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Life expectancy in the U.S. is declining for middle-aged people of all groups (nytimes.com)
141 points by pseudolus 6 days ago | hide | past | web | favorite | 201 comments

> “The whole country is at a health disadvantage compared to other wealthy nations,” the study’s lead author, Dr. Steven Woolf of Virginia Commonwealth University, said. “We are losing people in the most productive period of their lives. Children are losing parents. Employers have a sicker work force.”

For profit healthcare in America is devouring its people and economy, full stop. We can either have a society where half a million people go bankrupt from medical debt each year, thousands die from treatable illnesses and lack of access to medicines, while hospital CEOS and insurance execs walk away with millions. Or, we can have one that excises their parasitism like the rest of the developed world figured out was necessary decades ago.

There's also an entrepreneurial angle:

If you don't have to worry about health care, it becomes much easier to start and run a small company.

Indeed. As someone who works in the arts, it’s quite apparent how much easier it is to survive for my friends and colleagues in Canada and Europe. Even discounting the public funding for the arts many of them receive, simply not having to worry about healthcare and medicine costs as a freelancer makes a huge, obvious differences the length and viability of their careers.

"simply not having to worry about healthcare and medicine costs as a freelancer makes a huge, obvious differences the length and viability of their careers"

I've been a freelancer for 10 years and have always purchased my own health insurance in the US. When I was single, it was only around $150/month (even only a few years ago). This included Doctor visits, prescriptions, and if I had an emergency..I wouldn't go bankrupt.

If Canada and Europe are great places for startups, why do they lag so far behind the US? The reason is because while it seems great that you get free healthcare, as your company grows, it's many more times difficult survive because of the taxes and regulations imposed on you.

An increase in taxes and regulations only helps large companies because they have the attorneys and employees to handle all of the paperwork and can still survive when a large percentage of their revenue is given to the government.

Rates of entrepreneurship are comparable to (and in some cases higher than) the US in most wealthy European countries. The difference in “startup” culture has more to do with the access to capital and the US government’s historic, unmatched investment in technology infrastructure in the context of the Cold War. It’s the same reason why Russia today still punches above its weight in the IT sector.

Startups are just one small category of business: the sort which must grow at 6% per week or else they will fail.

The U.S. does great with these “bet the farm” business models because most of them can fail, and the few that succeed can pay off the capital class handsomely.

Personally, I would rather live in a world where all of my most talented friends can start lifestyle businesses that allow them to do their best work, and be healthy.

The success of startups has some nice macro effects on GDP, but does not solve the problem of labor exploitation that, for me, is just as important a goal of entrepreneurship as making a windfall for the capital class.

While taxes are high, employees in Europe are still way cheaper than say SF or NYC. You can get a decent web developer for EUR 60-80k in total cost per year in Austria. Spend 100k and you get the top 5% talent.

What Europe lacks is private funding. I don’t find the article now, but years ago read that there’s 5x as much funding in the US market as compared to the EU market. Seed funding is 3-5x less than you would expect in the US.

This has seemed to me to be a key problem for the European tech industry. A few seemingly minor structural differences mean there is very little domestic VC available. Those are:

1. In the U.S., there are many pension funds that put some of their money into venture investment. In general in Europe it is illegal for a pension fund to invest in such risky assets at all.

2. In the U.S. there are many more private foundations and private universities that have large investment funds, and some of this gets put into VC. For a variety of reasons, there aren't many large private foundations and there are few private universities with large endowments.

If I were doing industrial policy in a European country, the first thing I would do is to start to invest a couple percent of the state pension funds into VC like vehicles. Given how underinvested it is, the returns should be great, and the extra economic activity should help the fiscal health of their economies a lot.

> it's many more times difficult survive because of the taxes and regulations imposed on you.

There are several things going on here:

* "Europe" isn't one place.

* It can both be true that there are higher taxes and more regulations, and the health care system is better. You're still paying less for health care as a % of GDP, so it's not like you're paying the same amount, just through taxes.

* There are a lot of other factors such as universities, access to capital, and simply 'culture'.

I work in the visual arts in the US and the triple-whammy of student loan debt (MFA's are basically a prerequisite for almost any job in the field), high real estate/rental prices, and lack of healthcare make it extremely difficult for anyone who lacks outside funding (partner in stable job, family money, etc.) to set up a studio and make a viable living at their art. If we at least had universal healthcare it might just be doable.. As it is now, most artists that I know are without insurance or on Medicaid.

Yeah, it’s a horrible situation. Some illustrators I know live in terror of earning too much that they no longer qualify for Medicaid (which they rely on for various health conditions). It also pushes people in the arts into the gray economy where they’re more likely to get taken advantage of or build a stable, growing career.

Not to worry about healthcare and medicine costs is not really true. I just commented about it. Most people pay extra for private insurance even if they get public healthcare for free.

I’m in regular contact with artist friends in the UK and Canada and absolutely none of them do this. And neither did any of my family in the UK. Not sure where you’re getting this idea from.

The only people who generally have private health insurance in the UK (other than dental care) are those who work for companies where, usually senior, staff get this as a taxable part of their package. I wouldn't have thought that artists would belong to this category.

Here in Canada health insurance is seen as important. Government does not cover dentistry, mental health, eyecare, physiotherapy, ambulance. There are provincial programs to help with prescription drug costs, but the deductible that must be met first is quite high.

That's true for the UK but not for many European countries. See https://www.oecd-ilibrary.org/docserver/health_glance-2015-3...

I'm Canadian. Almost nobody does this, although health benefits through work will usually cover the cost of drugs and dental. But nobody is paying extra for medical coverage outside of those areas.

According to this 67% of Canadians are paying extra for supplementary insurance. (it's a few years old but probably didn't change much since) https://www.oecd-ilibrary.org/docserver/health_glance-2015-3...

That supplemental insurance is most likely just dental and prescription drugs. It’s not for the more expedited care you cited. Drugs in Canada are still cheaper overall because of government involvement in the market and many Canadians actually wish their national system was expanded to include dental care.

That might be true in some eu states (Mostly the newer and poorer news)

From experience in the UK Private insurance is not worth it as an employer benefit as you get taxed on it.

And even in newer and poorer EU states it is not that bad as in US.

I'm in the UK, I know of no one who pays for private healthcare. You can often get private healthcare from your employer, but I believe you incur a tax cost to do so. Something something benefit in kind?

I'm from belgium and I'm considered as having complementary insurance beside regular free insurance. The complementary insurance is part of the same package as regular insurance and is not even optional. I pay 40€ every 3 month. According to the study you posted, I have a complementary insurance. It has to be taken with a grain of salt...

I an European and I have worked and lived in 4 different EU member states, some rich, some more poor. I know almost nobody who gets private insurance.

Currently I am in Germany, and I had a serious health issue. The sort of thing that makes you go bankrupt in the US. I had surgery and months of treatment for free. I stayed on my own private room in the hospital, and it looked like a hotel room, with a private bathroom. I payed zero euros, this was all on public healthcare. They even offered me a few days in a SPA to recover after surgery. They even funded the metro tickets to go from my house to the place where I received the treatment.

Some other EU member states do not have the resources for such niceties, but you will absolutely get the treatment you need.

I feel sorry for people in the U.S. I read about all sorts of situations that are heartbreaking, and it confuses me that most people there still vote against universal healthcare. This serves nobody except the very rich people exploiting the situation.

I listen to North American podcasts and such, and I am still surprised to hear educated people repeating lies about the situation in Europe, as if we were some almost-communist repressive society about to collapse. The most common assertion is that, after all, the US is the only country with "real freedom". To my European ears, this sounds exactly like the sort of propaganda you get from any authoritarian regime. As if "freedom" is some simple one-dimensional things that can be measured like this.

I think it would be good if U.S. citizens had a more realistic picture of how the rest of the western world lives.

That varies a lot from place to place. Most people in Italy, where I lived for many years, did not get supplemental insurance.

I don't know anybody here in Israel who pays for private insurance.

What?? Read https://www.calcalist.co.il/local/articles/0,7340,L-3755829,...

To quote for the non-Hebrew readers: "83% of the people paid for extra insurance in addition to what they get from the government"

Oh, but that's such a minor expense I don't consider it at all. It's an extra 10$ a month for the absolute majority. Top insurance is about 25$ a month. Practically negligible for the absolute majority of people and nothing like the hundreds of dollars a month most people pay in the US.

Also, it's not "private" insurance in any meaningful sense. It's out of pocket adjustments for exactly the same services. This is what I was alluding to.

I'm assuming 10$/month you're talking about the supplementary insurance like "mashlim" that 90% of the people with reasonable income do. The article also says that 53% of the higher income group also have private insurance, which I'm sure is more expensive than that. (the article is from a few years ago so things might have changed since; I don't know). But I agree that most people probably don't need private insurance.

Also to make things clear, when you say people in the US pay hundreds of dollars a month, that's also true for many Israelis. The public insurance is not free if you have a job. The more you make the more you pay. If you work in tech it's likely you're also paying hundreds of dollars a month. (don't get me wrong, I think this system makes sense, it's the same as income taxes). The situation in the US isn't great but it's been much better in the last decade. For example, I live in Massachusetts and everyone in the state is required to have health insurance. If you're low income then you get your insurance from the state.

