holding the saline bag for 30 minutes, at ten times the billed-to-patient rate of anyone else in the operating room.
I wish I was kidding.
I wonder if our attorney could prepare a contract that stipulates no out-of-network interaction without authorization. But who would we get to sign it?
...in our Toronto office.
The uninsured should always get the lowest price the hospital is willing to charge anyone for that service, period.
An incredible number of boomers are going bankrupt due to medical expenses and have nothing for retirement.
I like to think we’ll have together in 30 years, but if the last 30 years is any indication, we’re in big trouble.
Remote work will probably only expand, and I should be able to handle that well into my 70s and 80s if I make it that far. Medical issues caused by chronic computer use probably won't be that bad compared to laborers a few generations ago (and if we're lucky, I'll just plug something into my brain 10-20 years from now or replace my arms with some Deus Ex stuff). There's going to be some new tech to learn. They'll need people to know that tech.
I got a decent chunk of cash and got lazy about getting a job because tech is still in such high demand and I can fall back if I have to, and to be honest, having nothing to do feels exactly what I imagine retirement to be, and it's fucking boring.
The only way this changes is if I get hit with a mental disease like Alzheimer's or get in a paralyzing accident. Then I'm getting an exit bag for myself. Or someone starts a nuke war.
It feels difficult to envision retirement to me because I can't even imagine technology 5 years from now. We're advancing rapidly and our rate of advancement is only increasing. This includes healthcare technology (although I imagine Epic and Allscripts will still be around).
I’m in favor of universal healthcare, but billing it as something that will help the majority is disingenuous. This is the most likely outcome. Costs stay the same or go down a little bit, but nowhere near what it would take to make costs competitive, even as a percentage of GDP, with Europe. That means taxes will have to go up, and by a lot because our public sector is so inefficient compared to Europe. (It costs is 7 times more to build a mile of subway than France, why on earth would you expect building a hospital to be any different?) These taxes will have to be paid by the middle class—because that’s how it’s done in Europe. It’ll be totally unfeasible to have much higher capital gains or corporate taxes than France. (Which has low business taxes and pays for universal healthcare through regressive taxes.) At the end of the day, the middle class household making $80k/year will pay a lot more taxes, and their out-of-pocket healthcare spending won’t go down by much, because they had employer-paid healthcare to begin with.
But the hourly workers and those folks will be able to see doctors! And that will be a good thing. But it will also be quite unpleasant for the majority of people who we’re doing okay under the current system.
One hospital bought a CT machine. Doctors who are the most important customers for any commercial hospital, began to sign contracts with that hospital because it made access to the CT machine for their patients easier. The other two local hospitals had to compete and bought their own. Now there were three machines and only enough patients to support one of them. That didn't reduce the maintenance costs. The cost inevitably is passed on to all patients. This is only one example from hundreds where competition led to unnecessary cost from duplication. Add to that the overhead for people who specialize in insurance billing because the competing companies are different and very complex, add to that the profit for the investors in the hospitals, the profit for the investors in the insurance companies and that's not even touching the similar stack for pharmaceuticals and supplies. That's not even adding in the cost of delayed and emergency treatment due to lack of preventative medicine for the uninsured and the under insured. All of that adds up to the $99 bag of $0.99 saline that comes out of your pocket one way or the other.
It would be difficult to create a more wasteful or expensive system if you set out to do it on purpose.
The insurance I used to have negotiated with the hospital to charge ~$2000 for a five minute CT. The radiologist charged like $30 to interpret it. You can a buy a brand new machine every year with 5 or 6 patients a day.
The anecdote may have been true in 1982 or something.
Meanwhile, no one else can buy a CT because the state regulates who gets to own one.
The cost of a new full size CT machine with surrounding equipment is quarter of a million USD though. Some are more expensive than others, but you can get a new good one for this much.
USG costs few tens of thousands, and maintenance is super cheap, mostly consumable gel, some $8 per patient.
MRI machines are more expensive at half million USD and $120 per patient. (cooling costs)
This includes salaries.
Hospital bed is like $12 per night, staff included.
Germany and Sweden have even better healthcare, mostly due to larger number of doctors and nurses. Not that much more expensive too. Our education and salaries don't keep up.
Possible solution to duplication: decouple tech (test labs) from doctors (hospital)
And it's all amazingly cheap compared to the US, even as a private pay patient. An overnight hospital stay is about 200 EUR, including the attending doctor's fee.
Vet services, by the way, do cost approximately as much as they do in the US, at least for birds.
Some of the newest CT machines are more like $2 million.
Sure the problem is lack of information? Other industries do well with competition.
Almost all medical / dental procedure in Australia has an item number with a roughly known cost. Providers know they can't charge much more than that without losing customers.
And of course competition leads to unnecessary duplication, inefficiency is a well-known criticism of capitalism. But this inefficiency is like the inefficiency that comes from using Python instead of C; it is slower and uses more resources, but it actually gets things done, unlike health care where the inefficiency seems to come primarily from government regulation and lack of transparency.
