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The Amish health care system (slatestarcodex.com)
223 points by bookofjoe on April 22, 2020 | hide | past | favorite | 315 comments

I thought the most interesting part was the commentary on non-Amish care in the past

> I asked my literal grandmother, a 95 year old former nurse, how health care worked in her day. She said it just wasn’t a problem. Hospitals were supported by wealthy philanthropists and religious organizations. Poor people got treated for free. Middle class people paid as much as they could afford, which was often the whole bill, because bills were cheap. Rich people paid extra for fancy hospital suites and helped subsidize everyone else.

In other words... allow rampant inequality in the healthcare system. The rich would pay for their designer surgeries, and let that subsidize the rest.

That inequality is still present, except that now, the system is:

* Poor people either get hit with huge bills because they're uninsured, or, if they know how to navigate the system, sometimes get these bills written off through "financial aid."

* Middle class people frequently have insurance, but get hammered by deductibles and out of pocket maximums, rarely qualifying for "financial aid." This can be ruinous.

* The rich still get what they want.

If the rich are "subsidizing" things anymore, it's not to a great enough extent to benefit the poor and middle class. The system has been broken over the past 40 years by medical and insurance costs that have risen much faster than the rate of wage growth for the average worker.

I currently believe rising administrative overhead accounts for most of the cost increase. Single payer is a straightforward proven solution.

Switching from fee-for-service to prevention (capitation) would give us another 25% savings.

But I'm newly interested in notions related to cost disease. Am keen to hear anything anyone has to say about mitigation.

The biggest administrative costs in health care are the insurance companies' costs. [0] To the tune of more than $200 billion dollars/year.

[0] https://time.com/5759972/health-care-administrative-costs/

You have to be able to see that the numbers do not add up, right? 200b is how much out of 3+ trillions? Also, just because Canadian adminstrative costs are hidden, does not mean they are proportionally lower than in the US

The Canadian comparison had nothing to do with my comment, or the GP post to which I replied. I cited a cost, and provided the source for it. You're assuming I was in some way affirming the other conclusions of that article: I was not, and did not consider them one way or another. The GP comment was about rising administrative costs. I gave the source & amount of those costs. That was all. I otherwise agree with you: administrative costs are not the prime culprit in understanding why US costs are so high.

What do you mean, the numbers don't add up? From the article: "Insurers’ overhead, the largest category, totaled $275.4 billion in the U.S. in 2017, or 7.9% of all national health expenditures, compared with $5.36 billion in Canada, or 2.8% of national health expenditures."

What I meant is that if insurance costs disappear completely, US healthcare will remain 5 times more expensive than Canadian. It is percentage based markup on already super overpriced system. Therefore, real reasons for why it is so expensive are elsewhere

Thanks. I've reluctantly come to agree with your conclusion. There is no silver bullet.

Repeating myself:

Another low hanging fruit is transition from free-for-service to rewarding wellness (capitation). Some are already doing this.

I'd like to understand if, how, why cost disease is a factor. https://en.wikipedia.org/wiki/Baumol's_cost_disease I have zero understanding, intuition about this. Feels like black magic. But some of the experts I've read say it's important.

There's no shortage of management efficiency and quality of care innovations to explore. In the spirit of Atul Gawanda's book Better, like specialized clinics for cystic fibrosis, diabetes, and whatnot. And whatever we're calling people traveling for procedures. Like USA people going to Thailand and Mexico clinics.

USA's R&D and regulatory overhead (FDA) carries the world. That first adopter expense might be easier to accept if the accounting was transparent.

Any way.

I designed, implemented, supported 5 regional healthcare exchanges. Even in our little corner of the problem space, there was so much room for improvement. Alas, most of it was prevented, because our participants were competitors, so the incentives were all wrong. A single payer system (or rough equivalent) completely moot most of those roadblocks.

One snare is that that a lot of overhead takes the form of jobs in the insurance industry. Any reasonable plan to reduce that overhead means eliminating all of those jobs.

1. FWIW this is a recognized problem under M4A plans those people would be taken care of.

2. Nobody has a right to earn a living by causing suffering to others.

1. That’s a good idea. I’m personally concerned about the political fallout of “m4a causes job losses”.

2. Is a good slogan, but understand that most of those people don’t think they’re doing a bad thing. Spending too much time demonizing the line level workers at insurance companies is probably counterproductive.

2. Yeah I have dealt with these people a lot as I and my wife have a chronic condition. I sympathize with them, most realize they have a horrible job and just need to make money to eat. Some are just bad people because systems like that everywhere tend to be selective over time for people who don’t care. (The ones that do try to leave.)

But the principal still stands, no matter how much I may sympathize with someone they don’t get any right to make income from causing other people suffering.

If they’re being “taken care of”, how is the plan to eliminate their jobs supposed to save money?

Well probably not by just giving them their salary anyway. I guess there are many other options so I imagine it would be one of those!

I think it’s important to have a solid answer to this question. When people believe that a plan is weak on the details, this is what they are talking about. It gives the impression that the promises of the plan stated upfront (we will save money by moving away from wasteful health care system) are some sleight of hand, moving costs from a well-defined bucket to a mystery bucket we don’t measure.

That sounds like a good thing.

It’s a political liability for the transition period.

Public healthcare in general, not necessarily single payer. Most of Europe is not on single payer, but they are doing fine on costs.

USA has a problem with 3 scams - student debt, dumb lawsuits, and health insurance.

All 3 are connected and make healthcare absurdly expansive.

Am keen to hear your thoughts.

One such common thread is the financialization of consumer debt.

I recently learned (from Michael Lewis' Against The Rules podcast) that removing ban on usury debt (high interest rates) opened the flood gates. Sorry, I forget which episode.


Well - first you have absurdly expansive universities required to be a doctor.

They can be absurdly expansive because there is an expectation that students will indebt themselves with this one kind of debt you can't default on. So doctors have to earn more to be able to pay it back.

Then you have lawsuits where cost of lawsuit is paid by both sides, no matter who is at fault. So if it takes 2 years and costs 100 000 USD to determine you weren't at fault - you are still going to default (except yo ucan't default on your student's debt). So doctors are expected to be insured against lawsuits. Which is expansive. So they have to earn more.

Then there is a system where one drug company has 100 insurance provider customers who have to buy that drug. Who has more power in that relationship :) ? So you pay absurdly high prices.


re lawsuits, I advocate a specialized healthcare court for adjudicating those cases.

Our current system of legal precedent does not recognize progress of science. So we end up with nonsense like unnecessary c-sections for decades because a jury of laypersons determined vaginal births increases cerebral palsy.


We already have separate specialized courts. Bankruptcy, youth, etc. My local judges have innovated by creating separate courts for vets, addicts, and so forth. Much more fair, efficient, and effective.

re education. Yup, totally on board. We (society) need more healthcare workers, of all flavors.

re big pharma. I don't know enough to comment.

I never understood how precedent system works, doesn't even have to be about progress of technology. Morality has progress too.

If someone ruled once that Indians aren't people and can be expelled from their property is that still a law? It can't be, right?

Or how about when you legalize something?

It’s about separation of concerns. The courts use precedent to ensure fairness through uniform interpretation of the law. It’s the legislature’s job to update the law to reflect what’s best for a changing society: when the text of a law changes, the courts obviously need to take those changes into account.

Precedent isn’t really about outcomes, it’s about lines of reasoning. If the law says that something has to be purple, the courts may need to decide what standard to use for purpleness. If another case then comes along that requires something to be green, the courts will try to make their greenness test work the same as the earlier purpleness test as much as possible. That way, everyone can get an understanding about how the courts reason about color. If the legislature disagrees with the court, they can amend the law to specify more precisely which color they wanted.

There’s a little bit of extra subtlety in that the US court system is hierarchical, and precedent is only controlling if it came from a court in your part of the tree. Different circuits may apply different reasoning for the same issue, and that’s probably the most common kind of case for the Supreme Court to take: two competing standards are in use, and they need to decide which one the whole country should use.

Canada has single payer and rising administrative overhead is a major problem here too. Looking at spending on medical staff vs spending on administrative staff, the former has barely gone up at all while the later has gone up over 500%. Plus we deal with the serious problems of lack of care. I know several people who have waited over 2 years for important surgeries like hip replacements. My mother died because they didn't want to keep her alive, and we get no say in the matter. Single payer doesn't magically make health care work well.

Damn. I am very sorry for your loss.

Thanks for tip re Canada's admin overhead. Will research.

The NHS in the UK is suffering from huge administrative problems as well, due to ageing digital and organisational infrastructure which is becoming increasingly difficult to replace or modernise.

The government tried to centralise and digitise the whole thing but because it was mismanaged, most of the project was abandoned and cost billions to the taxpayer https://en.wikipedia.org/wiki/NHS_Connecting_for_Health

Now we are in a bit of a catch 22 where the costs keep increasing, and the government is always under pressure to spend more but there doesn't seem to be a solution to slowing down the increasing costs.

> if they know how to navigate the system, sometimes get these bills written off through "financial aid."

Yes. I have a friend in tech (contractor, bay area) who doesn't have insurance. his plan is to just show at the ER without an ID if he needs anything and give a fake name.

^ why we can't have nice things..

> Middle class people frequently have insurance, but get hammered by deductibles and out of pocket maximums, rarely qualifying for "financial aid." This can be ruinous.

How large are these OOP maximums and deductibles on average? I’ve always kept an emergency fund that’s well in excess of my OOP max. Is this unusual? Also, I’m off the impression that you can get onto payment plans if you can’t pay your bills right away? These aren’t rhetorical questions (although that won’t stop people from downvoting as though they are, I’m sure), I’m genuinely curious.

> I’ve always kept an emergency fund that’s well in excess of my OOP max.

29% of households have < $1000 in savings, and the median is $11,700[1].

$1000 disappears almost immediately given deductibles, and $11,700 isn’t that far off either. People just don’t have the chance to “get ahead” when making <$15/hour.

[1]: https://www.google.com/amp/s/www.cnbc.com/amp/2018/09/27/her...

I agree with this, but we're not talking about <$15/hour; we're talking about the middle class.

OOP maximums can be up to $8200 for an individual plan or $16400 for a family plan. But, that doesn't tell the whole story. Because health insurance is tied to employment in the US, getting seriously sick can not only easily trigger those maximum amounts, but also lose you your insurance.