Fair enough. I'm glad more states are following suit. Both of us appear to understand the differences between the systems and so I don't think we should be bogged down with semantics. Israel has a single-payer public healthcare system, almost entirely paid for by taxes, which is utilized by a large majority of the population.

Is it basically single-payer healthcare there?

It is, yeah. If you go to the ER and are admitted, you pay literally nothing, even if you needed an ambulance. Subsidized medication is extremely cheap, etc etc..

I kinda agree, but in reality Europeans are much less likely to start and run a company.

But that's because there is much more capital available in the US so it is easier to find investment.

Americans are more entrepreneurial in spite of their healthcare system, not because of it.

Yes and one of the reasons there is more capital is because US takes a capitalistic choice on most things which is one of the reasons why healthcare is private.

Which is clearly why the U.S. is such a terrible environment for starting new businesses.

It's not that simple, it would be possible to have a socialized healthcare system where entrepreneurs paid for everything and lost more than they gained as a result. It could happen, the public line for that policy would look like "let silicon valley unicorn billionaires pay their fair share" and the private line would be "come on Mr. Congressman, you aren't seriously thinking of taxing your future employer, are you? Find somebody else with money."

Neither of the proposed single-payer models (Sanders and Jayapal bills) do anything like this.

I’ll grant that in the Biden/Buttigeig/Warren plans, there’s a lot of room (and incentive) to tank things like this or in any other number of ways.

Without tackling the obesity/sedentary/nutrition problems the healthcare issue will persist.

Similarly the opioid/meth epidemics of the last 2 decades are not (just) healthcare problems.

A good public healthcare system actually puts money into trying to address those problems, as does the government who pays for it. A private healthcare system may be a little more... ambivalent.


They earn money for treating the symptoms.

The same thing goes for quality of medical care - when they mess up they get to fix their own mess and charge for it.

For example when our first kid was born, the gynecologist had her trainee pull our son out with their rope thing. She was supposed to apply pressure during the contractions, only she panicked and pulled my son out in one go (she was using her legs to push for force, you can't make this up). The result is that the baby was born quickly and my wife was ripped open. She required urgent surgery to put herself back together, then a month stuck laying in bed and about three months before she was mobile. She still have problems because of it.

The hospital were happy because they could charge three times as much for the corrective surgery than they charged for delivery.

My example was in The Netherlands, where the healthcare costs are well under control and the culture isn't quite so brutally selfish ("free market") as other countries. I can't imagine what it's like living in the US.

In the US, we have medical malpractice lawyers on every street corner. Hospitals absolutely aren't profiting from malpractice.

>A report issued by the US Department of Health and Human Services estimated the cost of malpractice insurance to doctors alone at $6.3 billion in 2002; with an additional cost of $60–108 billion related to the practice of defensive medicine, i.e., costs related to physician behavior in response to the threat of a lawsuit alleging medical negligence


US healthcare spending represents $3.4 trillion[0]. $6.3 billion is only 0.18% of the total costs.

Not to mention that malpractice claims paid has decreased substantially (55.7%) in the last 2 decades [1].

[0]: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5470361/

And for a reference, we spent around $30 billion in the US in 2016 for healthcare marketing and advertising.


Also from your source:

> Mean compensation amounts and the percentage of paid claims exceeding $1 million increased

I'm not saying it's a huge component of healthcare costs overall, I'm just saying malpractice not a good profit motive.

That's an awful story and I'm sorry that happened to your family, and I'm sure you were charged for the additional care.

I'm curious how you know the hospital was "happy" about it though. I ask because a close friend is a nurse/midwife who delivers a lot of babies and I find it very hard to believe that caregivers, at least, would be happy about this outcome. I also find it hard to believe that the hospital administration would reward them for this outcome; indeed, hospital administration usually inclines toward bureaucracy aimed at preventing mistakes, rather than incentives to create mistakes.

Under a single-payer system, new providers would still need to train on the job; mistakes could still happen; and the provision of care to mitigate those mistakes would still cost money. Doctors and nurses don't work for free just because of a mistake, even under a single-payer system. Administrators would still get paid too. In general, medical employees get paid to treat people; that is true regardless of how patient insurance is structured.

I don't think customers should pay extra for medical mistakes; but I also don't think providers in a for-profit healthcare system intentionally and happily create medical mistakes for the purpose of profit.

I'm strongly suspect that the complexity of for-profit health insurance spills into operational complexity. Billing, negotiating for payments, claims denials rework, etc that all spills into hospital management in a significant financial, and focus distracting way.

It sounds like that trainee fucked up so badly, that you would have been able to sue the hospital for malpractice even in Europe. :-/

Whilst in the US I snapped the tendon on my little finger. When you do this the little finger just hangs there and you can´t do anything with it.

US hospital did a terrible job of splinting it, told me to come back following day to see a surgeon. (Cost $1000+, high copay since I didn´t yet have my work insurance which didn´t kick in for another month etc.)

Went back home and googled it. NHS treatment, splint for 6 weeks do not disturb splint under any circumstances, followed by simple physiotherapy. I re-splinted using a plastic spoon handle (which is perfect for this btw.) and today the finger is completely recovered.

A year after all this, I ran into a guy at a rental place in the US who had a little finger sticking out at right angles, and which was functionally immobile. He´d had the operation - several years previously, you could see the stiches. Finger had never recovered properly.

But you can see where the profit incentive would lie for the American hospital.

How is that related to what I was asking about by the OP comment? Which was:

> Without tackling the obesity/sedentary/nutrition problems the healthcare issue will persist. > Similarly the opioid/meth epidemics of the last 2 decades are not (just) healthcare problems

In practical terms, the NHS for example sinks a lot of money into anti-smoking campaigns and into advertising campaigns about weight reduction .On the government side this tends to translate into things like taxation on sugar in drinks.

I've just been called in for a check up on my blood pressure and if it had worstened, I would on the end of quite a lot of dietary and excerise advice in an attemp to avoid additional medication. Many GPs in the UK has teamed up with Parkrun and now prescribe park run participation for certain patients and conditions.

This sounds like a nightmare on privacy. Government collaborating and sharing your data with outside Companies. Am I getting this right, or wrong?

I think you're getting it wrong. The publicity campaigns are just that - publicity campaigns.

In terms of Parkrun, there's no data sharing. GP Practices simply encourage patients to go running and have all the details of their local parkrun to hand https://www.runnersworld.com/uk/a776238/parkrun-uk-teams-up-...

They don't share your data, they just encourage you to go for a run.

Occasionally public-private data sharing gets in the news. Where I see it reported, it’s treated as a scandal even when the company in question is Alphabet and they got the data for AI research: https://www.theguardian.com/society/2019/jun/10/nhs-data-goo...

Medical privacy is one of those places where I wonder if a personal desire for privacy might hurt society as a whole — Almost, but not quite, like the tragedy of the commons.

Still, it’s easy for me to say that, none of my embarrassing aspects have medical consequences.

"This sounds like a nightmare on privacy. Government collaborating and sharing your data with outside Companies"

Unlike Private companies sharing our data with other private companies?

Private healthcare optimizes for profits and value extraction. Public healthcare optimizes (one would assume with the proper governance, oversight, and controls) for quality of life, but also for reducing costs (it's cheaper to treat your type 2 diabetes with diet and exercise before we have to start amputating appendages and you have chronic issues, for example).

Disclaimer: Medicare For All (single payer) supporter

I'm in the healthcare analytics industry. I see the private payers optimizing for the things you say they don't. It's simply more profitable to have a healthier patient.

I would posit it's more profitable to have customers that pay for insurance monthly but don't actually utilize any resources or services. Not using health care seems to be what is encouraged with high deductibles and copays for visits.

https://www.axios.com/health-care-industry-on-track-massive-... (Health care industry on track for massive profits)

https://www.forbes.com/sites/brucejapsen/2019/08/04/as-sande... (As Sanders And Warren Attack, Health Insurer Profits Soar; "Take Humana, which last week said it made more than $1 billion in profits in the second quarter and raised its earnings and revenue forecast for the rest of the year thanks to growth of seniors signing up to Medicare Advantage plans. Cigna, too, which said it made more than $1 billion in the second-quarter, also increased its earnings forecast last week for the rest of the year. And the week before, Anthem, which operates Blue Cross and Blue Shield plans in 14 states, also reported more than $1 billion in profits in its second quarter and said its profits are ahead of expectations for the year due in part to the money its making off of government contracts with Medicare and Medicaid programs. Meanwhile, UnitedHealth Group's UnitedHealthcare health insurance unit reported last month $2.6 billion in earnings from operations in the second quarter and the parent company boosted its earnings forecast for 2019.")

https://www.cnbc.com/2017/08/05/top-health-insurers-profit-s... (As Obamacare twists in political winds, top insurers made $6 billion)

https://www.gq.com/story/eat-the-health-care-ceos (Last year, 62 CEOs of health-care companies made a combined total of $1.1 billion in compensation. That's according to a new report out from Axios, which coincidentally notes that CEO compensation eclipses what the Centers for Disease Control spent on chronic disease prevention by $157 million; The average CEO makes $18 million annually while one out of every five Americans is struggling with medical debt.)