It does mean you sometimes have to travel further but it works out better for everyone, even for you as the specialist care is within one “centre of excellence” (whether it is excellent is a different point but they could potentially be)
With our current system epipens are like a thousand bucks
with our current system insurance can say no to treatment.
I am one of the luckier ones, with a good healthcare policy that pays for a lot of shit, and I still would prefer universal healthcare to the current system.
I don't want to run my care by my insurance company. I don't want to get 5 forms every time i visit, 4 that say 'this is not a bill' and one that looks the same as those but IS the amount i should pay.
I don't want to factor in what its gonna cost when i go to the doc. Just go to the single-payer model, take it out of my taxes instead (it'll probably be the same in taxes as my monthly insurance premium) and make it simple for me to get the care i need.
PS. my health insurance goes away when i retire, unless i wanna pay something like 1.5k or 2k a month to keep it going. My retirement plan currently is 'try to die quickly'
Also, you appear to have a very warped view of what single payer healthcare is like. The UK NHS for example, is extremely aggressive in “saying no to treatment.” They reduce it to a calculation of cost per quality adjusted life year. Service rationing is an intrinsic part of any healthcare system.
> $1,100 per year out of pocket in USA, versus $690 for Germany
I don't think these numbers are being interpreted properly or they are they just hand-waiving away your employer contribution (which ultimately is part of your employee compensation). I've been self employed in both countries so I can tell you first hand the actual price of health care in both.
In Germany your public health insurance premiums scale with your income. It maxes out at around 700 EUR per month for family coverage. You pay extra for prescriptions (not that much though) but there is basically no such thing as a co-pay or a deductible. My daughter had part of her kidney removed, was on chemotherapy, had club feet treatment, tons and tons and tons of treatment, AND physical therapy. Zero extra charges. We even got a free 4 week vacation in the Black Forest "for families with children who have a severe disease". So, total out of pocket cost for me was 700 EUR per month.
Now back in the US my own company's health care plan, which isn't awesome but it's also not terrible, costs my company $1300 a month for my family. And on top of that we have a $1500 per person deductible with a $7000 out of pocket maximum. Physical therapy here also costs $40 per session.
So, the math is pretty simple. By far Germany is way way way way more affordable. And this isn't even counting how much time and energy you spend in the US dealing with your fucking insurance and billing.
Also, I'm assuming "out of pocket" is exclusive of premiums and deductible payments.
Probably, but nobody in Europe is afraid to call an ambulance because they'll go bankrupt. First time I read on Reddit about people in US with "Don't call ambulance" bracelet, it really blew my mind a little bit.
This hasn’t been my experience and I don’t know anyone the NHS has turned down for treatment.
I know of things like hip replacements where they said the patient should be older so they don’t have to do it again at a riskier age.
I know sometimes they don’t always approve every treatment but generally they don’t aggressively say no, not at all.
Aggarval et al. have the data: https://www.ncbi.nlm.nih.gov/pubmed/28453615
Of course, under either system, if you come up with the 50K, then the treatment is all yours.
Now whether that’s a good thing is a separate question.
It’s hard to find data on this, but I haven’t seen any basis for concluding that private insurers are “just as quick” to deny treatment. In the past, private insurers tended to have lifetime limits. They’d let you blow through the lifetime limit, and then deny care. In the NHS, the cost benefit of care was more carefully scrutinized from the outset. There is a lot of coverage of the NHS denying hip replacements and cataracts surgery, which is almost universally covered in the US: http://www.telegraph.co.uk/science/2016/04/27/hip-replacemen.... The US also does quite a bit better in cancer survival rates, suggesting that insurers aren’t just denying treatment to cancer patients: https://qz.com/397419/the-british-seem-less-likely-to-get-ca....
The ACA eliminated lifetime limits, but also limited insurer profits to 20% of expenditures. So now, insurers really have no reason to deny care.
The hip replacement issue is known as the "little old lady problem" in NHS circles. Hip replacement is not urgent, you'd like to concentrate the limited funds where lives are at risk. Unfortunately, little old ladies are fodder to enemies of public healthcare and always rolled out in this context.
Take every man over the age of 50 and then give them prostate screening, and then don't do anything else at all. Don't test any of the prostate cancer that you find.
Your 5 year cancer survival rates go up, because most prostate cancer is slow growing.
But this situation isn't what happens. The US screens a bunch of men, and then treats the cancer they find. Does this reduce all cause mortality?
This is what people in the American system pay for: testing and treatment that causes harm and which doesn't prevent death.
Ex. If a cancer will kill you in 5 years and there is no treatment. Catching it year 2 vs 3 will prolong your lifespan 50%.
People didn't live longer, many of them died sooner, and most of them had pretty severe side effects.