Unfortunately, it is unusual among Americans to have an emergency fund this large.

I don't know the answers to your questions, but one thing I do know is that OOP maximums have exceptions and are not absolute. So please don't treat them as a 'maximum level of risk' or something like that. The insurance company can still screw you over, even if you do have an OOP maximum.

There are those that receive emergency room care without ever shouldering any of the cost.

The past is not a useful guide, because until recently, there was relatively little that could be done medically, and costs were commensurably low. The elephant in the room is that medical technology has advanced to the point where any person's needs can potentially greatly exceed their lifetime's ability to produce. When there are relatively few who find themselves in this state, insurance (and what is described in both Alexander's article and tathougies' post are informal forms of it) works, but not when it is a majority.

Big agree with this. Also there's no all-encompassing definition of 'healthcare' that will cover all categories, the way there is for groceries or cars or servers. As people get more disposable income to spend, they'll gravitate towards what is not so much medicine as improving their bodies (speaking as an older athlete who's spent significant money to repair shoulder, hip injuries & stay relatively young- my grandparent's generation would've said 'your shoulder's done, you're not young anymore, it's over', etc.) And then also end of life care- some amazing % of our healthcare costs go into the last 6 months of life, which is all totally optional care and we don't 'have' to have- but we want to because we have the disposable cash for it. We want the $27,000 cancer drug or the $100k for an extra two weeks of life on the backend

Right, this difference of scale is enormous. Back when hospitals couldn't do that much, and were not far from being hotels with better hygiene & worse food, then how to pay for them wasn't such a hard problem. But now US healthcare is 17% of GDP (if I recall correctly) and this proportion rises with GPD, unsurprisingly, as more other needs are already met. It isn't going to go down.

Pensions are in a way similar. When steelworkers retiring at 65 could expect on average a few golden years, then deciding how to pay for that wasn't such a huge deal. When they can expect a third of their lifetime to be in retirement, then it's very different.

You say it won't come down, but that's because the US is in it's own ballgame. In most other advanced western country healthcare "only" accounts for 7~11% of GDP.

The chart on [0] is incredible. I also shows how much that percentage has grown over the last 45 years.

[0] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea... [1] Source data OECD: https://stats.oecd.org/Index.aspx?DataSetCode=SHA

I agree it's higher, and while some of this is waste, some of the higher proportion is explained by the US being richer.

Whether it will come down, I guess that's partly a forecasting guess. Will the healthcare sector be a smaller part of the economy in 10, 20 years? Employ fewer people? I would be extremely surprised if this happened in any advanced country.

Agreed, healthcare became a human right right around the time it changed from being mostly palliative care to curative care. I'll pinpoint it to somewhere between the invention of insulin and penicillin. It's at that point where healthcare outcomes really start to diverge between rich and poor.

Something I'll note, Jay Gould, one of the wealthiest men of his time died of tuberculosis - something we now think of as a poor persons disease.

I see what you are saying but prices are completely out of control precisely because an insurance company will pay a 6 or 7 digit bill.

If insurance was gone tomorrow and there was a cap on how much a single payer system would pay I am pretty sure million dollar surgeries would go down significantly in price.

I mean surgeons are paid well but a million dollars for a few hours of their labor?

Constraints on how many people are permitted to become doctor's also reinforce this issue.

also we've thankfully left behind the age of caste systems, where you just were poor, because well, peasants be peasants. Today I don't see any rich people engaging in that kind of (really screw up, if you think about it) "philantrophy" anymore... Especially in America (with Amazon and Walmart-slavery) the attitude is more like: you're poor, because you are not putting enough effort in.

What's screwed up about philantrophy? And it's still here, Bill & Melinda Gates Foundation is a most prominent example.

The inequality that creates philanthropy shouldn't exist. Bill Gates did not himself earn his fortune.

the one where people somehow think, the status quo is god-given and that it's their godly duty to give alms. And no, Bill Gates is not an example for that - I think it's basically limited to the 3rd world, people in the US are still supposed to get their life together ;).

Since 1980 or so, the caste system is on a return. Not in rhetoric, but in outcome. "Social mobility" is down, down, down in the US.

yeah, I reckon that. But compared to the old caste systems the people on top tend to show even less regard for the ones down (because they are so great and all selfmade!)

Behind the bastards has a good podcast about the lady who mainstreamed adoption. She convinced rich people that they could adopt poor children and they wouldn't be genetically inferior, to be blunt.

She also stole kids and let babies die from lack of care...

Why do I always see articles like this? I am pretty sure that everyone knows that Amish eat healthier, exercise more (very low obesity - the cause of 60% of Western health problems), don't drink or smoke, ingest and inhale far less plastics and chemicals and a large portion of their health care money isn't wasted on health care system overhead (administration). Oh one more thing, 80% of doctor visits and filled prescriptions today are completely unnecessary and unhelpful, also 20% of surgeries. The Amish only use health care or get surgeries or see a doctor when they really need too. Cut out the cost for that too.

It's funny how today's most complex problems are so simply avoided by simple people.

> 80% of doctor visits and filled prescriptions today are completely unnecessary and unhelpful


>I am pretty sure that everyone knows that Amish eat healthier

By what definition? According to mainstream health organizations and even still government guidelines, they eat very poorly. Their diet is very high in saturated fat, which although healthy in reality, is not healthy according to the government. They also eat plenty of sugar, the other common scapegoat for dietary problems.

>don't drink or smoke,

They drink and smoke at lower rates, but they absolutely do drink and smoke.

That's what some universal systems already do. I was reading up on Singapore. There is a baseline of insurance for hospital stays, but it's in a ward with 6 other patients in the same room.

If you want something better (and there are tiers), you pay more. You can buy insurance policies that pay for the more comfortable stay.

Another place in SEAsia where it’s single payer but while everyone (legally employed persons) people who want good treatment go to private hospitals because of expertise, availability and the ability to get private rooms.

The same in Fiji.

We have universal health care, but anyone is of course free to forego that and pay (or use their private insurance) for a private room rather than a ward, or just go to a private hospital instead.

I don't understand the debate about this in the US. It's as if the rich assume that things will change for the worse for them if universal health care is enacted.

The big difference between the two camps that I see is that one side recognizes the cost benefit of their position and the other side doesn't.

Price controls on healthcare (socialization) has positive and negative impacts. The positive impact is universality. Everyone gets approximately the same basic level of care. In some countries you might be able to pay for a nicer room, or quicker service, but generally speaking it's all the same. The downside is that price controls stifle innovation. That's just basic mainstream economics and is the case in every industry, not just healthcare. The trick about stifling innovation is you don't feel it immediately. On day 1 of the price controls, the rich are about the same but the poor are better off. On year 50 of the price controls, everyone is worse off because of all of the innovation that never came to fruition.

I never hear advocates of universal healthcare have an adult conversation that they are trading long term benefits for short term gains. I think that's a reasonable position to hold, but if we just pretend that it's all benefits and no cost we're not having an adult discussion. It's not as if one side is right and one side is wrong. Once we accurately discuss the economics, it's easier to understand that this is a very difficult moral decision and not the trivial one that is sometimes portrayed in the political sphere.

My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.

On the other hand, right now, only the rich, or those with good enough medical insurance (if your co-pay is more than you make in 6 months, are you really insured ?), have access to the expensive treatments. On a universal heathcase system, whatever the form it may take, more people would have access those expensive options. Is it better to sell your treatment to more people but at a smaller price tag, or to fewer people at a bigger one ? I guess the economics depend on each treatment.

Fostering innovation is of course important. Which is why you can deduct a lot of your R&D expenses from your taxes. Again, each country has its own tax code, so generalization might not be possible, but in a lot of cases, the hard work of finding new drugs is funded by the citizens, through tax breaks or research grants. The public sector, via universities and public labs, is a major player (although not the only one, of course) in the medical field.

Let's not forget that forcing people to stay with their employer to maintain insurance coverage is also a way to stifle innovation. How many of those workers could have and would have started a business, if not for the fear to loose everything in case of medical issues ? Surely the republicains would love to remove those kind of barriers to worker movement and innovation, wouldn't they ?

The universal healthcare system obviously isn't free. Altough some studies, and real life examples elsewhere in the world, showed it wouldn't be the money pit some imagine, it certainly doesn't run on love and compassion and fresh water only. The taxes in my country can show you that. But the social benefits and the peace of mind I enjoy are, in my very own and somewhat biased opinion, worth the cost.

I feel like all you've done is point out exactly the cost in the cost/benefit analysis I gave. You pointed out that some treatments are expensive without acknowledging the high price encouraged it to be invented in the first place. Nor did you acknowledge that the patents will eventually expire and then that treatment will tend to become available to basically everyone.

We're talking about changing the velocity of innovation. Let's do a thought experiment about what innovations might be missing today if we implemented price controls everywhere in the globe 50 years ago. We might be missing the HPV vaccine leading to many cases of cancer for women. We might not have CRISPR. We might not have HIV treatments. High prices, profits, however you wish to put it, incentivized people to create these thing and go through the extremely difficult process of bringing them to market.

Now that's just a thought experiment about the past. It's impossible to know exactly what would have happened then, just like it's impossible to imagine the things that won't get invented 50 years from now. But we do know, according to basic mainstream economics, that price controls change the velocity of innovation. Since the velocity decreases, the farther you go into the future the more harm you cause through the lack of innovation.

I'm glad you brought up the fact that healthcare is tied to your employer. If you look up the history of this situation, you can see that it's the result of price controls enacted by the government on wages. Dumb things happen when we implement price controls.

The drugs/treatment you mentioned where all developped thanks to public contributions, not purely private research.

HPV vaccines were first developed by the University of Queensland in Australia [1] and further improved by the the University of Queensland, Georgetown University Medical Center, University of Rochester, and the U.S. National Cancer Institute [1].

CRISPR was discovered by several researchers from the University of California, Berkeley, the Broad Institute of Harvard and MIT [2].

The public helped in the discovery of those treatments (through tax payer subsidies), and as such, in my view, are entitled to some kind of retribution. Having a form of universal healthcare, where the public can put pressure on companies to decrease the price of different treatment, is exactly that.

Regarding the velocity of innovation, I don't think it is hurt by a universal healthcare system. Everyone has access to those treatments, and so the profit on each instance of the treatment can be lowered while keeping the same total profit for the company manufacturing the pills.