Those profits (which you mention they're optimizing for) are dollars that could be used to improve healthcare delivery. That's actual care someone could receive, instead of going to unnecessary middlemen and shareholders.

How long do US citizen stay with a single healthcare provider (/insurance)? If, say, only 50% are still with the same provider at age 50 as they were at age 30, there is a discount on the benefits of preventative measures compared to single-payer systems.

As a US citizen I can say that we change Healthcare providers whenever our current employer changes our Healthcare provider option. This can be every single year.

Huh? So it's healthier to have patients that never see the doctor? I'm not sure there are many fields in which prevention per unit provides higher margin and revenues than repair and recovery.

You can’t divorce poor life choices from the economic context they are made within. These are complex issues, but is it controversial to say that people are more interested in investing in their health when they have less stress and more opportunity?

Likewise, you aren’t going to get a healthcare system which can make a meaningful impact on improving the lifestyles of the kinds of people you’re talking about without changing the current economic incentives.

> Without tackling the obesity/sedentary/nutrition problems the healthcare issue will persist.

Without healthcare system improvements, you aren't going to succeed in tackling those.

But, yes, it's true that there are more problems with US health than the health care system (though the issues in the broader economy that are at issue are very similar to those effecting the helathcare system.)

What kind of improvements?

I imagine being able to go to a doctor without worrying about whether they can afford the copay. Wellness is as much about needing a coach as it is a medical practitioner.

Ban advertising of prescription drugs to the gen pop

It's certainly true that the health care system in the US is bonkers, and there are manifest injustices in how things work, but it also represents an enormous failure in public health efforts. 4/10 US adults are obese. Only 30% of the country manages to not be overweight!

The absence of good public health initiatives is also the result of the fractured, poor quality, expensive, private healthcare system in the US.

That doesn't at all follow. People aren't fat and out of shape because health care (aka being able to see a doctor) is private or because it sucks; they are so because it isn't considered a national priority like it was at one point in US history. How many people graduate high school knowing how to take care of their bodies?

For example: https://www.youtube.com/watch?v=fISgKl8dB3M

You can have the best healthcare in the world and it won’t overcome modern lifestyle choices.

I spent the last week in 4 different states and airports. The BMI variety between them was staggering. Diabetes rates aren’t soaring because some healthplan is expensive.

People blame opoids like they’re causal. Those people have always been in physical agony, there’s just a magic pill now for their disability and as more people make worse choices that population is only going to grow.

Until K-12 diets and physical activity become mandates I don’t see how we get ahead of this problem with tech or cheaper healthcare.

The dirty secret is that for profit healthcare runs the rest of the world. The majority of new drugs are created in the US and nations that have government-run healthcare create generics by ripping off/taking the IP and creating cheap alternatives. This is the only reason drugs are cheaper in other parts of the world.

The R&D, which costs millions (and sometimes billions) still needs to be paid for by someone..and the government just isn't efficient enough to do this effectively and within a decent time frame.

The problem isn't for-profit healthcare. The problem is the insurance companies. They create an un-needed middleman that inflates the cost of everything. A better alternative would be to get rid of insurance for most things, allow doctors and hospitals to charge directly to consumers (which would bring the costs way down).

Surgeries would also come down in cost because of competition. The ones that don't come down are most likely because they are rare and have little competition. These can be covered under insurance.

> The majority of new drugs are created in the US and nations that have government-run healthcare create generics by ripping off/taking the IP and creating cheap alternatives. This is the only reason drugs are cheaper in other parts of the world.

So all those Swiss, German and French pharmaceutical companies are a figment of my imagination then.

I've had this debate on HN many times before. Look at every WHO essential medicine developed in the 21st century. All but one was developed in the US. The only one that wasn't was developed in Japan. That's just pharmaceuticals. The same plays out with other innovations in medical treatment such as medical textiles used in vascular implants or even wound care dressings as simple as Tegaderm from 3M.


I'm not even sure if you even read that list, given that it has tons of medicines that were discovered by researchers working for Roche, Sanofi, Chugai, and GlaxoSmithKline.

And the information on the pharmaceuticals involved fails to mention the feeder research that comes from universities in Cambridge, Zurich, London, Tokyo, etc. Most of this had gigantic participation of state research institutions, and if you look at the American pharma companies, almost all are based and house most of their research efforts in the state of New York and New Jersey, Massachussets, and the Bay Area, to the exclusion of pretty much everywhere else.

That makes for a great case of the utility of the well-funded research universities in forming staff for pharma, but it's not exactly a proof that any particular model of funding for pharma works better than others.

It's also interesting to note that most of these pharmaceuticals target and _incredibly small_ number of people worldwide at outrageous costs. Not to take merit away from the huge research efforts, but honestly it just shows where profit-driven research efforts go instead of rational, nation-wide public health initiatives that are objectively far better at increasing quality of life for entire populations.

> I'm not even sure if you even read that list > Roche, Sanofi, Chugai, and GlaxoSmithKline

Yes, at their US research labs. Most of these companies do a lot of their research in the US these days and continue to move more R&D to the US. If it's developed in the US by individuals working in the US because the opportunities are in the US, that makes it a US-developed drug. I went through each and every WHO essential medicines drug developed since 2000 and verified where each was developed.

> It's also interesting to note that most of these pharmaceuticals target and _incredibly small_ number of people worldwide at outrageous costs.

As someone that uses an orphan drug developed in the US to improve my quality of life, I'm glad. Do you want to take that option away from me and others like me?

> As someone that uses an orphan drug developed in the US to improve my quality of life, I'm glad. Do you want to take that option away from me and others like me?

I don't believe that medicine is a zero-sum game, but I _really_ wonder if a country where thousands of people die from not being able to afford relatively accessible medication is spending its money wisely.

For what it is worth. I've been taking this medicine for the last 2 decades. It was only recently made available in Canada and Italy. It's available in no other countries.

It's not zero sum, but there absolutely are tradeoffs and everyone championing the national healthcare model used in countries like Canada and those in Europe are being willfully blind to the collateral damage to US-developed medical innovation.

When thousands of people die because treatment doesn't even exist for them, where is that accounted for? My father has a disease that he is likely going to die from and most of the research done on that disease is done in the US and almost everything I read on this disease is published by US-based researchers.

The United States spends the lion's share (>50 percent!) of R&D money on pharmaceuticals worldwide.


Given the marketing budgets of pharma for direct-to-consumer marketing in the US, which is a complete abomination, I'm not exactly convinced that they'll be running out of cash for research. Not to mention that R&D expenditure can be trivially gamed for tax avoidance purposes.

Not to mention the hundreds of millions of dollars in NIH funding and public university research that makes any of these drugs possible in the first place.

I find the public vs private debate unfolding here extremely interesting, but I have no idea about it. What are your sources? Where can I learn more about the contribution of the private sector to healthcare, the returns on their investments, and how insurance companies affect that equation?

So let's say the worst case scenario happens, and 500,000 people do go bankrupt due to medical expenses every year for a while. Let's say this happens pretty consistently over 10 years. How will that affect the broader political landscape, economy and society?

Your healthcare costs more, and the lives of 500k people suck more than they needed to.

500k people per year would be bankrupt and basically ineligible for credit, probably unwilling to work if all their wages get garnished to service medical debt, yet ERs still can't turn these financially crushed people away.

So I think at some point or threshold there will be more elaborate effects than simply "healthcare costs up, people's lives suck".

So, first thing I see is a Public Health crisis.

The medical profession is cripplingly dependent on trust. Decreased faith in the goodwill of medical practitioners may lead to people not doing things that have major impacts non overall public health, like getting immunizations.

I'd expect a potential rise in suicide rates due to mental problems becoming more prevalent; if not because of escalating paranoia due to "don't get hurt, you can't afford the medical costs", then due to the over-time integration of the assumption of not having any societal value assigned to some injury being fixed. I think this is an oft overlooked aspect of the social experience of having a problem. There are many who look at people with medical issues that are dismissive that it must somehow be all that person's own fault. While the argument can be made in some cases, in the case where you can't afford medical treatment, the message is sent that your (the injured party's) suffering doesn't matter at a social level unless somehow you can demonstrate you can produce X amount of worth where that worth becomes at least strongly correlated to some significant fraction of whatever the Medical Industrial Complex decides.

It is funny, because I'm reminded of the story Erehwon, where physical ailment vs. Social ailment was flipped around in how it was handled. If you had a chest congestion, you'd be locked away in a prison, away from everyone else, but moral failings like stealing things were not crimes, but things treated as being in need of slight adjustment. The argument put forth against "Doctoring/Medicine" in the story is that eventually, a medical Doctor would accrue too much power over too many people's lives. It seemed ridiculous to meat the time; but as I look at what we have now, I see echoes of it.

If you can't afford to exist in the system, you are cast aside. Can you receive treatment? Yes. Will you financially weather that storm without the advantages of full-time representation, negotiation, and legal counsel? No.

"First, do no harm" means something; and harm comes in many forms nowadays. I know not where the capacity for ruinous financial inflation is being introduced; the exorbitant costs of medical schooling, the production and certification of medical equipment/research, administrative overhead and profit skimming; but it needs to be addressed and evaluated at each point.

Prescription drugs are a start, but the entire infrastructure needs an audit and readjustment in my opinion to bring it back within some semblance of sane operating parameters.