> The Cancer Drugs Fund (CDF) has not “delivered meaningful value” to patients with cancer and may have exposed them to “toxic side effects of drugs,” an analysis has found.1
> The CDF was established in 2010 in England to provide “patients with faster access to the most promising new cancer treatments” and to ensure “value for money for taxpayers.” It funded drugs that were not available through the NHS because the drugs had not been appraised, were in the process of being appraised, or had been appraised but not recommended by the National Institute for Health and Care Excellence (NICE). The fund was overhauled last year.
On the other hand, nurses especially are too few and underpaid. Not enough doctors too. They still do a great job and are achieving some raises via protests. Polish healthcare is not rich. German is. Buildings and some facilities here need some refurbishing, which is happening slowly over time.
The last time I checked, the total cost of family health care at my last job (including what the employer paid) was $12,000 a year. Even at $100,000 a year - $40K more than the median income - that’s still around 10% of total compensation.
No it isn't.
> With our current system epipens are like a thousand bucks
No, they're not. One brand name EpiPen or EpiPen Jr. package (which contains 2 auto-injectors) will cost roughly $650-$700 if you are paying cash. Plus, you should be buying a generic, not the brand name.
> with our current system insurance can say no to treatment.
If they couldn't, then a lot of people would be getting the "super expensive experimental buy unlikely to help treatments". Sure, insurance companies turn down things they should not, but they also turn down things they should. Don't push for them to never be able to say no. Instead, push for them to only be able to say no when it makes sense.
If you're going to make arguments for universal healthcare (or even better healthcare), then do so in a responsible manner. Otherwise, you're just hurting the overall effort.
> No, they're not. One brand name EpiPen or EpiPen Jr. package (which contains 2 auto-injectors) will cost roughly $650-$700 if you are paying cash. Plus, you should be buying a generic, not the brand name.
These two?  and ? Maybe as a point of reference from outside the US: Both seem to be USD 10.40 with a doctor's prescription here in Germany (which some people could get exempt from), and retail price seems to be 103 USD.
However, if you're going to make an argument for the US healthcare system having problems, then don't use numbers that are trivially shown to be false. Because then your entire argument (which could be compelling with real numbers) can be discarded offhand as false.
Don't sabotage your own argument with invalid numbers.
I feel like one of the responsibilities and benefits of living in a modern society is that you should be sheltered from these kinds of problems, and that comes with a cost, as you note, in higher taxes. It sounds like you don't feel that way, and that's fair, but I want to make sure there is not another solution you think would work where the OP recommendation would not.
But, I look around most US major cities and see the rampant homelessness and drug addiction and (often the same people with) mental health crisis, and it scares me for the future of our country.
I did not see any of that in Europe a few weeks ago, even in cities like Barcelona and Greece, situated in countries that have "bad" unemployment and "bad" economies.
At the same time, the left is trying to pull a fast one on the American public. They are acting like universal healthcare will be this win-win situation. But lots of people will lose. Our neighbors, who have solidly middle class jobs but good health insurance benefits, will end up paying more in taxes than they will save in out of pocket health expenses. (Back when I had an entry-level engineering job in Atlanta, I made about $60k per year with full benefits and no premium contribution. Circa 2008 me would be worse off under universal healthcare.)
Even at the aggregate level, the idea that savings on premium contributions will offset the increased taxes is a fantasy. It assumes our costs will go down to European country levels. I have zero reason to believe that will be true. The US public sector is fantastically inefficient. The New York MTA spends twice as much to move a passenger one mile as compared to London, and building a mile of subway costs seven times as much. The US spends more on social welfare than Canada per person already, and that doesn’t even include universal healthcare. It is pure fantasy to assume we can get universal healthcare without European level taxes—20% payroll tax, 20% VAT, the works—on the middle class.
I think it’s worth it, because I think providing for the most vulnerable trumps having more TVs per capita. But it’s dishonest to pretend like it won’t require a major hit to material standard of living.
The CBO estimates it will cost $3 trillion a year to provide universal healthcare. You will notice that no Democratic candidate has proposed raising taxes sufficiently to come anywhere near raising the required revenue. That is very telling.
It would be a wake up call to see how much we are really paying in taxes.
Agreed, but is anyone really arguing this? The US has very low overall taxation rates (as a % of GDP), well below the OECD average. It should come as no shock to anyone that in order to get Euro-level services, we need a higher tax burden. High earners have the most to lose so it's also not a huge surprise it's an especially concerning issue for them. Most Americans (including those that would benefit most from these changes) are not high earners and they will pay a more measured amount.
I'm not an expert in health care cost containment but there are many doctors, administrators, and number crunchers in the industry who think we can get there if we want it badly enough. Over one third of our total health care expenditure is on administration. By some estimates, we'd drop 15% of the cost (in the trillions) overnight with a single payer system. It's a good start.
Yes, a single payer would have huge negotiating power to drop these silly costs you pay.
This isn’t really true with healthcare. We spend 2-3x what Europeans do on healthcare per capita. We even spend about the same in taxes as they do, PLUS our immense private spending.