What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?

Even if some treatments, like drugs, can be made generic, and through that, have their price descrease in the futur, what about medical procedure ? Hip replacement won't suddenly or magically become cheaper in 5 years. Look at the price of stitches in the USA (For patients without health insurance, stitches typically cost $200-$3,000 or more, depending on the provider, the injury and the complexity of the repair [3]).

I do not propose to slash the profit of pharma companies. Like you said, academic studies consistently show that a reduction in current drug revenues leads to a fall in future research and the number of new drug discoveries [4]. Forbidding them one way or another to make a profit would be a net negative on the long term. But were our differences arise are in the implementtion of this principle. You propose, and correct me if I misunderstood, to let them set the price, and those how can will buy it. I propose to contain the cost so that all who need can afford it. The net result could be the same.

Price controls, like other types of controls, are a necessary evil in lots of case. It would be cheaper to allow companies to pollute everything and everyone, but we decided that society as a whole is better off with environmental controls. It would be cheaper to not test all those drugs and just let the market sort out which pills are working and which ones are dangerous, but we decided against it.

[1] https://en.wikipedia.org/wiki/HPV_vaccine#History [2] https://time.com/time-person-of-the-year-2016-crispr-runner-... [3] https://health.costhelper.com/stitches.html [4] https://itif.org/publications/2019/09/09/link-between-drug-p...

>The drugs/treatment you mentioned where all developped thanks to public contributions, not purely private research.

There's no such thing as a new drug that reaches the market without massive investment from private companies to do things like pay for FDA certifications, drug trials, etc. These are different categories of activities besides research. I don't think we're in conflict here.

>What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?

What is the point to avoid discovering ways to create insulin altogether just because some people might not be able to afford it while the patent is active? What are the regulatory hurdles preventing generics?

>Hip replacement won't suddenly or magically become cheaper in 5 years.

Regulatory capture by medical unions is a separate topic.

>I propose to contain the cost so that all who need can afford it. The net result could be the same.

The net result is NOT the same if the new treatment is never created in the first place. That's the whole point.

>Price controls, like other types of controls, are a necessary evil in lots of case.

Again, this whole thread is about making sure we acknowledge the "evil" part, which is long term increase in death and suffering but short term reduction in death and suffering. After that, you can decide on your own whether or not things are "necessary."

The peace of mind and knowledge that everyone gets taken care of no matter what is worth the world to me.

The "no matter what" in this case is that more people suffer and die for all time into the future so that fewer people can suffer and die today. That's a steep price to pay because the future and the amount of suffering people in it is functionally infinite. I think as long as you're willing to say that out loud and really mean it we've had a principled and honest discussion.

> stifle innovation

The most innovation I am seeing coming up from the US health system these days is in finding ways to extract more wealth.

Innovative things like "let's make a cartel, increase the price of insulin by 1000%, and use some of that money to buy politicians so they don't stand in our way".

1.) Your theory assumes that the cost difference at the hospital goes toward innovation. It ignores role of public money that goes into research. It is also not analyzing where the money are actually going.

2.) With this theory, if it is true, you are basically volunteering American patients to pay for innovation worldwide. That is quite a bad deal for quite a lot of American people.


> My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.

They have also different interests. Good cost benefit tradeoffs for one group is often very bad deal for another group.

1) No it doesn't

2) America doesn't have to let this happen. We could charge other countries for our innovations or otherwise demand reciprocation.

3) For people rich enough to have serious political power, the short term price difference is negligible or perhaps even cheaper under price controls.

What about middle class people who can't afford private care but fear that the socialized healthcare system will be of worse quality than what they currently have?

You can look at austria to see that that doesn't happen.

An MRI cost me about 0€.

A 4000€ test which tests for nearly any rheutmatic diseases markers and the visit to the hospital for that test cost me 0€, both things got done within two weeks.

Even if you are poor and want to go to a private doctor it will cost you not nearly as much as in the usa. For me it was about 100€, for one visit and that was on the higher end.

Socialized healthcare is always cheaper.

I can buy an out of pocket (uninsured) MRI test in the US for less than $500. With a little bit of negotiation I could probably get it down to $300. An insured MRI can be free too depending on the plan.

My mom is a doctor, she worked ICU, ER, etc, board certified in 10 states and holds a medical license in 3 countries(yes, she did residency three times, it's a long fascinating story for another time). Eventually she decided to open a private practice for family medicine bec it was less stress, but she's got tons of experience, and is highly regarded, and she charged less than $40 a visit for the uninsured. She would spend ages talking patients out of procedures that were harmful or simply unnecessary. You got high end care from her each time.

The gist of this is: you have no idea what you're talking about and individual anecdotes don't prove one system is better then another.

I'll just add as food for thought: nothing is free, avg effective tax rate in EU is 50%

Avg ETR in the US is less than 30%.

It’s not that their care will get worse, it’s because their care gets worse due to “those people” getting better care. Source: my in-laws.

The bulk of the (public) opposition is from people who like their employer provided insurance. We'll soon learn if the mood changes, due to pandemic induced high unemployment.

It doesn't matter if the mood changes. Democratic voters are in the mood for medicare for all already and biden is the democratic candidate. This is america, the public mood isn't a factor.

Last I looked at the polls - before coronavirus stole all the attention - Democratic primary voters were split roughly evenly between single payer (M4A) and public option, in polls where the distinction was highlighted.

Perhaps they should be taught about capitalism.

If there is demand for private healthcare affordable to the middle class, the demand will be met with supply.

And if that fails, they should be taught about democracy.

That if it turns out that socialised healthcare doesn't work for most Americans most of the time, then the country can revert to the system it currently has.

They have a hard decision. Unlike the US they are allowed to be an adult.

> It's as if the rich assume that things will change for the worse for them if universal health care is enacted.

Well, it depends on the implementation, but Bernie Sanders has been on record numerous times as stating that his Medicare-for-All proposal would absolutely ban private insurance. Elizabeth Warren is another Democratic front-runner who indicated that she's on board with that, though her proposals didn't necessarily reflect it.

For what it's worth, the M4A _plan_ from Bernie's camp that I've seen didn't actually specify that it would eliminate private insurance, but he's also been keen on reminding us that he wrote it, and knows best what's in it.

So while it seems unlikely to me that political reality in America would prohibit banning private insurance, there are definitely those who espouse banning it for the greater good, so perhaps that fear isn't wholly unwarranted.

It's a slight misstatement to say that any of the M4A plans would have "banned private insurance." None of them prohibit supplemental coverage that would be secondary to Medicare.

I didn't say that any of the M4A plans would ban private insurance. That doesn't change the fact that Bernie has stated that his M4A plan would, even where the plan he's put forward doesn't show that.

I think it's fair (if a bit naive) to take politicians at their word on occasion. Moreover, I think it's more than a bit disingenuous to assert that plans that are disallowed by law from competing with Medicare services still being allowed to exist for only elective operations as "not banning them." If I disallowed Netflix from streaming any videos longer than a minute in length, I guess technically I have not banned Netflix, but in practice, I have totally banned Netflix, and that's exactly the scale of disallowance we're discussing here.

Your analogy is false, though. A more correct one would be "Netflix is allowed to show all initial movies in a franchise, but sequels are fair game to anyone."

Do you understand the difference between primary and secondary / supplemental insurance coverage?

I don't believe that my analogy is false, or that supplemental coverage would be allowed for the kinds of care being provided by M4A. I think perhaps a more on-the-nose analogy would be that "Netflix is not allowed to distribute anything that Apple TV is distributing or claims to distribute."

Again, I'm not making the claim that it's what's in the policy, but it's what Bernie has said, and others have echoed. Reasonable people can disagree on what policies are practicable or likely, but if you're a person who believes their health insurance might change based on those statements, then it seems like a warranted fear.

This doesn't apply to procedures that are covered, though, does it? Like, a private plan that provides higher-quality / reduced wait times for all services you'd normally get from the public system.

Regarding the implementations I was talking about, the private market would exist exclusively for elective procedures "like cosmetic surgeries." [0]

For any of the services covered by Medicare. Quoting the Kaiser Family Foundation, "private insurance would be prohibited from duplicating the coverage under Medicare."

[0] The full quote here is "If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries. That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries."

[1] - https://www.bloomberg.com/news/articles/2019-07-05/harris-ke...

> For any of the services covered by Medicare. Quoting the Kaiser Family Foundation, "private insurance would be prohibited from duplicating the coverage under Medicare."

That's correct. Supplemental insurance can still cover copays and other out of pocket expenses. It can also cover procedures not covered by Medicare.

Now, tell me, how is that "banning private insurance" if insurance companies can still sell those policies?

From a Bernie Sanders interview with NPR.

Q: "Does private insurance go away under Medicare for All?"

A: "Yes, it does, because you're not going to a have a need for private insurance"

A tweet[1] from Bernie Sanders: You're damn right we're going to get rid of greedy health insurance companies.

CNBC describes Bernie Sanders plan as "Bernie Sanders is pushing a “Medicare for All” bill, which would create a government-run program and end private insurance."[2]

The Hill's headline covering Bernie's policy is "You're Damn Right Health Insurance Companies Should Be Eliminated"[3] and references a quote in an interview from MSNBC in which Bernie says universal health care can't be achieved "unless you get rid of the insurance companies."

So feel free to quibble over the nuances of what "eliminate," "end," and "abolish" mean as much as you like, but if you're a person who is concerned that your private insurance is going to be eliminated, and you're listening to Bernie Sanders talk about it, it seems like his statements would reinforce that fear.

[1] https://twitter.com/berniesanders/status/1111363118867927040...

[2] https://www.cnbc.com/2019/07/18/these-2020-democrats-want-me...

[3] https://thehill.com/policy/healthcare/436033-sanders-youre-d...

Nonetheless, the fact remains, no M4A plan proposed by any candidate in the 2020 race would disallow insurers from offering supplemental coverage. Bernie is just simplifying for purposes of making himself understood to the general public. Nobody would "need" private insurance under his plan:

> In other words, while Sanders' plan doesn’t ban supplementary coverage from private insurers, it does offer such generous coverage by the government that there's not much room left for private coverage to fill any gaps. This is the logic upon which both conservative critics — and supposedly nonpartisan mainstream reporters and pundits — hang the logic that Sanders' plan would "ban" private coverage. It's a dramatic "gotcha" question.... [0]

You're essentially reinforcing a right wing talking point that completely mischaracterizes what Bernie's M4A plan actually does.