Not to diminish the argument that it would cause huge problems. But federal law limits wage garnishment to the lesser of 25% of disposable income or income over 30x the minimum wage.

More like laws would be passed where ERs can turn away people in favor of some shitty hospitals that can't actually fix any issue but just give out bargain bin painkillers.

It can always get worse

I dunno, maybe you would see things like sharp curbs in life expectancy among middle class people. Or a rise of reactionary politics that cynically (but not falsely) targets affluent liberals who turn a blind eye to the suffering of the poor...

Private health insurance and lack of universal public health insurance that is.

All doctor offices in Canada are private corporations, for whatever reason the hospitals are not and that is where the worst of our problems lay.

Care to expound?

But from 2010 to 2017 (the cited years) are the years of the ACA.

Was it a failure?

Unpopular opinion but I think the ACA did more to cripple hourly workers than any other legislation in history. The mandate to provide healthcare to anyone working over 30 hours resulted in work weeks being cut to 29.5 hours for many

Do you have data/citations? I could believe this happens, but would like to see data on how wide-spread an impact this is.

There are always consequences and tradeoffs - if we had actual numbers about the magnitude of the impact, we could start to discuss if ACA was worth this particular tradeoff.

The fact that our healthcare system is messed up is not synonymous with getting rid of profit.

Every time something is screwed up in the US, there’s a bunch of people who scream “See! Capitalism!”

This, to my mind is unproductive and rather transparent advocacy for an underlying ideological inclination.

Sometimes things can be fixed without resorting to “Socializing” them.

Here’s something broken under a socialized mechanism: every piece of NYC infrastructure.

I find it interesting that your condemnation of unproductive ideological advocacy is couched within a hyperbolic rant wherein you seem to assume the privilege of having your words taken metaphorically and not literally ("every piece" of NYC infrastructure is broken, implicitly due to "Socialism"; people are "screaming" about the ills of capitalism) while simultaneously refusing to extend that same privilege to the people you decry. Whatever your intentions, your use of bad-faith argumentation practices reflects poorly on your stance and mirrors the condescending messaging employed by advocates of the obviously untenable status quo. I claim that your comment was written in bad faith because it feels both divisive and derisive and makes no attempt at offering a bridge of understanding for balanced discussion to occur.

"This, to my mind is unproductive and rather transparent advocacy for an underlying ideological inclination."

And you're not ideologically inclined in the opposite direction?

Look at what is already socialized: fire departments, court system, police service, the three-letter agencies, military, politicians presumably?, a lot of education (despite student loans), a chunk of the health service already, road network, probably a lot more things.

I put it to you – given that so much related to the public good is publicly funded and given that examples from the rest of the world abound that public health services are cheaper why wouldn't you socialize the bulk (> 90%) of health.

Clearly, to my mind, the reason why it hasn't yet happened in the States is down to government capture, a.k.a. lobbying, a.k.a. legal bribery.

Healthcare has little to do with health. Its this thinking that is the reason why Americans are declining in quality of life.

Stop blaming the other, its not making you stronger or better. Better healthcare will not stop you from drinking too much , eating too much, not exercising enough. No drug is going to fix your social anxiety. Drugs fix symptoms not causes.

This "health disadvantage" what is it exactly. I bet its lung and diabetes issues. We do it to ourselves. Once you accept that you will see the fix. Its not some billionaire giving you money , it you not giving money to the drug dealing (alcohol, unhealthy food, weed/tobacco/vape) billionaires and getting active.

Religion used to be a good way to get out before, a secular nation needs to find a similar motivation that gets people out of their houses. Maybe the worst drug is the media keeping us planted in our chair. Either way I dont trust the gov. so even if we put more money into "healthcare" they would fuck it up. Prove me wrong.

"No drug is going to fix your social anxiety."

But access to afforable medicine will definitely fix a big chunk of my anxiety about not being able to afford medicine!

"I bet its lung and diabetes issues."

It's really hard to take care of diabetes in america, due to the costs of adequate insulin and related medical purchases such as bloodwork and glucose testing devices.

This is a diversion and a false dilemma. What you're saying is not wrong in that people should live healthy lifestyles, but it is also true that the health care system is now strongly disincentivizing preventative care, early treatment (or any treatment) in a way that can lead to increased mortality.

> For profit healthcare in America is devouring its people and economy, full stop. We can either have a society where half a million people go bankrupt from medical debt each year, thousands die from treatable illnesses or lack of access to medicines, while hospital CEOS and insurance execs walk away with millions, or we can have one that excises their parasitism like the rest of the developed world figured out was necessary decades ago.

The majority of the world still has, to my knowledge, for-profit health care: Britain, Germany, France, Switzerland , Sweden and Italy all have at least some form of private health care.

The United States definitely have a problem with health care prices. It doesn't appear from where I sit to be an issue with individual bad actors (although of course they do exist) but rather structural. In part, the well-intended federal and state attempts to improve things have backfired — as they tend to do — and made things even more expensive (which reminds me of federal student loans, another instance of well-meaning attempts to help the lesser-off which somehow seem to benefit the upper middle classes most of all; cf. also federally-subsidised mortgages).

> The majority of the world still has, to my knowledge, for-profit health care: Britain, Germany, France, Switzerland , Sweden and Italy all have at least some form of private health care.

While private health care exists in all of those countries, and in some of them it's a significant part of the system, a lot of what exists isn't actually _for-profit_.

For instance, in Ireland we have a dual public and private system (primary care is private unless you're old, very young, or low income, private hospitals exist as an option), but most of the private system is either outright non-profit (most private hospitals, the statutory VHI health insurer) or is heavily constrained by the existence of the non-profit portion and regulation (private insurers have to compete with the VHI, and are not allowed charge risk-based rates for most customers).

in Germany, the actual doctors office that treats you may be a for-profit, but they get the cash from your (mandatory) insurance, and the law regulates what kind of treatment is essential and therefore included in the mandatory healthcare plan. You can have a private healthcare plan that gets you extra treatment, or pay yourself for it. But it's really Stuff you can live without.

another example, in Russia, you have _theoretically_ the same system, but the level of treatment covered by the mandatory insurance is totally insufficient by any reasonable modern standards, so you have to pay all the way. And it's not about debt, it's often about not getting live-saving treatment before you cash out.

The issue has never been whether private healthcare providers should be allowed to exist.

The question is whether a good publicly-funded alternative should be available, to allow everyone treatment for the vast majority of conditions and illnesses that are lethal or significantly affect quality of life.

Most countries that have the latter, also turn out to have much cheaper healthcare overall.

This system doesn't solve or treat every problem, and the US system manages to provide better quality of care in some cases, but there's a serious morality issue here that it does fix. Along with many pragmatic socioeconomic benefits (e.g. healthcare for retirees, early-stage and failing entrepeneurs)

Private health care exists in the UK but the NHS is public, though there are attempts to change this [1] as apparently the US model is considered something to emulate. I definitely wouldn't use the UK as a comparison to the US' private system as the funding models are completely different.

From the outside it seems that government attempts to shape the market (by the measures you mention) seem to work out worse and more expensively than measures to make the market (e.g. NHS). We have this in the UK with the government providing subsidies to buy private houses rather than just build enough public houses. I'd be interested in some economic insight into this if anyone has any.

[1] https://www.theguardian.com/society/2019/nov/08/private-surg...

IIRC the issue is not that private healthcare exists in first world countries. The major issue is that private healthare is the primary healthcare insurance provider for USA citizens.

The countries you listed are all dominated by public health care systems. The NHS in the UK is entirely public (insurance and providers). The other countries have public insurance that covers everyone, and a mix of public and private hospitals. It's a bit complicated in Germany and Switzerland, where there are multiple semi-public insurers, but those insurers are so heavily regulated they're basically public entities (price, coverage and payments to providers are all fixed by government).

> at least some form of private health care.

a very tiny proportion of them yes, in the US the whole thing is private

> the whole thing is private

The US has several public insurers.

About 72 million Americans are enrolled in Medicaid or CHIP.

About 60 million are enrolled in Medicare.

The MHS covers about 9.5 million people.

The IHS covers another 2.2 million people.

insurance is not the same as e.g. UK NHS which is wholly run publically

The US occupies the large gap between "wholly run publicly" and "the whole thing is private". Besides public-payer insurance, there are government hospitals in the US too.

21% of US hospitals are government owned.

at teh government owned hospitals, do people still use "insurance"? or is it free at the point of use? what criteria applies to treatment there, limitations etc?

It all depends on which program/hospital/patient/government we're talking about. Everything about government in the US is fragmented.

Scenarios range from completely free at the point of use, to 100% out of pocket, and everything in between.

The 5 programs I mentioned above are just the largest federal programs. States and localities in the US often implement their own programs. There are hundreds of government healthcare programs that someone in the US might take advantage of, depending on where they're at.

The problem with healthcare in the US is not that there is no government healthcare initiatives. The problem is that we have too many. Fragmentation is inefficient and expensive.

Governments in the US spend $4,854/person/year on healthcare. The NHS spends $4,192/person/year.



The US private healthcare system has lots of problems and I'm not trying to defend it. However, the public European model is very misleading. The reason is that most people who can afford it pay for private insurance, even in Europe. Otherwise they need to wait months for a doctor appointment.