At the very least, I think you have to assume we won't be more efficient than Europe in terms of getting healthcare spending down to a lower percentage of GDP. If we get healthcare spending down to 11.3% of GDP like France, we still have to find about $2 trillion per year in taxes to cover that cost.
At the same share of GDP, we’d still be vastly less efficient per capita.
> If we get healthcare spending down to 11.3% of GDP like France, we still have to find about $2 trillion per year in taxes to cover that cost.
No, you only have to find a bit under $0.8T, because public healthcare spending is already a little over $1.23T of the $2T it would be under that model. And I think people would be happy to lose ~$2.3T in private bills for ~$0.8 in additional taxes.
Are you asserting $2T in taxes is somehow worse than the current $3.5T we pay for healthcare (taxes, premiums, out-of-pocket)?
Everyone is arguing this. None of the Democratic candidates who have proposed Medicare for All have proposed corresponding European-style taxes. Nobody has proposed a VAT, which averages 20% in the OECD. Sanders has given a "menu" of options, none of which raise anything close to the required revenue. The closest thing in Sanders' plan is a 4% employee + 7% employer payroll tax. That's less than what Germany or France assess in payroll taxes to fund their healthcare systems. All of Sanders' proposals put together only raise about $13 trillion of the projected $30 trillion over the next 10 years: https://www.sanders.senate.gov/download/options-to-finance-m....
> It should come as no shock to anyone that in order to get Euro-level services, we need a higher tax burden. High earners have the most to lose so it's also not a huge surprise it's an especially concerning issue for them. Most Americans (including those that would benefit most from these changes) are not high earners and they will pay a more measured amount.
Actually, middle income earners "have the most to lose." Again, look at how Europeans actually pay for their universal healthcare. Here in Maryland, the top marginal income tax rate is 42.75%, as compared to France or Germany's 45% rate. The top marginal rate in New York or California is higher than in France or Germany. What pays for the healthcare is not higher taxes on "high earners" but higher taxes on middle income people. In France, the 41% tax bracket kicks in at $83,000. In Maryland, the marginal rate on that income is just 26.75%. (In Texas, it's just the 22% federal rate.) Capital gains is higher in France, which is unusual among even European countries in taxing capital gains like ordinary income, but there's not much capital gains income to tax. ($650 billion or so in the U.S.). Germany's and Sweden's capital gains rate is 30%, about the same as Maryland. Corporate taxes in both France and Germany are comparable to or lower than the U.S. (after Trump's tax cut).
To fund universal healthcare, we need to raise another $3 trillion per year in taxes. The total income of the top 1% is 2 trillion. Raising taxes on those people to French or German levels won't raise much more money. This is obvious from Sanders' proposal: https://www.sanders.senate.gov/download/options-to-finance-m...
Sanders proposes to raise the top bracket to 52%, above France's or Germany's. It proposes to treat capital gains as ordinary income, like France but unlike Germany, Sweden, etc. Even raising taxes on the rich to levels higher than France only raises $1.8 trillion over 10 years. The payroll tax proposal, by contrast, raises $7.7 trillion, four times as much. Going all the way and raising social insurance taxes to French levels would raise 5-6 times as much as raising taxes on the French to higher-than-France levels. So would a European style 20-25% VAT.
> projected $30 trillion over the next 10 years
This is a projection and there is much disagreement. If we spent as much per capita as Canada, the cost would go down by around 50%. Single payer is not feasible at the cost per person the US currently spends. Every other country in the world spends less (a LOT less). We have a lot of real examples to follow.
> Actually, middle income earners "have the most to lose."
You have a good point, here, but again it could vary significantly depending on revenue-raising changes that are enacted. The Sanders plan includes mostly progressive tax changes.
Actually I dislike this statement - the federal government will be collecting and disseminating a lot more money than it is today, but less money will come out of people's pockets. It is the case that taxes will go up, but "taxes + health insurance" today is more than "tax + health insurance" under medicare for all, the tax goes up, the health insurance becomes 0.
1. At least for primary care, it's highly probable that a lot of "extra" medical care wouldn't be captured like vision insurance, dental and pharma.
This will be influenced a lot by whether the employers give what they currently pay to provide healthcare back to the employees or if they just pocket the difference.
That’s not $3T on top of what we currently spend, though. It just moves payments that go to insurers over into taxes. We already spend that $3T (and more!) on health care.
We know from the rest of the developed world that this is cheaper, too.
Someone is paying for insurance - that’s just a part of your compensation that is deducted from your paycheck. Theoretically, that means employers should pay you more. I think it would help the cause of universal health care if employers were not allowed to subsidize health insurance invisibly. They should increase everyone’s paycheck by the amount they are subsidizing the insurance and then have it as a line item deduction.
When Obamacare came around, I saw people complaining it'd cost them $1k, and comparing it to the $40/month they had to chip in on their employer plan, as if that was the total cost of it.