[0]: https://theweek.com/articles/850638/no-really-wants-ban-all-...

Whether he's simplifying or restating seems orthogonal to my point, which is that people who are worried that things are going to change and if they'd like to "just go to a private hospital instead," well - if Bernie is to be believed - in his vision of America, those may not be allowed to exist.

Where did anyone, Bernie included, say that private hospitals would not be allowed to exist?

Firstly, it's implied when he proclaims that companies shouldn't be profiting off of health care. But to answer the question less obliquely, here's a quote of him saying it (from Politifact):

"I could whack pharmaceutical companies, and I don’t need Medicare for All to do it, but I do need Medicare prices for all to deal with what the real profits are — whether you call them profits or not — which is hospitals."


Where does that say private hospitals shouldn't exist? All it implies, and which the article explicitly states, is that private hospitals will have to deal with making lower profits under M4A, which is obvious.

You're reaching. Why are you trying to push a right wing spin on M4A, when studies show that it would reduce costs and increase access to care?

I'm not pushing a spin at all. I care approximately zero about the current healthcare debate or its future direction. I think my initial statement was apolitical and factual. If it's being interpreted otherwise, that's by inference, not implication.

But to the point of why people might be wondering about changes to their healthcare policies, well, perhaps it's because they've been listening to the politicians. If folks would like to obliquely sidestep what I feel was a rather small, simple point and have an argument about efficiency gains in healthcare, you're free to, but I'm not trying to participate in that argument.

Edit: Actually, consider this my last post on the topic at hand, as I'd rather not engage in any argument where reputably sourced facts and direct quotes are regarded as "right wing spin."

Mischaracterizing M4A as a policy is what I'm considering "right wing spin," not "reputably sourced facts and direct quotes." Yours are exactly the words I would expect to hear from scaremongers in Washington telling people M4A "takes your freedom of choice away." If you can go to any doctor or medical facility and have your coverage accepted, and also have as much supplemental coverage as you want, again, how is that "banning private insurance," or "banning private hospitals?" Please explain.

> Mischaracterizing M4A as a policy

I did not do that

> Yours are exactly the words I would expect to hear from scaremongers

I quote the author and it's scaremongering? Yeah, count me out of this conversation altogether. You've uncharitably interpreted what I'm saying, and are doubling down on the sort of rhetoric I explicitly stated having no interest in.

You are spreading deliberate falsehoods. That is literally the definition of "mischaracterizing." As for "scaremongering," or "right wing spin," do you have a better word for amplifying the "you're going to lose your freedom of choice" meme by saying private insurance and private hospitals would be banned?

And, as for the conversation, you were supposed to be out already. It would be better if you stayed out rather than amplifying false statements. If you want to critique M4A, then quote the actual policies put out, not the rhetoric.

a) I'm not spreading falsehoods.

b) I've made no critiques of M4A.

c) You're wrong to the point of malice, perhaps deliberately.

Why are we still talking about Bernie Sanders?

His ideas are still relevant, even if his candidacy is not.

For what purpose would they not ban it?

To be clear, I misspoke in my closing sentence, and intended to say "It seems likely to me that the political reality in America would prohibit banning private insurance" -- but got mixed up in my negatives and now it's too late to edit.

That said, answering your question, they would presumably not ban it because a) the aforementioned arguments upthread make it pretty silly to do, and because b) it seems impossible to me that banning a wholly legal service just because it competes with the government would ever be deemed as constitutional.

Well, not ever -- but not today, and not with the direction that the Supreme Court has been taking for decades now in regards to government power. Licensure seems possible, but I think even prohibitive licensure intended to dissuade private entities from competing with the government would be tossed out, and we already have such programs for insurance providers anyway.

Part of it is because the “Medicare for All” proposal outlaws private insurance.

No, it does no such thing. Because there isn't one single "Medicare for All" proposal. There are a variety of plans proposed under that title, and only some would do away with private insurance. Many are some flavor of opt-in, granting access to the ability to buy into Medicare in the same way current Medicare recipients choose their level of coverage and pay accordingly, while leaving private insurance intact.

M4A gives everyone, rich or poor, the same base standard of coverage. And if you want coverage for other things that aren’t included under Medicare then you can get supplemental private insurance for it. That’s absolutely not outlawed.

If that's the case then they really screwed up with the term "single payer", and a lot of Bernie's own supporters were wrong. Lot of crap all over reddit about ending private insurance for the last year.

It’s not the case, but it’s apparently still not worth engaging with the Bros.

That's not how insurance works, expensive insurance has a lower max out of pocket.

What you are talking about is that rich people don't need insurance at all. They just pay out of pocket.

That is how health insurance works in New Zealand.

If you want private health insurance for say $50 a month[1], then insurance gives access to procedures more quickly and the rooms are much nicer than the public health care system. It may give access to rare but expensive procedures.

If you don’t want insurance, then the default is the public healthcare system, which is paid for by taxes. You will usually be in a ward with other patients. You pay small amounts on use (to prevent abuse, and even those amounts are reduced to nearly free if you are poor). The level of care is reasonable, but can be slow for non-urgent elective surgery, and extremely expensive procedures are not available. The public healthcare system handles ongoing chronic conditions much better than a private system could.

[1] You can see a quote from https://www.southerncross.co.nz/ if you give your age, gender and tick whether you smoke. Note that Southern Cross is a nonprofit co-op, most premiums get returned to members (on average, less an approx 10% administrative overhead).

They still pay taxes, though.

Germany allows people to opt out entirely, although there are a bunch of conditions and limitations. Most people don't, so the public system can still pay for itself.

Sadly in germany it's rather difficult to switch between public and private or no insurance. Or rather, it's very difficult to get back on a public insurance once you're private or self-insured. The best you can hope for is pulling it off once, maybe twice.

That doesn't seem unreasonable.

If you're avoiding paying into a system because you don't want to claim from it then letting you hop back on whenever you need it would destroy the system very quickly.

It's not that easy, luckily, if you're self-insured and have to take the service of a doctor, you can't switch just like that. It takes about a year of paper exchange with everyone involved to switch cleanly. Even then, any costs you started paying for from before will still have to be paid unless you're below a certain income bracket (or declare bankruptcy).

So if you were self-insured and broke a leg, then decided to switch back to insurance, you'd still be on the hook for the costs of the ongoing physiotherapy until it is healed back up. The insurance doesn't have to actually pay anything that happened before a switch (switching from public to public insurance or private to private doesn't have this limit, private to public and the other way round but you don't pay, your old insurance pays).

I'd wager that is by design, and one of the ways they keep people from avoiding insurance when young and healthy, and then getting it when old

It's possibly one intention, though there are already laws that prevent you from going back to public insurance if you're over 55 years old as well as if you're over a certain income limit.

The only universal way to switch is to marry someone in public insurance.

The most expensive plan for my family (2 parents and a young child) is $367 a month. Equivalent coverage in the US would be thousands of dollars.

I do not know the New Zealand system, but I suspect the base level of care is still covered by public funding and the insurance is only covering optional extras (like private rooms).

That system looks terrible for handling cancer and pre-existing conditions.

All NZers get treated for cancer or pre-existing conditions, within the funding limits of the health system.

Severe health problems don’t bankrupt NZers, and you are not locked into a job just to (a) keep your insurance, or (b) keep your insurance benefits.

How many recently unemployed in the US have lost cover for their pre-existing conditions?

I expect you can find the benefits list document for Southern Cross, if you wished to check out the details of cover for cancer or pre-existing conditions.

Cancer is not an elective surgery and gets treated with urgency. Across the Tasman Sea with a very similar system my father had bowel cancer removed the day after diagnosis in the public system and spent most of the recovery in no state to miss a private room.

As opposed to one where everyone avoids medical care at all costs to avoid extortionate bills?

I don't think there is any system like that in first world countries. The US isn't like that if that's what you're insinuating

Please look around you a little more. My buddy separated his shoulder snowboarding in Tahoe. He had a full time (40 hours a week) job at the time, but it didn't provide healthcare.

He couldn't afford to go to hospital, so never did. I was visiting from Australia at the time and was utterly horrified, having no idea the US worked like that. Now years later his shoulder is still screwed.

Of course people in the US avoid going if at all possible, it's horrendously expensive, and medical bills are the number one cause for bankruptcy in the US [1]

In a stack of OECD countries (all the other ones?) nobody has ever gone bankrupt from medical bills, because that's impossible.

[1] https://www.thebalance.com/medical-bankruptcy-statistics-415...

Sorry, but is this a good example?

There are people that cannot afford insulin. THAT is a problem. But the fact that he took a risk, for fun, and suffered the consequences, rather than having everyone paying for it? That sounds a bit reasonable...

Note: important that the risk is voluntary, optional and recreational rather than professional. Why would the collective bear the costs, in those circumstances? Why is that fair?

Person doesn't have insurance and injured themselves doing a risky activity, and can't afford treatment. If it's really bad, why not use bankruptcy, I can't imagine this person has anything valuable given the history you described.

Or use physical therapy, it's cheap.

What is insurance for? To cover risk of something bad happening. The bigger the pool paying for it, the less impact to any one person to cover all the risk.

Now imagine that was scaled up to a whole country. That's New Zealand. Check out the Accident Compensation Corporation. All medical costs related to accidents are automatically covered!

But who pays the costs! Everyone, via levies. How much? $2000 on a $150K IT income.

But how do you control costs? Who is entitled? Who is at fault? Surprise! It's a no-fault accident insurance system that covers all accidents.

In exchange for that, we gave up our right to sue in accidents for medical damages. Why pay a lawyer when they're not required?

I guarantee the average US worker that makes 150k (not an avg salary) pays more then 2k in SSI taxes that cover Medicaid. They pay all over again for private healthcare, probably in the 6k range if they don't have kids.

So you think it's fair for someone to spend 2.5% of their income on a flu test when they have good reason to believe they may have COVID-19?

Do you mean monthly or annual?

If monthly, the answer is still no, but only because testing for covid is a significant public good.

Otherwise, yes, sure?

It is an unpredictable, low probability event, with not so big an impact (the payment, I mean, not covid)

It absofuckinglutely is. If you don’t see that you may want to check whether your perspective is informed entirely by a (quite rich) bubble.