A couple of thoughts:

1. In the UK the number of people with private medical insurance was (a couple of years ago) around 12% (according to one source). I don't know anyone who has it personally, I don't (and I can afford it). Do you know what the figures are for other European countries?

2. Is it possible that having a (relatively) cheap and functional state provided health care system keeps insurance costs down? If you're charging some large amount of money for health insurance and the alternative is effectively free* then you'd think that people wouldn't bother with it.

* you pay for it anyway in taxes, it's not a lot of money, or it's free, depending on your income level.

According to the WHO the rate for the UK is 3.4% – the reason why you personally don't know anybody who has it is because hardly anyone (1 in 33 people) has it.

source, WHO: http://www.euro.who.int/__data/assets/pdf_file/0005/310838/V...

> However, the public European model is very misleading.

The phrase “the public European model” is misleading, because there are lots of European models which provide universal healthcare, and while almost all of them involve a vastly greater public share of all expenditures than the US system which fails at universality, in some, IIRC, a substantial share of that is through publicly subsidized private insurance. The British model is not the French model is not the German model, etc.; the two things they have in common is universality and not being as ludicrously inefficient as the US model.

Germany ringing in: nope, we don't.

Who cares if you have to wait 3 days or 3 months? What matters is outcomes. If you wait three months, are properly treated and have a good outcome, that is a healthcare success.

If you wait 3 days, go deep in to debt, and get the exact same outcome, how is that better?

Obviously, people are not dying as they wait for their appointments throughout Europe. Otherwise their health metrics would not be so consistently better than in the US. Maybe focusing on wait times is not the right way to look at the issue.

How healthcare works in Europe changes quite a lot per country. Which country specifically are you talking about?

Ones I know of based on friends and family are Israel (follows the European public healthcare model) and Spain. I'm not saying it's the same everywhere in Europe, but I wouldn't be surprised if it's the case in many European countries.

In Spain the rate is 4.4%

Israel is not in Europe, but anyway the rate there is 10.3%

This indicates to me that the circle of people that you know is not representative of the population at large at least when it comes to health insurance coverage.

There's no need to infer statistics about the whole of Europe from your small sample size. All you have to do is look up† the data.

Page 4 (Figure 2.1) here: http://www.euro.who.int/__data/assets/pdf_file/0005/310838/V...

The majority of countries (38 versus 11) are below 5%, only 5 are above 10%


† I googled: percentage private health insurance european countries

I guess it depends what qualifies as private insurance.

See Figure 7.2: https://www.oecd-ilibrary.org/docserver/health_glance-2015-3...

Israel is 83% and not 10%...

Figure 7.1, Health insurance coverage for a core set of services – Percentage of total population

Total public coverage: Israel 100%

Figure 7.2, Private health insurance coverage, by type, 2013 (or nearest year) Note: Private health insurance can be both duplicate and supplementary, in Australia; both complementary and supplementary in Denmark and Korea; and duplicate, complementary and supplementary in Israel and Slovenia

Israel: type = Supplementary = 82.9% .

What is supplementary?

“Most OECD countries have achieved universal (or near-universal) coverage of health care costs for a core set of services, which usually include consultations with doctors and specialists, tests and examinations, and surgical and therapeutic procedures (Figure 7.1). Generally, dental care and pharmaceutical drugs are partially covered, although there are a number of countries where these services must be purchased separately (OECD, 2015)”

“Private health insurance offers 95% of the French population complementary insurance to cover cost-sharing in the social security system. The Netherlands has the largest supplementary market (86% of the population), followed by Israel (83%), whereby private insurance pays for prescription drugs and dental care that are not publicly reimbursed.

So this doesn't mean that 83% of the market is private, you understand? It means that 83% of the market (whatever that market is) that isn't covered by government access is covered on a supplementary basis. How large is that portion? If you look at the 2019 publication: https://www.oecd-ilibrary.org/docserver/4dd50c09-en.pdf?expi...

Figure 7.11. Health expenditure from public sources as share of total, 2017 (or nearest year)

Israel: 64%

What's important here is that the % in the US (wealthiest country in the world) is 50%, far below the OECD average of 71% which is the point being made here.

don't view the world through the anecdotes of your friends and family. They are not a representative sample of the world's population. When quoting statistics make sure they are the correct ones.

> Ones I know of based on friends and family are Israel (follows the European public healthcare model)

While every developed country (and every OECD country, which are overlapping but distinct sets which are not subsets of each other in either direction), except the US in both cases and maybe Mexico in the OECD case, as I've seen sources going both ways on Mexico and universality, has a healthcare system providing universal access to comprehensive medical care with a substantiallty larger percentage of total healthcare funding coming from public sources than the US (though often not more per GDP or especially per capita public spending), there is not, whether in Europe or more generally, single model for this, there are many, fairly radically divergent models from the government-as-provider model of the UK NHS, to the government-as-exclusive-insurer-of-core-services, to mandatory-and-need-subsidized-insurance-with-a-default-public-option, among others.

So, except for “don’t emulate the US’s broken system”, there is nothing even approximating a single “European public healthcare model”.

Nope. My grandmother and extended family in the UK received great, high quality care as working class people for all of their lives. There have been more issues with access to care since right wingers started attacking and defunding the NHS, but hopefully Corbyn will soon put an end to all of that.

> hopefully Corbyn will soon put an end to all of that.

Unfortunately it is very likely that this will never happen. Realistically we're getting Boris as the next Prime Minister.

To be clear, I don't want this, but Corbyn getting in is a long shot. The best thing he could have done for the Labour party and the left in general was to stand down years ago.

The Tories in the UK have been following the "starve the beast" strategy: constrict funding to the NHS until the system starts to fall over, and then argue that privatization is the solution.

> And while suicides, drug overdoses and alcoholism were the main causes

It looks like there is increasing mental health issues that aren't being addressed. This seems to get blown past too quickly.

We tend to look at the medical side of things and the way the healthcare system works. But, somethings have changed that caused the mental heath of many to go down. Will changing the US to single payer or medicare for all change the mental health problems? Given the research I've read it's highly unlikely.

Can we please put more time into understanding and addressing the increasing mental health problems? This is important for forums like this because studies have repeatedly found we have a hand in it.

Don't you think these things are directly related?

A friend of mine had some minor mental health issues going into their 20s. Lack of meaningful opportunity paired with obscenely expensive and inaccessible healthcare helped drive those to become major health issues, including drug addiction, due to intoxicating themselves to "help" distract from their grim reality.

Absolutely I think it would have been different had they had access to general preventative healthcare from the start so they could get routine dental, physical, etc. Would they be cured of their mental health problems? Probably not. Would the effects have been less destructive? Yeah, I would bet on it.

> Don't you think these things are directly related?

From what I've read there isn't a strong relation between them. Some of it is obvious. The system has been roughly the same for many years but the change happened to mental health anyway.

As I start to read studies on it I learn there are other factors affecting mental health.

The people who study these things are predominantly saying it's related. Why should we think it is?

The universal health care proposals by Bernie Sanders and Pramila Jayapal include mental health and substance abuse treatment services.

https://www.congress.gov/bill/116th-congress/senate-bill/112... https://www.congress.gov/bill/116th-congress/house-bill/1384...

Why does everyone think this will help? Don't we already have more mental healthcare than ever before? Why is the assumption that even more would help?

What was mental healthcare like 30, 50, 100 years ago? Was there a lot more of it back then? Why do people attribute the suicide and drug use to lack of care? It seems like the most extreme dodge of actual issues to paper over it with yet-more-healthcare. For all we know, none of what we have already is really helping, and more won't help more.

We have more food on this planet than ever before, yet people still die of starvation. All of the advancements in mental healthcare in the world are meaningless if the people who need it cannot access it, which, in our current system (at least in the US) of employer-provided healthcare, is generally the case.

In the past 10 years there has been a 2.5x increase in teen girl suicide rates. Those kids can either get healthcare through their parents employers or though other means if their parents can't provide it.

Those kids have access to health care.

How many of the parents know how to spot the problems? Do they know when to get their kids into a professional?

Researchers have documented many of the causes yet we rarely talk about them or do anything about them. For example, smart phones and social media are a major factor. This was first correlation and then researches later figured out the causation.

How come we don't even talk about what's causing this?

Looking just at the means by which we get healthcare isn't going to fix all the things. We need to talk about the other elements and do something about them if we want change.

I'm contesting that access to healthcare is the problem at all. I don't think it is. I think all available evidence we have, including historical OD rates and the like, point to "other things" being the problem.

Maybe access to more healthcare would help, though the US already uses more healthcare than almost any other nation, but I suspect, like the rest of health, the real gains are to be found elsewhere, and this is a huge canard so people can feel like their pet political policy will solve something real.

We have other developed countries we can compare to. Also, you can consider the lack of care as a smaller part of the general economic anxiety that plagues the areas described in the article.

Stress and mental heath are strongly linked. So, the current system with it’s high costs and uncertainty is actively making things worse.

On it’s own it might not make a huge change, but in aggregate this is a significant effect.