You forget about the fact that universal healthcare will bring healthcare costs down as fuck. Ever looked at the price of a GP appointment before insurance in France and the US ?
> And The Times observed construction on site in Paris, which is building a project similar to the Second Avenue subway at one-sixth the cost.
This is an extreme example, but this is the persistent story of government programs in the US: they do far less while costing far more than in European countries. The US spends almost 30% more per student on K-12 education while getting worse results.
The problem of excessive cost for rail, for the most part, is specific to English-speaking countries and Japan, not just the US. Quote: "Observe from the low costs of Italian subways that corruption alone cannot explain high American and British costs. High Japanese costs can be explained by strong property rights protections and a process that favors NIMBYism…"
There was a study that I can't find offhand that led to really interesting conclusions: despite the tendency of everyone to think that their own locale's government is uniquely inefficient, wildly late and over-budget public works projects are the norm everywhere. (Look at the Amsterdam North-South line in that blog post, now 2x over budget, for example.) Public support for most infrastructure megaprojects wouldn't be nearly as high if authorities were better at estimating costs. But that means that, if authorities were better at calculating costs in advance, virtually nothing would be built, including things that everyone now considers essential such as the Interstate Highway System (estimated at $25B over 10 years, actual $114B over 35 years ). The tendency of public works projects to be delayed and over-budget seems to be, paradoxically, what allows us to make progress in the first place.
56% of Americans suffer from financial hardship due to medical concerns: Adults under 65 were more likely than their older counterparts to experience these effects.
Using stats from another poster- ~34% are on medicaid/care. Another ~40% are covered by private insurance. Insurance companies have high-paid smart people negotiating prices. Government pays what it wants (pay by law mandate) regardless of costs. ~34% of hospitals patients therefor are losing the hospitals money- 10s of billions per year. They can go out of business and treat nobody, or jack up the costs on the one group available- self-pay uninsured.
The uninsured pay a lot because of government- they basically help subsidize these programs. If everybody moves onto a socialized programs that pays less than it costs hospitals to operate then hospitals close. Or taxes go up a lot to make it "free".
Don't get my wrong- as an uninsured person I don't like the way it is either. The only way I can think of is to make it all personal and private- get rid of employer deductions. Then add deductions/credits to cap medical cost at 10% of income or something. Anything above 10% is covered by taxpayers but individuals are responsible for shopping around and saving to make the market work as well.
Please cite your sources. I'd be very interested to dig into this data.
2/3 of people who don’t have Medicare have employer-paid insurance. Or put another way 73% have either Medicare or employer paid insurance. (Obviously Medicare isn’t private healthcare, but the two groups are for the most part mutually exclusive.) The remained are for the most part covered by Medicaid or through direct purchase.
20% of adults have student loan debt.
15 percent of the U.S. population get Medicare. 19 percent of the population get Medicaid. So, the government subsidies heathcare for ~34% of the population. And that’s excluding prisoners and VA which make up ~0.5% and 10% of the population, but may overlap with the above. Further the government also pays insurance for government workers and their families, or other special programs that subsidize heathcare costs like Ryan White or various rural heathcare initiatives.
Saying the majority as in over 50.01% of the population has insurance is a very low bar. What percentage of the population without healthcare is a sign of a well functioning system to you?
Second, what suggest public funds going to heathcare is a sign of a well functioning private insurance model?
Also, significantly less than 50% of the population has completely non publicly funded heathcare. It’s a really odd system when you start breaking down the numbers. We have surprisingly close to a 50/50 public private system, but people get wildly different amounts of public funding.
So he was excluding some but not all people who received government funded insurance. Which is why I was pointing out that was a very odd way of counting.
We're talking about existing trend - things seemingly change quite fast into that direction, but haven't reach majority (yet?).
When everyone has insurance by default or transit is free and we pay it via taxes then there is no free rider problem.
Things are a lot less nutso if creditors can't ruin your life in general - the healthcare crisis just means that everyone needs to be aware of how to handle a bankruptcy.
What an absolute nightmare. Hard to see this system being sustainable for more than a few more decades.
Its taxpayer funded however.
You have no idea. I work a small community hospital and we have 9 VP's and 44 Directors. One department has 9 employees and 2 Directors.
Germany went from 2889 to 5986, 2.1x as much.
France went from 2686 to 4965, 1.8x as much.
Canada (yes, I know Canada is not EU...I'm tossing them in as a bonus) went from 2451 to 4974, 2.0x as much.
Italy went from 2029 to 3428, 1.7x as much.
Japan (another bonus) went from 1851 to 4766, 2.6x as much.
UK, 1561 to 4070, 2.6x as much.
Data here: https://data.oecd.org/healthres/health-spending.htm
Uncheck the "latest data available" box to activate the range sliders and get a graph of costs over time.
Two things stand out in the graphs:
1. US is more expensive over the whole range of the data (1970 to 2018).
2. They are all going up, mostly at roughly comparable rates. I just looked at the G7 countries above, but the same holds for most OECD countries. It looks like the US has averaged going up a little more than many of the rest, but it looks like nearly everybody has got a problem in this area.