The hospitals I'm familiar with have VIP suites for the "haves". The only difference is everyone else gets into a lifetime of debt now too. Ability to afford medication and insurance is a question that is brought up during liver transplant panels. An alcoholic physician, politician, or celebrity is much more likely to get an organ transplant than any other alcoholic. Inequality of health is still rife here.

Medicine was also way less tech-heavy, so the costs were objectively less. Invasive surgeries and similarly advanced treatments are incredibly complex high-tech and high-skill undertakings. If you look at the high end of medicine it's like they're routinely pulling off moon shots: carefully excising brain tumors, separating conjoined twins, transplanting living organs, etc.

I am not suggesting this explains all of it. Our health care system is definitely overpriced and overloaded with badly designed bureaucracy, but it definitely explains some of it.

How do you come away with an inequality issue from a setup where everyone got treated at a fair price and the rich subsidized others?

I believe the inequality is that the more wealthy purchase better care, or conditions, at the hospital. Therefor not everyone gets the same care.

I’m not sure how that’s different from today, other than the exorbitant costs that exist today.

It's not an 'inequality issue'. I don't have much problem with inequality of wealth or inequality of experience. It's just my experience that most people do and would rather pull down those who can afford better even if it hurts themself.

We still have the rampant inequality today. I believe NYU Langone let's people pay a large yearly sum for access to a special phone number and "skipping the line" on appointments.

Believe it or not, if you have a lot of money you can purchase nicer things than most people can afford

that hides a lot of detail.

Like just chopping off a leg instead of spending a 12 hour operation and months of physiotherapy to save it.

Letting people die from chronic conditions instead of managing them.

Letting old people die, because the cost of medical treatment was too high.

Not performing operations for heart disease, so people got one heart attack and then died a year later.

Which we could totally go back to, it really is a lot cheaper.

That's American healthcare for the majority of Americans. Luckily most old people don't worry about this because of Medicare.

Medicine was much cheaper then, mostly because if you had any of the sicknesses that require 100 000 USD drugs now - you just died.

Part of it is patent law, part of it is dysfunctional American healthcare system that drives prices up, but big part of that is that medicine just got much better and much more inherently expansive.

I cannot imagine this covers access issues. There are a great number of communities without wealthy people near them.

Its already an issue in some areas where the Medicaid patients dominate over private insurance patients. Often times hospitals balance things by overcharging those they think they can.

I think there is much more expensive tech in medicine today. But in general I would be fine If I had affordable health care that’s maybe a few years behind the cutting edge. In most markets things get commoditized and cheaper but this doesn’t seem to happen in health care.

Perhaps a market analysis of medicine in the u.s. doesn't work because it isn't really a market, but more like a cartel. This also provides a good frame for understanding how it is that nothing improves: how do other cartels interact with governments?

I'd be fine if it was akin to airlines. More private suites, if you are willing to pay a massive premium. Pricier food. I would find it abhorrent if standard of care is any more economically stratified than it already is.

Why does nobody look at the medical profession as the racket it is? You don't need to be an MD to handle %80 of hospital visits, and you can train trades people to handle most emergencies.

Insurance companies are awful, but seriously, we can train field medics to do stitches and set bones, why should it cost $3000 to have an MD do it? Listening the hand wringing about it is infuriating when you realize that the reason you have to wait for simple procedures that barbers used to do is because there is a med school bottleneck.

Everyone with absolutely no knowledge of our healthcare system "look(s) at the medical profession as the racket it is." They then proceed to point at things as the root cause that every health policy expert in the country can tell you is not the root cause, and that doesn't hold up to even slight scrutiny by comparison with other, similar, countries.

Could that just be a way of saying that health policy experts are attached to the status quo? Do they have a consensus on how to fix commonly cited problems, and agreement that we ought to?

Yes to both of the latter, but no authority to do so. Academics ain't legislators.

So, I've spent over a decade consulting to public sector health agencies in charge of delivering everything from electronic health records to cancer research to chronic disease management, long terms care, mental health, and privacy, among many other areas.

Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.

Oh, I didn't judge you on your professional history. I judged you on the content of your comment - that is to say, on the merit of your statement rather than an appeal to authority.

That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude.

As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.

The #1 job of policy analysts is to preserve their ability to make policy. While you have spent a respectable amount of time working in bureaucracies, a criticism of the legitimacy of those institutions' ability to improve outcomes is not something people encounter on the inside. Meaningful endogenous change isn't going to happen.

As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers.

Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.

So what's up then? Or if you can't say what's up -- fair enough, you're not an oracle -- what slight scrutiny in particular topples this particular root cause hypothesis?

It doesn't cost 3k to have an MD do stitches. That money's going somewhere else (Actual experts may or may not know where).

I ama surgeon in MA. I get less than $800 for a hernia repair. That includes all the face time with the patient, explaining everything, doing the procedure and taking care of him after. The hospital gets $8000 and lets me use a 'special' room for an hour and another 'special' place for a few hours for the patient to 'sleep off' the anaesthesia. The doctor who provides anaesthesia gets <200$ for every 15 minutes. The gases and his machines cost a multiple of that. Hospitals inflate their costs by running red budgets (basically up spending for everything so they can justify higher budgets). A urologist in my facility who does robot surgery gets $1500 to remove a prostate for cancer. The hospital bills $80,000 for the procedure. And cancer surgery is being permitted even though a few weeks' delay will make little difference in the outcome for most cases. The hospital, who rents me my office by the way, is not giving me any breaks on the rent even though my business is down 50% . Even comcast gave me a $100 rebate because my volume is down. Can you imagine hospitals as corporations worse than Comcast?

The concept of 'efficiency of scale' does not translate to service industries. The only efficiency that happens is efficiency of funneling more money to higher salaries of higher executives. Hospitals are driven by profit and their incentives do not align with the precepts that led to their formation.

Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it.

By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage.

If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure."

Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1]

We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them.

[1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.

can I say 'bullshit' here without being rude? Hospitals ONLY provide services they can profit from. They could have a doc in an office to do the stitching you refer to. And save a crap ton on overhead. By offering a 'luxury pathway' not only do they up their profit, they make everyone else who is trying to save money for the system look bad. Hospitals CHOOSE not to offer cost effective care because there is less profit in it. And then they hide behind Stark regulations - 'we cannot help private practitioners, sorry'.

The primary issues - root cause - of our systemic faults lie in approximately three places:

1. We are fractured. There is no "healthcare system." That's a singular noun. We have a marketplace: that means things like three top-tier specialty centers in walking distance of each other in some areas, and nothing at all in others. About 90% of our problems derive from this. As do a number of our strengths (if you're in Boston, you should never have to wait more than two weeks for a colonoscopy. Ever.)

1a. The healthcare "system" is not equivalent to hospitals. Hospitals are a single strain of profit-seeking enterprise (non-profit hospitals are the same shit.) People keep confusing the two, resulting in advocacy for policies that just concentrate power harder into the hands of a few, massive, corporations.

2. We are bipolar. A huge, huge proportion of our healthcare dollars flows from medicare. A large portion of our people are uninsured or underinsured. The result is that healthcare operations are built (generally) around Medicare's billing practices and needs - that's what you optimize on to stay afloat. This means when someone uninsured comes in, though, they're thrown into an operational flow for which they're barely an after-thought. Prices set as a negotiation point with private insurers are brought to bear against uninsured people - and they get nailed with ridiculous, unpredictable prices that have nothing to do with... almost anything. These people either need to be brought under the umbrella of contracted rates (Medicare For All), or I don't know what. You're not going to convince an organization with operating margins <2% to launch a massive operational restructuring to accommodate people that generate <<1% of its profits. And don't think there isn't legislative collusion in this - in places like CA, hospitals are obligated to go to collections for all patients. They used to say, fuck it, that guy was poor as fuck, write it off as uncollectible and deduct it as charity care. The state didn't want to lose the tax dollars the hospital didn't bother collecting, so now hospitals are required to send those indigent patients to collections, or else the hospital has to eat the entirety of the cost - not even a tax deduction to soften the hit. That adds up to a lot of dollars.

3. Unfunded Mandates. Every policy change pushed through our healthcare system is perceived as targeting "those wealthy doctors" (doctor != hospital != healthcare system). Most docs I know drive a Nissan Altima or a Camry - they're middle-class cogs buried under debt. But the stereotype makes a good excuse for pushing policy changes and then not allocating money to accomplishing them. Which means every policy change fractures the system further apart socioeconomically - you have wealthy-client practices that can afford to stop taking insurance, opt-out of Medicare, and thus avoid all these unfunded mandates... and then you have everyone else. Which puts basically everyone but hospitals out of business, because only hospitals have the capital and the scale to be able to meet the new requirements. You think FB likes privacy regs because it builds a moat? Hospitals don't just get moats, they basically get to buy up every small practice in the area at cost. Your local PCP is small and nimble enough to say "oh, you're uninsured? Fuck it, $40." It's the hospital that says, "Oh, we'll send you a bill later," and then ho boy, get ready. This also includes getting docs who are super-bought into the status quo: "We profited off charging you hundreds of thousands in tuition. We sold the idea that you'd be set afterwards, and could just be a good doctor. Turns out that while paying off your loans, you're just middle-middle-class, after having been impoverished into your 30s. And now, for the good of society, we'd like to cut your income by another 20%, while asking you to continue working like a madman. No, we will not offer you one penny of federal loan forgiveness, even though it is the federal government that is gutting your income. In fact, we won't even let you declare bankruptcy - that's cause for revoking your license." Yeah, docs are going to buck really hard against most changes in hc reimbursement. Even so, look at organizations like Doctors For America - a shit ton of docs still agitate for reform, for the good of their nation, if not the good of their own pocket. A related point is the "shortage" of docs: training positions in hospitals are funded by the federal government. Funding which barely crawls. "We have a doctor shortage!" "Will you open new training positions?" "No." "Then..." "No worries, we'll have nurses take some night classes, skip the entirety of actual residency training, and then we can call them doctors, too! We'll just confuse people by telling them they're going to see 'providers', and that way we can avoid paying doctors for doctoring."