These are diseases of despair. The financial inequality in this country is literally killing us. Sure there are other mental illness issues, there always are, and always will be. But this inequality is the root of the issues causing the . declining life expectancy. If the average person can't feel somewhat secure in their life, like they aren't completely struggling and beat down just making ends meet, if we are living one paycheck away from homelessness or bankruptcy, buried in debt from student loans, medical bills, credit card debt, mortgage etc... Most people can barely stay afloat, let along save for retirement, and have time to actually feel relaxed and able to enjoy their lives. What do we expect from this situation? A healthy society?

They are diseases of despair, and that is key. (have an upvote)

But casting this as primarily an issue of financial inequality seems misleading. I wouldn't feel one whit less awful if everyone in the country was poorer than me.

It's absolute want that matters. If you can't afford medical care for your kid, it doesn't matter whether or not anyone or everyone else can--you're still going to be devastated.

> Given the research I've read it's highly unlikely.

Can you expand on this? I see a pretty direct line through an unpayable medical expense, inability to afford housing, and declining mental health from all of the associated stress. Add in the unpredictable nature of health scares and that seems like a terrible mixture for mental health.

I'll start with one example. The rising suicide rate. Since 2010 there has been a large increase in teen girl suicide rate. A significant cause of this is social media and smart phones. This has to do with bullying, comparisons, and other things. [3]

Now take a place like Texas where the homeless population has decreased [2] in the same window the suicide rate has gone up [1]. This is just an example.

I know there is a lot of political talk on some of this. I would suggest taking some time to read the data which is prevalent. You can easily find it with search engines.

> I see a pretty direct line through an unpayable medical expense, inability to afford housing, and declining mental health from all of the associated stress. Add in the unpredictable nature of health scares and that seems like a terrible mixture for mental health.

Can you point me to some research on this? Data researchers have observed? I've not seen this.

[1] https://www.utsystem.edu/sites/default/files/news/assets/Sui... [2] https://www.thn.org/wp-content/uploads/2017/05/2016-Infograp... [3] http://www.jeantwenge.com/research/

Your original comment claimed that research suggests that improving access to healthcare is "highly unlikely" to change the state of American mental health.

I'm not following how this second comment makes that case. It looks like you are extrapolating from "social media use causes poorer mental health" to "access to healthcare and housing are less important to mental health than social media use". The statistics and studies cited don't make this claim, so I don't understand where you're getting it from.

I have no studies in mind that connect mental health and access to healthcare and housing. I was curious if you had studies suggesting the opposite, since the connection appears almost tautologically true to me.

To use an analogy... when people were smoking a lot of people got lung cancer. Doctors can try to treat that and many people died. Access to health care did not mean that everyone who got care was cured of their lung cancer. Instead, people had to go to the root of the problem. Smoking causing lung cancer. They worked to reduce the rate of smoking to reduce the rate of cancer. This was not related to someone's access to medical treatments because access to medical treatment wasn't a silver bullet fix.

The same idea applies here. We talk a lot about healthcare access (and I'm not suggesting that should stop). We don't talk enough about going after what's causing the mental illness and fixing that.

> A significant cause of this is social media and smart phones.

We don't know this, and your comment is not supported by your link. Suicide is a complex phenomena and to distil it down to only social media feels a bit reductive.

One interesting rabbit hole is that children who live with and are raised by both parents have very low levels of mental health issues.

Currently, less than half of the children in the U.S. being born will experience this.

The lack of empathy and solidarity is only growing in the U.S. so this problem won’t be solved any time soon.

I have a more optimistic view. Bernie Sanders’ campaign explicitly asks people if they are willing to fight for people they don’t know, and his campaign has the largest donor base and the biggest rallies.

I love Bernie and I voted for him in the 2016 primary... that said, I won't be voting for him in 2020. He's not indicative of some great revolution, of some kumbaya moment...Sanders is going to get less than 20% of the vote in the primary and, as a socialist, he is hated and a non-starter for 30% of the populace who rabidly support Trump.

Bernie, Biden, Trump: We do not need elderly presidents. 80 year olds are scientifically proven to be cognitively declined relative to younger individuals. They are much more likely to die in office, more likely to have memory issues, slower to comprehend new things, and are just much more out of touch with the average citizen.

So, while I laud Bernie's character, I don't think a 77 year old man being preferred by less than 20% of one half of the electorate is cause for optimism.

Who do you recommend, since you like the policies but not the candidate it appears?

For the primary: I don't know, to be honest. I really don't want to vote for anyone so elderly, you can see with Trump and Biden that their cognitive capability to form words and give good speeches is pretty lack luster.

For the general: Whoever is not Trump, they are all superior in myriad ways...the only Dem who isn't superior to Trump is Marianne Williamson, because she's just as qualified and sensible as Trump.

Key quotes for me:

> Dr. Woolf said one of the findings showed that the excess deaths were highly concentrated geographically, with fully a third of them in just four states: Ohio, Pennsylvania, Kentucky and Indiana.

> “What’s not lost on us is what is going on in those states,” he said. “The history of when this health trend started happens to coincide with when these economic shifts began — the loss of manufacturing jobs and closure of steel mills and auto plants.”

> The increased deaths from drug overdoses reflected increased rates of addiction to opioids. But they have also risen because of changes in the drug supply in the East and Midwest. Over the last decade, the synthetic drug known as fentanyl has been mixed into heroin — or in some places has replaced it. That has made the drug supply more deadly, since it is difficult for users to know the dose they are taking.

> Life expectancy in the coastal metro areas — both east and west — has improved at roughly the same rate as in Canada.

These together point to me to local crises: people in hard times due to economic shifts turning to drugs, etc, as an outlet.

There are many ways to improve the lot of these people, but being blind to the cause does not help them. Also let’s be clear about the scale of the problem:

> While the total number of excess deaths — meaning the number of deaths that would not have happened if the mortality rate had continued to improve — is small, at 33,000

For context, total overdose deaths are ~70,000/year. https://www.cdc.gov/drugoverdose/index.html

Anyone who has followed presidential candidate Andrew Yang knows this. This is why he wants the "American Scorecard" which consists with indicators including life expectancy, suicide rate, drug overdose rate...rather than things like GDP, unemployment.

The country is not healthy. Until we put these numbers in the forefront, we will keep trying to just increase GDP at the cost of people's lives.

How happy are you? Truly, ask yourself. Think back and think of how things have drastically changed in society.

This is telling of a world that cares more and more about the "economy" then they do people. With little to no focus on living and so much emphasis on "success," "Business," and "economy."

Work with little pay, a buy in club for access to healthcare and no work/life balance in many jobs. It does not surprise me even the smallest amount. Health insurance (at least in the states) is more like a Costco membership. It just gives you access to healthcare.

Healthcare profits have been in decline so I don't think it is about the "for profit" system as much as it is other things in our environment (work/natural.) I think this is more telling of how our culture chooses to live and has structured the work environment.


The CDC report gives a much better view of these findings [0]. I would really suggest reading the report. It is not jargony and takes maybe 15 minutes to zip through. They really put a lot of time into making it accessible and it shows.

In reading that report some things that I noticed are [1]:

Pg. 8: Alzheimer's Disease caused deaths for both males and females increased a fair bit! And for males, Unintentional Deaths also increased recently. Note that the Y-axis is in a LOG scale; any movement upwards is a lot.

Pg. 10: Yeah, Juul and the like really are hurting children. Grades 2 & 3 Obesity are increasing too. Both are not good.

Pg. 11: Asthma in black children has gone up a fair amount.

Pg. 14: West Coast and Virginian essential vaccination is under 2/3 babies (3 years or younger). That is WELL below herd immunity. New England, Deep South, and Plains states are above 3/4.

Pg. 21: Ages 15-44 have seen an uptick in mortality. Note: The y-axis is in LOG scale, so it's been a fair bit of an uptick.

Pg. 22: A big uptick in infant mortality due to unintentional injuries.

Pg. 23: ... Jesus ... a huge increase in child suicide rates and an increase in teen homicide and suicide rates. Note: The y-axis is in LOG scale.

Pg. 24: HIV deaths are WAY down (!), unintentional injuries and liver cirrhosis are up.

Pg. 25: Alzheimer's deaths in the elderly are up a fair amount.

pg. 26: Holy shit ... overdose rates are just ... wow ...

pg. 27: Appalachia and New England ... good Lord ... I mean, you hear things about it all, but wow.

pg. 29: Cirrhosis deaths in middle aged men are really climbing. The booze, it ain't good.

BTW here's the scihub link for the JAMA article that the NYT is talking about: https://scihub.bban.top/https://jamanetwork.com/journals/jam...

[0] https://www.cdc.gov/nchs/hus/index.htm

[1] this is mostly a summary that I posted here 38 days ago when the report first dropped. Seriously, just read the CDC report!

> pg. 29: Cirrhosis deaths in middle aged men are really climbing. The booze, it ain't good.

The vast majority of cirrhosis is not related to booze, about 80% of it is caused by hepatitis.

> Pg. 14: West Coast and Virginian essential vaccination is under 2/3 babies (3 years or younger). That is WELL below herd immunity. New England, Deep South, and Plains states are above 3/4.

It's disgusting what is happening. Parents from the most educated places in the nation are knowingly putting others at risk. If those states can justify a sugary beverage tax they should be able to justify a tax on antivaxers.

When you say: >Note: The y-axis is in LOG scale What does this mean?

It runs by orders of magnitude, e.g. 1, 10, 100, 1000...