Whoever decided $2000 dollars for a feeding tube is fair market rate is part of the corruption.
> The $164,000 billed to Waldron for intestinal surgery was more than twice what a commercial insurer would have paid for her care [..]. Charges on her bill included $2,000 for a $20 feeding tube.
Let's say I'm going out and offer to bring you back a sandwich. I can't give you the sandwich and then claim you owe me $20 because that was my price. I either need to form that contract up front, or I can only expect reimbursement for the amount I actually paid.
I don't think we definitively need single payer, but we do need uniform (per provider) pricing and price transparency. (Although allowing everyone to buy into medicare/medicaid would be a no-brainer)
Barring systematic reform, I'd really like to see a trend of "healthcare extortion trusts" to keep everyone's life savings safe from these vampires.
And I want to add to this: patients can't even be held at fault for this: have no ability to even find out! I've asked and asked for this up front (after being hit myself with a huge bill for what was a tiny visit! No surgery, just an examination!), and been told by providers that it is "impossible" to provide even an estimate of a price, even when the provider has all of my insurance information. Which is bullshit.
To make a patient choose between an unknown bill and their health is extortion.
How is that corruption? Who is being corrupted, and by whom? The state cannot corrupt itself.
Obviously if you define the term "corruption" so that it is inapplicable, then there is no "corruption". FWIW I'm totally on board with viewing "the state" as a singular malevolent actor, I just don't think that paradigm is particularly useful here.
The questions is, intended by whom?
Intent is a serious factor in crime.
With the right kind of paperwork you can not only rob a bank you can also make yourself a beneficiary of multiple bailouts and benefits. With even better paperwork you then claim the losses as part of lowering your tax obligation.
I mean... is it really there ?
Also, at the risk of not getting that question answered, what does lobbying have to do with people being underinsured?
You also need to look at PBMs that eek out a living as a middleman between pharma companies and insurers and survive by bulk offering pharmaceutical consumption in exchange for rebates while advocating for higher pre-insured prices to maximize the price difference between direct purchasing and their rebate reduced price.
You _also_ need to look at health insurers that operate in pretty much the same manner as PBMs but with everything that isn't a drug, highers list prices at hospitals coupled with lower negotiated rates for their patients is why a person with good insurance may pay 130$ for a 13k list price procedure, and the people with bad insurance are hit with the full cost.
Lastly the siloing of patients to specific care networks gives healthcare providers better control over how much that after insurance take-home is for themselves, if there are three hospitals within a few hours of you but two are out of network and the last one won't give you upfront information about their pricing then you have no freedom to choose efficiently.
Oh also, the pharma companies, they've gotten a bad rap recently for opiods. But it's a generally policy that drug reps that monetarily reward doctors for prescribing certain volumes of medication without any relation to patient needs, thus driving up the unnecessary usage of medication (and the cost to insurers, and the cut of PBMs) while also potentially causing further health issues from side effects of a drug the person didn't need in the first place.
Everything in this system is broken and it's basically just a carousel of terrible where each pillar is supporting the other ones because everyone is making so much damn money - and politicians are happy to force any state offerings to play by the same rules for a share of that cash for themselves.
In a sane system without the lobbying and corruption this cartel of players would be unsustainable because public interest would force politicians to cut down on their crap, but that ain't happening. And, while I think some intents of the law were decent, the actual effect of the ACA has been to cement the improper running of this market into law while forcing absolutely everyone into insurance - the ACA was a huge gift to insurers and it, and the private insurance and healthcare market that spawned it, need to be nationalized.
What does this have to do with an extortionate bill from a state-run hospital?
If better priced options are available people are going to stop playing in that private healthcare sandbox - it's part of the same reason why the house has been unable to legalize purchasing drugs abroad... that too would weaken the price fixing abilities of pharmaceutical manufacturers and PBMs - also maybe pharmacies, they tend to get squeezed pretty hard by PBMs though so only in the case where a pharmacy is being squeezed by its own PBM (as is the case of CVS) is the pharmacy really embroiled heavily in this mess as a loss leader.
Do you have evidence of the Virginia legislature meddling with the hospital's charge master? I could certainly believe that, but in the absence of evidence I'm more inclined to think it's just the hospital administrators trying to extract every dollar they can out of patients. For some reason even non-profit and government entities often seem to have a disturbing emphasis on revenue enhancement.
This, and the number of bad actors involved with healthcare, is sort of the issue - whenever the PBMs are under attack they claim innocence and say it's the pharma manufacturers - similarly here the hospital did indeed act in a rational way in their pricing, but that way is only made rational by the broken national system - and if, while an aspirin at a hospital normally costs 100$, at this publicly funded hospital that aspirin cost you 3c then there would probably be outcry by the private hospital that the public healthcare offering is unfairly undercutting prices in a manner that private organization couldn't compete with - you can see this happening right now with the wonderful debate on municipal internet.