There's a lot of other headline bullet points, but most issues in American healthcare boil down to an interaction of the above three.

edit: I should add, big picture, that healthcare isn't magically divorced from the rest of our social ills. As wealth inequality grows, bear in mind two things: (1) wealth correlates to health, and disease burden to correlates to poverty, (2) people can still vote themselves healthcare allocation (i.e., medicaid). The result is that increasingly more disease is concentrated among the increasingly impoverished, which means they're legislatively allocating themselves healthcare ... without the resources to pay for it. Whether or not you like or dislike any of the above, a lot of our issues with hc reimbursement are linked - directly or indirectly - to questions of wealth inequality. Adjusted for inflation, most docs have seen their real income stagnating, hard, for decades - and that's specifically as a result of trying to cheapen them, because they're increasingly paid for with redistributed tax dollars rather than anyone actually buying healthcare.

The healthcare system in the US isn't a marketplace either. For markets to function you have to know how much something will cost before you buy it, and you have to be able to make decisions based on cost. For most Americans, health pricing is a black box indirected by hospitals and insurance companies. And good luck getting an ambulance to take you to a cheaper hospital in an emergency.

So does the developers. Anyone can code and do %90 of what a developer can do with a very little training.

Yet, these are highly paid jobs because It’s not about being able to do it, it’s about understanding what they are doing. This way, they don’t just know how to do it but why to do it and what are the implications of doings it and how to debug it when the outcome is not the expected one.

Any junior can probably do %99 of what their seniors can do, yet when you look for a highly paid senior you don’t take a cheap junior as an option.

US health system might be a racket but not the health profession. No where else visiting a hospital is a financial decision(yet the med staff is still well paid), you only worry about the medical issue and it’s impact on your life and the lives of your loved ones, except maybe when you need some very novel treatment for your rare condition.

I have to add that this way of thinking, in general, is a very blue collar mental model on how world works. Nurses claim that they can do what doctors do, mechanics claim that they can do what engineers do all the time.

There isn’t a legal requirement to have gone to programming school before one can practice software development. (And a good thing too!)

If someone wants to hire someone who can kinda program a little, because they charge less, and are likely able to accomplish the task the person has in mind, then they should be free to do that.

(Of course, if the task is one where failure causes a big problem, then one should get someone more qualified.)

> There isn’t a legal requirement to have gone to programming school before one can practice software development. (And a good thing too!)

The vast majority of developers cannot kill you if they screw up. In the cases where that isn't true, e.g. software for medical equipment, I'd expect to find some significantly higher hurdles to get past before you can release that software.

We don't generally require developers to have certain qualifications, but their output can be measured in other standardised ways nonetheless.

> their output can be measured in other standardised ways nonetheless.

What are these standardised ways to measure developer output? I've never seen any, beyond "burndown charts" and "LOC", which I don't believe pass the sniff test.

One example of a standard software might comply with is MISRA C [1]. For that, you ignore a large chunk of the C language to something much less prone to bugs. Others might be HIPAA compliance, how you handle personal information to be compliant with GDPR or the VW diesel emissions scandal a few years ago.

[1] https://en.m.wikipedia.org/wiki/MISRA_C

Lots of professions can kill people of they screw up. LOTS. Our society has various ways to deal with this.

That’s only because of the size if the impact if things go wrong. You need a license too to build a house or drive a truck because it’s actually very easy to do it %99 of the time well but you can’t afford that %1.

Low affordance causes spilled blood, blood causes regulations.

I would argue that bus drivers have a much larger impact in terms of lives lost if things go wrong, yet they have significantly lower wages and require less training. The same goes for pilots and air traffic controllers.

You can argue that but what’s your point? The current truck driver training system works well enough AFAIK. Do you demand more training?

How is it decided how many regulations are "enough" for a given field? It seems they are on an ever-increasing ratchet mechanism, often driven by mass hysteria.

> There isn’t a legal requirement to have gone to programming school before one can practice software development.

It is if you are developing software in some high risk settings!

A sibling of mine is a very highly paid medical specialist. She studied, worked and studied more doing exams into her early thirties. Combined with having to travel a lot to get experience meant she wasn't able to settle till her mid thirties. Prior to that she earned good money but worked insane hours not including study time. I know because I stayed with her sometimes. I work in a pretty stressful job but I couldn't handle the stress her job entails on a daily basis where she sees extremely ill people in theatre and whose lives are literally in her hands both there and later in the ICU. She's well into her fifties now but still one week a month had to be available to work in the middle of the night if called on a rota. She earns a good multiple of what I do but I think she earns every penny.

The current system restricts the supply of medics and results in overwork, often sleep-deprived stressed people in a rush to make decisions. It would be better to allow more people in who can take more time and consideration of each case.

Yeah, it's definitely not the insurance companies that extort everyone for outrageous fees under threat of death thus creating most profitable industry in the world, yet producing nothing of value whatsoever who are the problem, it's all the doctors fault.

This. Insurance companies want medical procedures to cost more so that they can charge higher fees and punish those who don’t choose to participate in their industry.

Exactly, it's the same for car insurance where (industry-wide) high repair costs mean the insurance industry has more turnover from which to extract a percentage profit margin. Exactly the same forces apply for medical insurance.


This gets so rarely uttered if ever I'm having a hard time believing it hasn't been down voted by hyper-credentialists on HN.

I fully believe the number of doctors allowed to start practicing medicine is heavily controlled using arbitrary rationales and spurious education / training thresholds.

There's no need for so much garbage bureaucracy in medical pedagogy especially when so many doctors are paid insanely lofty salaries.

The whole enterprise of medicine and the way its practiced in the U.S. ( including HIPAA ), needs some heavy de-bloating.

LOL. I agree with you- healthcare should be way more accessible and affordable. But I suspect that if you looked at what it costs to train and deploy a field medic in today's military, you would find that it is a lot. And the many reasons for that very high expense probably echo some of the issues that also exist in healthcare. Hint: the MD isn't getting anywhere near $3000 to do your stitches.

If you were to drop the arms training and all that stuff from a “civilian field medic’s” training surely the cost would come down. Not to mention that the Airfoce purchasing $10k toilet seats and related financially irresponsible decisions would probably be less likely to happen in any non governmental org

I think that there are certainly some issues with an artificial scarcity of doctors as well as overly restrictive regulations requiring MDs for certain procedures that don't require MD training, but the evidence shows that this is not the main driver of high costs. Physician salaries are only about 8% of healthcare spending[1] and according to my own research, only about 20% is due to all healthcare worker salaries (including physicians, nurses, physician assistants, etc. The remaining 80% is medicine, medical supplies, capital costs (MRI machines, hospitals) and administrative costs. Unfortunately there's no single cost that could instantly solve everything if eliminated; there's just a lot of middlemen each taking a tiny portion that add up to a huge total cost.


There are plenty of ways it could be made cheaper, hugely cheaper, but the regulatory system protects the established players / methods and prevents competition.

"Do you want the best medical care?"

"Of course" says everyone because it seems like an easy answer.

"Then you're sprained ancle will need a team of 20 super MDs, an MRI, CAT scan, sterile isolation ward and a helicopter to get you there. That will be 100 million dollars please!" says the greedy fuck maximising profit, and he's giving you what you said you wanted...

This is basically the US system in a nutshell. Other nations have an approach with more focus on affordability, but the US system (from hospitals, to doctors themselves, to insurers, to drug makers, to the courts) is entirely focused on maximum quality. That's what makes it unaffordable. That's also why you don't have teired treatment like you say: an MD is 0.5% better than a trained nurse at setting a bone. They cost 100 times more. But you decide purely based on the 0.5%

My sister is a veterinarian. Honestly, I think I’d rather have her give me stitches than most doctors. She’s had to give so many more than most doctors.

I am a veterinarian too. It's ridiculous how stitches are so impossible to have access to (at least where I live). Last time I had a coworker fix me up after a bicycle fall (was on the elbow sadly, could hardly do it solo), not because of cost where I live, gladly, but because a MD can't stitch me, so it's either the emergency department, or MD and then only referal (so yet another appointment and all the trouble that is) to a surgeon.

I mean I get it, wounds can turn (really) bad, but other people than MDs (like nurses, or pharmacists were even discussed for this in France) should be able to do them, and give a follow up appointment to some MD / nurse a few days later to check if recovery is going well. Only time tells how the healing goes anyways.

After seeing a vet work on a horse that had its leg stripped of all of its skin, I would agree.

Most doctors aren't surgeons though.

Because it's not. If you actually look at the numbers doctors only get about 1/3 of the money. Furthermore with the kind of money you have to loan it would make no financial sense to become a doctor. Noone is having a good time with this system. Doctors want the insane amounts of work and stress coming from the lack of personnel that justify the salaries just so they can pay the student loans.

Other countries have fully trained doctors yet they don't have this problem. Therefore fully trained doctors setting bones is not the problem.

It's another problem or set of problems that occurs in the USA.

In the 19th and early 20th centuries there was in the US a proliferation of medical schools - many unaffiliated with Universities - with very few entrance requirements, extremely uneven quality of education and little standardization in curriculum. In fact many people became doctors through apprenticeship right up through the turn of the 20th century. Many states had extremely lax or nonexistent licensing requirements. It was quite chaotic and unregulated.

In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations.

The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day.

The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues.

Targeted reform of the system is the best solution for American healthcare.

The number of physicians per capita in the U.S. is greater than Canada or Japan, both of which have cheaper healthcare. Yes, apparently most European countries have a significantly higher ratio. But, interestingly, all the Anglo countries (UK/GB, US, AU, IE) seem to cluster together.

The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes.

Data: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location...

EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.

The regulatory restrictions don't just apply to the doctors themselves, but have expanded to stifle innovation in every part of the system, from hospitals to equipment to drugs to administration. Each takes its toll.

“fully trained” has a different meaning in other countries. In the US the number of doctors that can be “fully trained” is artificially limited. Furthermore, many countries with cheaper healthcare have abbreviated training for doctors.

> abbreviated training for doctors

I mean do doctors really need to spend 4 years getting a bachelor's degree in "pre-med"? If you know you're going to be a doctor why not just start off with biology, anatomy, physiology, chemistry in year one and go on to cutting up bodies in year 2? It seems utterly ridiculous to spend 4 years majoring in humanities, or calculus[1] only to seek entrance to med school.

The UK doesn't feel the need to do this.[2]

1. https://prepexpert.com/pre-med-class-recommendations/

2. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...

You are speaking from a place of ignorance. The prerequisites needed to take the courses that you mention alone are >1 year, yet alone all of the material needed to become a doctor. Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other. If you don't know what a nucleophile is then you simply can't pass biochem, and that's how it should be.