The way things are going in the US are unsustainable and I'm not even talking about the impending climate problems. What is going to give out first and how long will it take?

If we don't fix healthcare costs it'll be that in 5-15 years, just looking at the increases in costs year over year. It's strangling the economy.

After that we very likely have a (lack of) retirement crisis coming in, I reckon, 15-30 years. I'd guess there'll be a concurrent falling off of generational passing-on of wealth (inheritance) that'll compound the issue and ensure it lasts much of the rest of the century. This'll be way worse if all we've managed to do with health care costs is hold them at their already-too-high levels, rather than lower them.

The worst risk is that crises aren't always blamed on the right people/issues, and sometimes end up causing scary shifts in the politics of a state (watch as I carefully avoid Godwinning the thread)—I suspect the mobility of wealth and how much money is in the hands of effectively stateless corporations will make any such occurrence rather more interesting than it has been in the past in the US, e.g. the Great Depression, as incentives for various actors may not be aligned the same ways they have been. One hopes the phrase "feeding frenzy" won't apply, but it seems possible.

Wouldn't less people reduce our carbon footprint? Thinning the herd (particularly the obese) may be what the world needs to combat climate change

“In the northeast and midwest” should be appended to the title.

California experienced negative growth. Texas, Georgia, Florida, Oregon, Washington “0-5% growth”.

Dr. Woolf said one of the findings showed that the excess deaths were highly concentrated geographically, with fully a third of them in just four states: Ohio, Pennsylvania, Kentucky and Indiana.

“I’m not sure the dramatic, ‘there’s something desperately wrong with the entire country’ narrative is entirely accurate,” Dr. Harper said. “Certain groups, such as Hispanics and Asians, are doing O.K. It’s not like the entire country is being subsumed by a single social phenomenon that can explain all of this. There are a lot of moving parts.”

I don't think people realize the increased mortality of being on the upper end of the (literal) scale.

Here's a journal article:


but to summarize BMI vs years lost:

  BMI    40-45   45-50   50-55   55-60
  men    -6.5    -10.8   -10.6   -17.0
  women  -6.9     -9.1   -10.3   -13.1

It's unregulated capitalism. Jobs are dead end unless you have advanced degrees which eliminates a huge portion of the country. Most jobs require you to be sedentary in office and work long hours. 70% of the country is living paycheck to paycheck. The healthcare industry is profiting massively at the expense of the population. Politicians have been purchased by big biz so this will not change. It's just going to get worse.

Is there something us devs with money to throw around can do to, well, not fix, but alleviate the insurance gap? Perhaps there could be a large pool we could pay into, that people could spend solely on necessary medical care.

Are you proposing a secondary level of insurance for a failing primary insurance system? Won't that just make it worse?

Everyone's got their own opinion about what is to blame for this, I'll toss mine in.

I see a lot of people with stress and despair related problems such as high blood pressure, heart disease, obesity, alcoholism, drug use. Diet can be an issue as well but diet problems on these come from stress management tactics, it's not the diet that's the root cause here.

Currently a major source of stress is the general political atmosphere of endemic bullshit, violence, fake news, lies, shout downs, cancel culture, cover ups, self dealing, and all this on both sides. And if you say both sides both sides jump down your throat trying to bullying you into agreeing with them their side whatever it is is perfect and the other side are literal demons who need to exterminated. By not agreeing only one side is at fault, then you as well are labeled a demon worthy of extirpation as well. Choose sides or be cast into hell. But choosing either side is to buy into a delusion.

Another cause of poor health has been mentioned: the health care system really is shit for most people. My insurance runs over $20,000 a year for a really crappy policy that doesn't cover anything since everyone is out of network or there's a copay that is more than the cash price, meaning I just pretend I don't have insurance to save money. Any hospital emergency I can be assured that either the plan doesn't cover the hospital at all or doesn't cover the people working there. In network coverage for anything involving more than one person doesn't exist. And although many doctors are good people and competent a lot more are money grubbing and incompetent, having practices managed or advised by MBAs with maximum profit as the sole motive. Specialists are particularly hard to get ahold of and charge absurd amounts compared to literally every other country in the world.

How to fix any of these? None of it is ever going to get fixed. The deep state is not just a government thing, it also extends to medicine, teaching, police, and other professions which have invisible networks that will thwart any attempt at reform or improvement to protect their own positions and lifestyles. Trying to fix it is a waste of time that only leads to being made a target of attacks, and introducing massive stress into your life. One might as well try to fix communism from inside Stalin's Soviet Union. You'll only be disappeared or end up dead. Best instead to figure out ways to have as little to do with the system as possible, and undermine it whenever you have the opportunity, hoping it will eventually collapse. The only way out is collapse at this point. Some cars are so far gone they can't be fixed. Likewise with houses. I've seen people try to restore an old farmhouse or victorian with a rotted foundation and floors and spend hundreds of thousands of dollars ending up with a crappy house with poor energy efficiency and little resale value. They are broke and stressed out and just spent a decade exposing themselves to black mold and sometimes things like asbestos. They could instead have demolished it and built a full size replica using modern efficient methods for a tiny fraction of what they spent "fixing" it. Why did they pursue restoration instead? Because they bought the rotted house for what they thought was a bargain and ignored its long term costs, and also they "fell in love" with it through simple familiarity and comfort of knowing it was theirs. Tearing something down or throwing it out and starting over again is the only way out of things that are far too rotted and broken to be worth fixing. Political and economic systems, houses, cars, and relationships all fall under this rule.

I'm not sure it's politics as much as a deeper underlying cause. A lot of today's salaries are just not sustainable to live and retire off of anymore. You read stories about how several decades ago, a man working at a gas station was able to afford a house, car, and support his wife and children. Today, you have people in their 30s who are still in debt, and whose salaries are barely able to sustain them. They end up having to work 2 or even 3 jobs if they have a family to support.

Combine this with a consumer heavy society, where people seem unable to control their impulses, and this is not a good result.

" A lot of today's salaries are just not sustainable to live and retire off of anymore. You read stories about how several decades ago, a man working at a gas station was able to afford a house, car, and support his wife and children."

I just moved into a new place and had a painter do the walls. He started working at Safeway with 17, retired at 52 with a pension, has 2 houses and raised 2 kids. that sounds almost impossible these days.


Spoiler alert: In a rather small number of years, everything that's wrong with society will become your fault. Enjoy.

This isn't just another cyclical generational war. Younger generations today are uniquely economically worse off than the older generations were at the same age. If that's the case in 30-40 years once economic and governing power has transferred to today's younger generations, then the blame would be well deserved.

I'm open to data and a serious analysis.

That said, it's hard not to see such complaints as a combination of entitlement and cluelessness. As a Boomer, I never would have considered taking on college debt without a pretty clear analysis showing breakeven in a reasonable period. The idea of getting an arts degree crossed my mind, and I dismissed it as ridiculous within a couple of months.

Most of my friends went straight into the military, the trades, or general employment. State college was for maybe the top 20%, and I'm not sure I even knew anyone that went to a name school.

Work? Full time every summer starting at 16, and half time while school was in session. Housing? Live at home, or maybe the cheapest dorm. Car? Find a friend and give them gas money. Phone? Picture an Obama phone that's nailed to the kitchen wall and shared with three other people.

By today's standards, Boomers were not well off. Even so, most of what I've earned has already been transferred to the following generation.

As a millennial I tend to agree. Anecdotal, but my friends that work hard and value money are becoming home owners and starting to raise a family. Those that focused on becoming an Instagram model are 80k in debt with nothing to show for it but a degree in Social 'Sciences'. I hope that the younger generations can see the traps millennials fell in to and plan accordingly

https://www.newamerica.org/millennials/reports/emerging-mill... https://www.cbsnews.com/news/millennials-have-just-3-of-us-w... https://www.pewresearch.org/fact-tank/2018/08/07/for-most-us...


To approach these systemic issues as just the individual faults of young people is to essentially accept that these problems will never get better. That's the centrist boomer motto.

I wouldn't know, as I haven't been invited to their meetings.

But seriously, I do accept that none of these problems will get better. The young and old are behaving as they always have and always will. As you get older, this becomes clearer, and the complaints of the young provoke a wry feeling when you remember issuing similar complaints yourself.

If it makes you feel any better, most of the people on HN are considerably younger and higher paid than I am.

It's interesting that Boomers are the latest scapegoat for all the world's ills. Last year it was the Russians. Oddly the Russians were also the fault of all that was wrong from 1950 to 1991, they get a lot of scapegoatry.

An older person advises a younger one that that apparently very cheap old rotted house (with years of poorly done repairs executed by a variety of amateur repairers and fly-by-night gypsy home contractors, many repairs of which exacerbated the decay) is too far gone and trying to fix it is going to be a waste of money that will lead to a loss of time and money invested. They'd be better off in the long run looking into some totally different better house, or if they must have that house and location, knocking down the rotted house and building a new one that looks like the old one but which has a coherent and efficient modern infrastructure underneath the gingerboard.

The younger person then will always say, "OK, boomer, so you think better things aren't possible. Whatever, cynical grandpa!", rolling their eyes. The old person shrugs because he expected nothing different. And the young one finalizes that purchase of the house and they set to being the latest owner that's going to fix it once and for all and maybe even flip it for a profit. Decades later, the house is worse off than when they started and they are broke.