1. Insert reasonable cost here, 3c seems much less stupid expensive to me, it's probably still like a 100% markup if buying in bulk but Amazon is willing to give me 100 pills of aspirin for $3.08
Insurance companies negotiate rates for everyone else. So much so that when my wife was going to get an Iron infusion the doctor couldnt let us pay for it out of pocket ( we were in a hurry to go somewhere and couldnt wait for insurance) we were told we couldnt pay out of pocket unless the insurance company allowed it
Let that sink in... you cant pay for healthcare out of pocket unless your insurance allows it.
Corruption is aggravating. Having to pay a massive chunk of my income for it is just nauseating.
Simple. There's not enough money. To do that there are a lot of people who have to get pay reductions or lose jobs.
But if you did that people would be anyway able to afford healthcare, so you kind of solved the wrong problem.
Good luck solving the pay problem, can you imagine a politician running on a platform of job losses?
Sure there is. US governments' expenditure per capita on healthcare is more than governments' expenditure p.c. everywhere else.
Wherever that money is going, it's not going to better outcomes, or being evenly distributed.
There's not enough money, for government, to pay all the Dr.'s etc, at current rates. Healthcare workers of all sorts will need to either have a pay reduction or be laid off, in order to bring spending in-line with how much other countries spend.
But ya, a lot of the health care industry in the US isn’t economical, and skims off the rest of the economy. Issues that competitor countries mitigate better. Fix that and you improve America’s competitiveness.
It should be an easier sell than it is.
the whole US health care system is a mess because government, state and federal, made it one. then they continue to pile on to make it worse all the while fattening their campaign chests at the expense of everyone else.
the only way to fix US health care is to forever remove it from influence by politicians. Yeah it would take a law to do it but the system setup should basically tell the government, pay us and shut up.
Politicians aren't controlling the health care system at this point - they've been entirely declawed. There is a strong enough cartel that it would survive anything the free market could throw at it, only active government action would actually resolve this issue... just... not entirely corrupt government action.
Oh, you meant solving it for actual people? That was never the goal of the self-serving architects of this rotten mess.
I don't expect the farmer to grow me food out of the goodness of his heart, but to quote Adam Smith, this is a conspiracy to the detriment of the public.
 Who charge absolutely ludicrous, jaw-dropping, nowhere-else-in-the-world-comes-close tuition.
 Who, after paying off the debts on their ludicrous tuition, are absolutely rolling in money.
 Who don't let their patients comparison-shop (Just try getting a straight answer on how much a routine procedure is going to cost), and in effect, can charge whatever prices they want.
 Who are happy to make billions of dollars off inefficiencies created by them, in the generic space.
 Who have created a captive market where not getting your healthcare through them is financially ruinous.
There are also a lot of things going on with consolidation and big medical groups, driven in part by pharmaceutical costs. As an example, we used to have several oncology practices as clients. We're not working with any of those anymore because they have all been bought out by hospitals or health systems. From talking with the doctors at the most recent one this was not because they got a big payday out of it but was instead because looking forward a few years they were not going to be able to afford to stock chemotherapy drugs. They sold out because they could see the time when the business was no longer sustainable as an independent practice.
I'm sure the doctors didn't come out of this hurting, but this was not a startup unicorn style exit.
Here in the US, our culture still praises this behavior because it props up the carrot that is the American dream. It's a cultural problem where everyone has been convinced they're the next billionaire to reap the rewards of the broken political and economic system... they're just temporarily and shamefully poor for now.
So the problem runs far deeper than healthcare, it's everywhere. Healthcare is just an obvious target because it directly effects people when they're most vulnerable and it actually angers them enough to complain a little. We need a cultural shift that is reflected in our politics (if it's not too late already).
I feel like there's no way to have both things.
That's because of the impedence mismatch of legislation in Europe vs the US.
I'd say it's comparable to the story on how US eggs are illegal in Europe, and vice-versa.
I'm not sure which anecdotes to believe in this case.
Those groups are going to hold any progress on this matter hostage. (Imagine the job losses! Imagine the loss in innovation! Imagine not being able to provide the best treatment money can buy! Imagine not being able to charge a million dollars for a medical education! Or being able to pay off my million dollar debt, accrued to finance my medical education!)
Consider, doctors start working at 30, usually retire at 65. That's 25 years. First 10 years is spent paying off student loans and gaining clinical experience. Friend of mine is a Sr software engineer with a masters and 20 years of experience. His slightly younger brother is a newly minted Cardiac Surgeon.
This is why there is no demand for real change and why all previous efforts got essentially stonewalled.
In this case it was a middle class family losing their 4 bedroom house due to "$164,000 in medical bills for emergency surgery". It's not just hurting the poor, it's a relatively small number of people organized in a cartel ripping off the entire country.