Granted, you could theoretically shorten the program by removing all the humanities courses; but shouldn't doctors-to-be take ethics courses?

> You are speaking from a place of ignorance

You're right, I hold my hands up. I don't have any medical training.

> Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other.

You obviously know what you're talking about and I won't debate you on how this works. But again, does a prospective doctor need to spend 4 years on this? How does every country other than the US and Canada manage to train their doctors without making them get a Bachelor's along the way in something non-medical? Why can't doctors study 5 or 6 years and graduate with a medical degree, ready to become a general practitioner? That's how they do it in the UK. Are you saying their docs didn't pass biochem or don't know what a nucleophile is?

> shouldn't doctors-to-be take ethics courses?

Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree.

My apologies, I didn't mean to come off harshly, it's approx 3 am here so I'm not exactly a ball of sunshine.

Do doc's need to spend 4 years doing an undergrad before med school? Maybe. There are a lot of things that you need to learn before you can learn what you need to be a doctor. Do you need to know physics? Eh, only kind of.

I'm not terribly familiar with the system in the UK, but at least where I went to school, most of the folks who were planning on going to med school studied either Chem, Biochem or straight Biology. In fact, it was something of an issue because the Chemistry courses tended to be weed out courses, i.e. you had to pass Organic chem 1 & 2 with a (3.0+)/4.0, or you didn't have a ghost of a chance of getting in to med school. I, personally, didn't know anyone who was planning on going to med school who was studying anything outside the STEM umbrella.

>Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree. Reasonably. I was really only picking on this point because of, what I had thought was, a dismissal to the usage of the humanities as a doc.

If it's anything like CS there's maybe a couple of semesters of applicable material and a bunch of filler to extract money for the university.

Good news! It's not anything like CS.

Things you need to learn, not an inclusive list, before med school: Chemistry, drug interactions, A&P, Ethics, Statistics, Maths, and Biology.

That's (6, 2, 1, 2, 3, 4) 18 courses minimum. Remembering that they have to be done sequentially rather than concurrently and you're looking at, bare minimum, 2 years rather than 2 semesters.

This is as it should be. To bring it back to your CS example, if you are making a web app and you fail to secure your attack surface, the worst that happens is that folks get their info stolen. If you fail to do your drug interaction math correctly, people die.

In other countries banks don't make five+ figures on every doctor's education, and their doctors certainly don't make enough to service six figures in education debt.

Finance capitalists keep the vicious cycle going. Doctors' unions scratch and claw for high comp because without it their new entrants are screwed.

100% on the (fiat) money.

The 250k+/year US salary of the fully trained doctor setting bones could be a problem. Many doctors are paid significantly less in many of those other countries.

It's not, though. It takes under an hour to set a bone, so that doctor's time is not driving the expense.

Why do I need to see a doctor to get a mole or skin lesion checked? Why is it necessary for someone to go through 4 years of undergrad, med school, etc etc just to examine a mole and remove it with a scalpel?

Are you trolling? Are you legitimately asking why you need a doctor to check something that might be, amongst the million other possible complications, Cancer?

The mole-specific training is probably a couple of months, max (if that's all the person needs to do). Division of labor.

Go back a step further. Why do they need a big income? Because they took on lots of education debt. Why did they take on so much? Why is it so expensive? Because the usurers extend that much credit.

The free market in shampoo is okay, sort of. For a lot of other stuff "free market" + fiat looks like a mess.

We don’t have a free market in healthcare. We have a highly regulated one. Free market healthcare is lasik and boob jobs. Both have come down in price because they are not part of the insurance system. They’ve also gone up in quality due to competition and demand.

Dental care is also a 'free market' and I don't think I need to say how much of a disaster getting any sort of dental work can be in the US.

Why haven't dental costs fallen through the floor if it's a free market?

It's covered by most employer health plans, so patients don't see the true cost and don't shop around much. That's not the case for lasik or elective plastic surgery.

Of course since the latter are elective, customers have the luxury of shopping around and taking their time.

I'm not sure where you've been employed, but dental plans have always been separate from the actual health plans and generally cover nothing beyond giving a pittance per year that hardly rolls over. Once that's gone, you get to pay the full cost.

I've had to deal with the true cost of dental work and I can guarantee you anyone that's needed to deal with significant dental issues has had the same experience. So why hasn't the free market dropped down prices? Why are we still paying more for basic dental work compared to other countries?

"Do no harm" sounds suspiciously like "don't be evil": https://en.wikipedia.org/wiki/Iatrogenesis

Just as with politics, it's mostly well-intentioned, "good people in a bad system"; nonetheless, each individual is perversely-incentivized to normalize the moral hazard.

The US has nurses and PAs for this stuff. A doctor is only needed as a staff supervisor, much like an engineering project only needs one licensed engineer to sign off.

It costs <$300 of an MD's time to set a bone, even if you get MD service. GP doctors aren't very expensive. The costs are elsewhere.

> You don't need to be an MD to handle %80 of hospital visits

You do, however, need to be an MD to recognize some of the other 20% as not being part of the 80%.

> why should it cost $3000 to have an MD do it?

Let me suggest you fire-up a spreadsheet and start to calculate the cost structures surrounding healthcare in the US. I don't think you have enough information yet to fully understand the subject enough to answer the question you posed.

I'll suggest you model something like a team conducting surgery at a mid size hospital.

You have to model the cost structure each person in that room is subjected to. Three simple items are the cost of their education, malpractice insurance and taxes.

The next step is to estimate the number of people who support that team within that hospital. From administration to nurses and janitors.

Add to that external services such as labs.

Now calculate the equipment costs. You could dig deeper and understand the regulatory costs, taxation and liability equipment manufacturers are subjected to. Interesting point to note: The Trump administration had to guarantee protection from liability before anyone was willing to make even something as simple as an N95 mask for use in hospitals.

Now calculate the cost structure for the hospital. Again, regulatory, liability/malpractice, taxation, etc. If the ambulance service is independent, add them to the exercise.

If you run through the above exercise you will actually be surprised that it only costs $3,000 for an MD to perform a procedure.

Notice insurance isn't anywhere in these calculation. Health insurance is an easy to point to evil, yet it is perhaps the most insignificant portion of the cost matrix that drives the cost of healthcare in the US. In fact, health insurance is NOT a driver, it's a symptom. You cannot fix our medical system by manipulating insurance. If the costs are high, care will be expensive. If the costs are lower, care will become more affordable. And this will drive insurance costs down as a result. Insurance isn't the cause, it's the effect. Remember that next time you hear a politician claim that they can improve things by screwing with insurance. They are lying to you. Don't allow that to happen. Be informed.

Logically this may make sense, but in reality it does not. Other countries with more sane healthcare systems have costs that are fractional compared to ours despite having the exact same costs you mention.

If the equipment is the same, the admin overhead is the same and the education is the same, then that leaves only one real difference between us and other countries. And that's our Byzantine insurance system.

Education is also vastly more expensive in the US than elsewhere, as is malpractice insurance (and everything legal).

But the most striking difference is that everything is for profit. Health care.

> despite having the exact same costs you mention

Exact same costs? Surely you are joking.

Costs, regulatory overhead, education and taxes are different everywhere.

My wife pays tens of thousands of dollars per year in malpractice insurance...and she isn't even at the top of the scale in terms of these costs. The cost of education? An MD can graduate with anywhere from $300K and more in debt.

And lawsuits? Show me a place on earth where attorneys will go after anyone, medical industry or not, as quickly, easily and violently as they do in the US?

Show me a place on earth where the government guarantees student loans to the extent that university costs are bloated to the point of creating financial slavery for graduates.

Show me a place on earth where doctors have to order a pile of unnecessary tests in order to protect themselves from being sued.

Show me a place on earth where developing the simplest medical device costs tens of millions of dollars in regulatory fees alone (if you are lucky).

Show me a place on earth where bringing a drug to market comes with potentially billions of dollars in regulatory costs.

Show me a place on earth where a manufacturer of N95 masks and gowns is not allowed to supply them to hospitals during an emergency due to regulatory burdens, the fear of lawsuits and has to demand immunity from the president of the country before they are able to do so.

I tried to develop a relatively simple hearing device to help people who suffer from SSD (Single Side Deafness). We have someone in the family with this condition. I designed and built a device for her. She loved it. I then looked into going to market with it. The costs would run into the tens of millions of dollars (or more). There was no way to take that leap. And that doesn't include protecting from or fighting the inevitable lawsuits.

No, nothing is "the exact same". And that's my point. Unless you pull-up a spreadsheet and analyze the cost structure you will never understand why healthcare costs what it does in the US. It has nothing to do with insurance, or profit, or greed or any of the nonsense ideas being floated around --particularly by politicians who just want to manipulate the audience for votes.

This is a simple equation: If you want to lower consumer costs you have to lower the cost structure driving the process and resources necessary to deliver the goods and services they receive.

I would urge you not to form opinions as you have until and unless you have taken the time to truly understand the details of the matter, which is to say: Analyze the cost structure tree down to a good level of granularity and then see what you would change in order to reduce consumer costs. Insurance will not be on that list.

There's a parallel here, between the medical field requiring 8+ years of schooling to put in stitches, and the days (not so distant) when most software companies wouldn't hire you to write an online mortgage interest calculator unless you had passed classes in compiler design and calculus.

edit: that said though, your opening question is kind of odd - doesn't pretty much everyone view the medical field as a racket?

I think what he's getting at is the concept of a "trustful society". Essentially one like the Amish he describes: people act responsibly with the community's money.

You might well think this has broken down in America. There's both a lack of formal restraint in the form of laws holding down the price, like in the Swiss private health system, as well as a lack of informal rules like he's mentioned, preventing people who've hit their deductible from going nuts with their treatment. And the culture of suing doctors has led to even more issues.

The trustful society thing is interesting. A friend of mine lost a grand-uncle in Denmark a couple of years back. Now this guy had grown up before the welfare state, and took pride in not taking handouts that he didn't need. He lived on a family farm on an idyllic island called Bornholm. When he died, the authorities called and asked what to do with nearly 2M DKK of pension money he hadn't collected.

At the other end, you get people growing up having never seen what preceded the welfare state. You often get debates about whether the kids are spending their student allowances wisely, because obviously you see them around town and they are having a good time. This is a cash grant from the government that you don't even need to use for tuition. Are they being profligate with the state's money? It's a debate that keeps going.