Your metaphor is missing the older person building the house on a the rotting foundation and the younger person not having another house to go to.

It's surprising that an entire generation has now joined the cyclical boogeymen of Russia, China and anywhere in the Middle East

What specifically do you propose for the "new house?"


> let the adults fix things

And when, pray tell, will that begin? I'm afraid I have to agree with the parent's overall assessment of the situation. The problems are endemic to the systems currently in place, which are self-defensive and won't be reformed without a bloody fight. We've seen how the attempts thus far have gone and in some cases they've only made things worse. I hold out hope that it is still possible to fix things, but I estimate the odds of it actually occurring as very slim.

Paul, you're only 41. I'm a lot older than you. I've spent 40 years trying to fix this broken down rotted house and things have only gotten worse in that time period no matter how much effort is put into it. It's a delusion to think this can be fixed using the method of repairs because the repair method has been the way it has been done for a century now and things continue to fall apart and many repairs lead to worsening the fundamental underlying problems, or not addressing them. The house needs to be rebuilt from scratch. It won't be though.

For the young, I recommend resettlement in a more sane region.

For the old, hope that collapse doesn't happen and wipe out savings and impoverishment.

For those in between, nothing really. They are stuck with their car and unable to move to a new one so they hold on to the hope that the next car repair is somehow going to be the last one and the car will at last work as if new and functional.

When a wiser older person cautions a younger one, offering life or career perspective, they always respond by contemptuously telling that wiser older person they are a moron and should piss off because "adults are working here". It's how things are and how they have been. Everyone has to learn their lessons on their own, and in the end recognize their personal failures only when it is far too late, and at that point they try to warn the next generations, and are called old fools. The cycle of life, which is based on delusions and cult adherance.

I don't know how old you are but I'm a lot older than 41 as well. I am also stymied by the increasing tribalism in this country and I don't feel like a member of either major tribe. But I will admit there's a fine line between a wise elder and a crazy uncle at Thanksgiving. You sound like you started as the former but you're drifting towards the latter if you think you are entitled to respect simply because of your age.

My own frustration is that most of our so-called challenging problems have relatively simple solutions, but one or more of the above tribes will block those solutions so we go nowhere fast. That said, the world is a lot better than it was a hundred years ago. And if we ever collectively get our heads out of our butts and own our bipartisan $h!+, we can fix this. But I'm personally betting that won't happen until we get a moment of clarity delivered to us from China or India. And I'm not sure I'll still be above ground by then.

> if you think you are entitled to respect simply because of your age

I'm glad you qualified that with if. When I said I was older the point was that "I too once stood where you stand now and said these same things."

Not only do I not think I am entitled to respect, I know for a fact I won't get it no matter what. That's why I said this dynamic is the cycle of life. Solomon commented on the phenomenon as well. Each generation is committed to learning their own lessons and knows for a fact that they know better than all that have come before. I would go insane if I thought offering advice would do any good. That is part of why the problems can not be solved. Everyone knows best and that their solution is going to work, and everyone that tried to fix the rotted house before simply didn't know what they were doing. The problem is not that the house is rotted, it can't be, because then how could we justify keeping it. Therefore the problem is not that it is rotted.

Let's check in in 20 years and see how all the various proposed costly repairs have worked out. It will be great to be proven wrong and see that restored house standing proud, working just as well as a brand new one using modern materials, and the repairs all done and delivered at a lower cost than building anew. Alternatively those "OK boomer" chanting people will now be hearing "OK millennial" directed at themselves from a new generation that is convinced their own proposed repairs to the nearly totally collapsed rotted wreck will be the ones to restore the house to glory and the only problem was that the millennials and the boomers didn't know how to repair it properly, not that it was rotted.

Forget 20 years, go out 50-100 years. Given a prior where we haven't annihilated the top of the food chain to give the planet a new shot at intelligent life...

We will have solved artificial intelligence and that's a game changer. It will create an age of limitless wealth. But what I wonder about is whether our hindbrains will insist on maintaining inequality in an age where everything is cheap and plentiful. And what will the AIs make of us?

Who cares about health care if there's cheap immortality? That's the best healthcare of them all. But will we make it generally available or will we try to attach artificial value to it as an entitlement?

And that's because once people stop dying from natural causes we're going to have a population problem. That means we're going to have to get off world.

That also means that climate change becomes irrelevant because if we can terraform Mars etc, then tweaking the climate of the Earth is trivial.

The one true god that has delivered on all of its promises is science and I don't think it's done delivering the good stuff. But it's also a wrathful and vengeful god in the wrong hands.

But even then, I'd rather live in the above future then in a future where we continue all of our petty squabbles over which nation state is the best. That's creating misery worldwide. We could end hunger and homelessness today for pennies on the dollar. But we refuse to do so in favor of a huge military and prison industrial complex. All that's doing for us IMO is giving other countries a chance to leapfrog us mid-21st century.

So I'd suggest you do as I am doing. Fight your own mortality to your dying breath and try to make a difference between now and your probably inevitable dirt nap because it might not be inevitable because we're heading for one hell of a phase transition (no singularity required).

> It will create an age of limitless wealth.

Uh-huh. We Boomers are still waiting for that electricity that's "too cheap to meter".

We failed to deliver on nuclear power. And that's on all of us...

At least we have Twitter...

With age comes wisdom. But sometimes age comes alone.

"Burn it down" is not a solution. You've lived a life of privilege, in a privileged time and now that it's not going your way you want to end it?

Life goes on and it will improve. Incremental improvement is light years better then war and famine. Too many people are willing to block any improvement because it takes a dollar out of their pocket, when the alternative is destroying much more of their wealth.

Maybe it's fracking?

I think US healthcare is poisoning people. Every office-dweller is on proton-pump inhibitors, SSRIs, or both. In most cases, the PPIs are there to treat people who have wrecked their GI tracts by popping ibuprofen once or twice a day. Every older person is also on statins. Then there's the oxycontin dominance in the red states.

People constantly going to the doctor over side-effects and dosage level adjustments. Doctors just see them as walking wallets, and prescribe a new pill to cover the old side-effects with new ones.

Your liver and your kidneys can only take so much--see the dialysis centers popping up all over the place...

Your post is not medically accurate. PPIs are not there to treat people who have "wrecked their GI tracts by popping ibuprofen once or twice a day". PPIs are very useful drugs for people with GERD, whether that's due to anatomic differences in their LES, dietary concerns, stress levels, excess coffee or alcohol consumption, or side-effects from any number of drugs/treatments (including the one you mentioned, ibuprofen, but that's a subset of a long list of reasons).

Second, "every" office dweller is not on these drugs, that's a gross overstatement.

SSRI's are not even close to universally prescribed; they are known to not be that effective, many people do not take them but treat mild or moderate depression with psychotherapy, exercise, behavior changes, etc.

Regarding statins, they are very useful and have prevented a lot of deaths. They may be over-prescribed due to their generally safe and effective characteristics, however it's a GOOD thing to improve healthcare among the elderly (which is what is stated in the article).

Dialysis centers are popping up all over the place due to the rising obesity/type 2 diabetes epidemic, the drugs very much take a second-hand effect in that causal pathway.

You shouldn't spout off incorrect medical knowledge in an off-handed way. There are many uninformed people out there who may absorb this and propagate these incorrect views. Facts matter, science matters, as a healthcare researcher I can't let these misstatements go uncorrected.

"as a healthcare researcher"

I wonder who's signing the paychecks?

edit: and I think it's fair to ask about conflict of interest when reply is an appeal to one's own authority.

While this comment could have been more tactfully written, I believe the substance has merit. These drugs are classified as “preventative” [1] when they are treating symptoms rather than diseases. We can at least consider the source.

[1]: https://www.irs.gov/newsroom/irs-expands-list-of-preventive-...

No, people are poisoning themselves.

~40% of the US population is obese and in total, ~72% of the US population is overweight (including those classified as obese).

Every doctor I know would prefer you to eat and move/exercise appropriately rather than prescribing you drugs. That's the preferred treatment and would prevent many of those issues.(especially when you also include other basics of a healthy lifestyle, like sleeping enough and not abusing substances).

However, as is obvious, most people are unwilling to actually do what's required for that. So doctors are left with trying to mitigate symptoms or reduce harm without being able to tackle the cause.


It will be interesting to see what happens in the coming decades elsewhere in the world, as most of the rest of the world is rapidly catching up to the unfortunate "norms" of US weight problems.

I suspect you will see the prevalence of many of those ailments rising elsewhere in tandem.

No, medicine is. If "healthcare" didn't offer alternatives to getting your shit together, people would either get their shit together, or die.

From past life expectancy stats, the former happened more than the latter.

Also, recent US life expectancy decline can be accounted for, entirely, by prescription opioid epidemic.


People do die. Most complications due to unhealthy lifestyles are causing people to die earlier and more often, or live frustrating lives.

The alternatives really aren't that great. Yea, prick your finger every day and regulate your sugar so you don't die or get sick. Fun.

The reality is, food is designed to be addicting to sell more food, just like everything else in our capitalist society.

"most people are unwilling to actually do what's required for that."

Correction...most people don't have TIME to do what's required because of capitalism requiring them to work immense hours.

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