Medical cartel needs to be investigated by FTC like any other cartel. Being under purview of HHS and state medical boards infiltrated with physicians is not working due to conflict of interest. Cartel can be broken down by rewriting scope of practice laws to focus on "standard of care" rather than "board certified license" as a gatekeeping regulation to practice medicine. Once the physician cartel falls everybody else leeching downstream (insurance, global pharma, PBMs, countless vendors, etc) will simply dry out.
Medicare for all (public option) could also have a similar effect if implemented properly in a way that strips power away from physicians. But if implemented by naively increasing taxes and throwing money into the current system it's going to do more harm than good.
MDs no less! Forget the Hippocratic Oath!
Perhaps white-coat fraud is the equivalent of white-collar-crime in the public health world. Nothing matters more than the bottom line. Not even human lives.
Medicaid, which even happens to pay reasonable amounts for procedures performed. The entire system would re-adjust into a sustainable steady-state, if all prices were equivalent to Medicaid reimbursements. But I suppose that under such a model, the average middle-aged surgeon wouldn't be able to afford their third summer home...
That said, the only way to win is to not play - never get sick and emigrate before you have any serious health issues.
OTOH, I'd say that the people who got really nailed with the ACA were the middle-class individual policy holders.
If all procedures performed were done at Medicaid-like prices, hospitals and physicians, and pharma firms, and, by proxy, insurers and medical schools would have to tighten their belts, and figure out how to cut costs. That's the entire point of such an exercise. We can't let health costs grow in an unbounded manner.
Dunno how 'Medicare for all' will work out if you simply start paying providers what Medicare currently pays. Dictating a price might work in the long run but would be plenty hairy in the short.
I can sympathize with the on-the-ground employees but the businesses they're keeping the lights on in are leeches on the healthcare market - I posted separately on this article going into the specific functions of PBMs, Pharmaceutical Manufacturers, Providers and Insurers if you're curious about the details, but there is a ton of inefficiency here.
And if the ER thinks you're a deadbeat, they will give you the minimal treatment necessary to make sure that you won't die on the hospital grounds - and discharge you.
Makes me ill to think of the cost.
Christian (judging others), logical (how much does she know), fiscal (most costs to system are not kids)
Forgot parenting (who else is supposed advocate for the kid?)
If the US paid the prices for care that other countries pay (pick any developed country you want, it'll be less), everyone could get a tax cut and universal care. It would save US governments money.
Even if I did sign something in an emergency, I may be able to claim to not have been capable enough to reason about it, due to shock/mental issues given the emergency.
Not a dumb question. If you don't have insurance, you can make such claim, and very likely you'll never have to pay. If you do have insurance, it's very likely that your insurance has pre-existing contracts with the hospital. Even though the hospital can't force you to do anything, it's likely that they can force the insurance to pay.
Of course that’s different to your proposed situation - but if you were indigent then Medicaid would be billed.
I’ve always thought it weird that people feel entitled to free (or massively discounted) medical care.
Consider the case where some business could sell you a product or service that might add years to your life. How much is that worth? Why is it somehow unfair or immoral if someone buys such a product or service, without considering their ability to pay, and bankrupts themself?
Yes the issues are more complex here in the US due to the opacity and arbitrariness of medical billing, but if we set that aside, how much is your health worth to you?
My gym membership is EUR 19.95, what's that got to do with anything? :)
> how much is your health worth to you?
Whatever percentage of my income currently goes into my health insurance over here in Germany. That's paying towards my health and the health of those unable pay in right now (or ever, I don't care, it's not their fault most of the time and could just as well be me). I plan on getting private health insurance to get better level of care for myself because I can financially afford it, that doesn't imply that those unable to should feel entitled when they seek treatment imho.
The opposite of the US system is neither free, nor massively discounted. You're just overpaying on stuff much of the rest of the world managed to put in more effective systems that do not put massive strain on the population. If you don't mind a different perspective here: Framing that as entitlement always seemed odd to me since I don't get why some medical corporation should be held in higher regard than the population of the country that provides them with a market in the first place.
> Why is it somehow unfair or immoral if someone buys such a product or service, without considering their ability to pay, and bankrupts themself?
Because those people suffer, in the worst case die, in the best case put other costs on society as a whole? We generally moved on from exiling the ill in most firsts world countries, which is what happens if society does not (at least minimally) provide for those that cannot afford to do so themselves.
I don't think we should offer advanced and highly specialized treatments for free. It's just crazy that there's so much wealth here, but you hear plenty of stories of peoples' lives being seriously damaged by an accidental ambulance trip or hospital billing horror-story.
The product or service that extends your life is essentially not critical to survival or even just your status quo health-wise. From an economic perspective, this is a price elastic situation so charge as you like (i.e. basically according to supply/demand).
The situation that is actually the problem (and way more common, of course) is that if I'm in a life threatening situation I don't have the option to chose a particular product or service, that's price inelastic and not beholden to supply/demand. So you're comparing apples to oranges from an economic viewpoint, especially when we're talking about something as critical as healthcare.