> The trustful society thing is interesting.

Yes, it is, but it doesn't scale. It only works for communities that are small enough that everyone can keep track of the trust relationships and how well everyone is honoring them. The problem we moderns have is that many of us either don't want to live in such a community (even Scott notices this when he says there is something to be said for not having your neighbors judging your lifestyle all the time) or don't have access to one. So we have a different set of priorities, and we therefore have to make different choices and tradeoffs.

Is comparing the per capita cost of healthcare to that of U.S. really fair, especially when advocating adopting certain elements of the "Amish system"? The U.S. is pretty the worst example of keeping costs down; other first world healthcare systems cost much less than the U.S.'s with similar or better outcomes. I suppose it's reasonable because the Amish live in the U.S. but I guess the question is do the Amish do particularly well or does the U.S. just generally do particularly poorly?

I do think there are some interesting insights in the article though.

Edit: another observation is that the author is probably not putting enough emphasis on the additional cost of end-of-life care (though he does mention it), especially if he's correct that the Amish tend not to spend as much on prolonging the life of older people.

This model already exists in other forms in the US. One of them is called a healthshare. Usually a religion-based scheme where you pay in a certain amount a month, and then you negotiate with the doctor yourself, pay the bill yourself, and then get reimbursed by the healthshare if there is enough pooled money.

This does a number of things:

1) It puts patient skin-in-the-game in that they have the direct incentive to shop around and/or negotiate lower bills since they have to front the cost.

2) it removes the costly middle-men referenced in this article and all the administrative cost that goes with that.

3) It puts much more of the administrative burden on the patient because they have to negotiate and pay, keep track of things, then get reimbursed.

These three things result in reduced monetary costs, but add other costs like the patient's time and stress level.

Healthshares previously could only exist if they had been grandfathered in via a special provision in the ACA. Since then enough of the ACA has been eaten away that new healthshares are taking advantage of the resulting loopholes.

I'm surely hopelessly naive and ill-informed for even asking, but is there a reason a hospital or clinic couldn't operate 100% without dealing with insurance? Do such places exist in the US? We always hear how the hospital sends a bill for $40,000, then the insurance company argues that down to $2000, but woe unto you if you DON'T have insurance because you'll have a hard time getting that same deal yourself. Couldn't a hospital just... send you a bill for $2000, and if you can't pay it you either ask about their low-income waivers, get into a payment plan, or I guess get blackballed as a deadbeat?

It's a good question.

There are some hospitals that proudly make a point of not accepting insurance. They avoid the administrative overhead of negotiating insurance contracts and pricing procedures, and accordingly have a smaller salary footprint.

As a byproduct of not working with insurance, they're allowed to advertise standard prices per procedure, because there actually is a standard price instead of 3-5 different "negotiated" prices. This price transparency is a competitive advantage, and it means they can attract price-sensitive patients for elective procedures.

The competitive advantage of price transparency is just enough to make them competitive with insurance-taking clinics.

The difference is that, in these setups, your clinic lives and dies by its reputation. Being in a big insurance carrier's network will effectively guarantee you a baseline patient volume. Going it "on your own" means you get no such guarantees. It's a riskier proposition.

I work in health insurance tech, but if you're curious to hear it from the horse's mouth, Keith Smith is the head person of an insurance-refusing operation in Oklahoma: https://www.econtalk.org/keith-smith-on-free-market-health-c...

The Oklahoma Surgery Center isone such place.


There are cash-only doctors, or doctors who will accept cash as payment, and for what it's worth, the discounts for not using insurance can be substantial.

More importantly to me though was this less-talked-about perk of having a doctor who -- once he knows he's not just going to receive a negotiated rate from an insurer -- will actually take a little bit longer with you and hear out your complaints. Knowing that if you take longer, he can bill you more is actually a net good, IMO.

>Knowing that if you take longer, he can bill you more is actually a net good, IMO.

You can easily flip that around too. The healthcare system would become less efficient because time spend gets valued instead of results.

In practice what you describe in the tail end of your post is how it works. Except the hospital can’t blackball you for emergency care even if you have a history of failure to pay.

The hospital will work with you and put you on a payment plan if you don’t just disappear. If you stop communicating they’ll sell your debt to a debt collector which is a bad deal for both you and the hospital. They’d rather have you paying $20/month for ever then sell your debt.

That's not how it always works. Sometimes they reduce the price and sometimes they play hardball. You are completely at the mercy of the hospital who charges whatever they feel like. And if you, the insurance or the hospital make a mistake they are happy to send you a 300k bill that you will have the responsibility to clear up over the next few years by constantly calling insurance and dozens of doctors who all somehow got put on your bill.

Sure. And the insurance plans will all tie you up with requirements for their firms to justify it or they won’t pay.

This should be easy to find out. Hospitals are required to publish chargemasters because of the ACA, basically the list price for their services.

> Amish people spend only a fifth as much as you do on health care, and their health is fine. What can we learn from them?

Given this opener, it seems bizarre that the article doesn't use the word "diet" even once. The comment there by "Scoop" seems right on.

Google tells me the USA is estimated to have around 300,000 obesity-related deaths per year. Apparently [0] obesity is around 10% as common in Amish communities as in the USA as a whole.

Aside: this is compared to around 35,000 gun-related deaths, around 40,000 traffic-related deaths, and around 50,000 opioid-overdose deaths. Presumably the Amish are spared these too.

[0] https://time.com/5159857/amish-people-stay-healthy-in-old-ag...

Both obesity in the "english" group and the healthier lifestyle of the amish group are discussed by Scott in this article.

No, they aren't. The article makes no mention of obesity, and does not discuss the Amish's healthier lifestyle. Unless I'm missing something here? Do please be specific if I am.

I'm seeing a single relevant sentence:

> As far as I can tell, most of the secret is spending your whole life outside doing strenuous agricultural labor, plus being at a tech level two centuries too early for fast food.

If that's what counts for improving health, why doesn't the article discuss that, rather than discussing only healthcare? (That's not to downplay the important issues the article raises, of course.)

I think my point stands here. There's an unfortunate trend to treat the healthcare system as the answer to health problems, and to dismiss the enormously important lifestyle questions. Compare the opening paragraph of the article with what the article goes on to discuss:

> Amish people spend only a fifth as much as you do on health care, and their health is fine. What can we learn from them?

An article that explores what we can learn from the Amish regarding health, should spend more than a sentence on diet.

I think you're right, but I'd slightly disagree.

Of course you point does stand, and diet and obesity are important topics to discuss, and perhaps scot should have gone into (a lot) more detail. But that is not to say that every article should focus on those, it seems to me that having articles focussing on these issued as well is not a problem.

Like you said, more than a sentence should be spent on diet.

Perhaps you and I wouldn't be having this discussion if at the top Scot had given a disclaimer that he's only focussing on this one side of the situation and neglecting the other side for the purposes of discussion.

> This is how I feel about the Amish belief that health insurance companies are evil, and that good Christians must have no traffic with them.

That's not really what they believe. Here's a better description[1]:

> Amish commonly believe that commercial insurance plans undermine the religious duty of community accountability

They don't pay social security tax (really, an insurance premium_ for the same reason, and were exempted from it on religious grounds.

1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198134/

> Amish commonly believe that commercial insurance plans undermine the religious duty of community accountability

As an atheist I find the Amish's religious view quite attractive. Ignoring god, it becomes plain humanitarianism and about helping each other.

Aside: I suppose one could well argue that non-commercial insurance plans would be just a formalisation of community accountability. Edit: and that's pretty much exactly what's described in the article, only without calling it insurance.

Remember to question your assumptions. "The Amish health care system" is like saying "The Christian church system". Amish communities can vary greatly, as does their income, transportation, diets, lifestyle, etc. The only time I've ever gone to Fogo de Chão in downtown Philly on a Friday night, a large Amish family was eating nearby.

> For people who rarely leave their hometown and avoid modern technology, a train trip to Mexico must be a scary experience.

You mean when they're not traveling all over the states to do business with the English, or carting themselves around in wagons with electric lights, or fueling their diesel generators to power batteries to run power tools and heavy machinery they use to create products for English customers? .... I'm pretty sure boarding transport technology that's been around since well before the 16th century to talk to "outsiders" is nowhere near scary to them (especially after Rumspringa, for example).

It's easy to get into a romantic, over-simplified idea of a general people based on some preconceived notions about them, and those can often cloud further ideas and lead to things like cherry-picking data to support a theory that "sounds right".

“ The Amish have had a life expectancy in the low 70s since colonial times, when the rest of us were dying at 40 or 50. Since then, Amish life expectancy has stayed the same, and English life expectancy has improved to the high 70s.”

I found that curious. Why were the Amish living so much longer than others in colonial times?

Humans would frequently live beyond 70 years in preindustrial societies. If you look at ages when colonial aristocrats died in colonial America you'll see a similar trend.

What pushed life expectancy down was infant mortality, and communicable disease. Amish would have likely lived for longer than average simply because they didn’t live in cities.

There’s also the obvious problem of the methods of old statistics, did it include infant mortality and childbirth deaths?


Less exposure to disease.

They lead non-sedentary lives involving manual labor, keeping their bodies in good health. They also don't have frankenfood and tend to have actual food instead. I'm surprised people don't understand just how important these 2 factors are towards longevity.

This doesn't answer parent's question. In "colonial times", most people did physical labor and ate real food.

In general, the healthcare profession could do the same double-blind studies they do on drugs -- but on substances that are not patentable, such as vitamins, minerals, fruits, vegetables, natural herbs and plants, etc.

They could even do double-blind studies on things that are not ingestable, like sunlight, doing enough exercise, getting enough rest, etc., etc.

But will they, ever?

No they will not.

That's because they will not make any money if these studies are successful.

Quite the opposite.

If there is any successful study in one or more of these areas, it could very well have negative and damaging economic impact to the medical community.

I like Doctors, and believe that most of them are good, honest, decent, hard-working (especially now, during CoronaVirus!) people.

They are not the enemy, quite the opposite!

But we really need to think about double-blind studies on non-patentable things that could potentially cure people, or at least alleviate their condition in some small way.

That, and the FDA needs to allow those things as treatments that Doctors may legally prescribe, if the double-blind studies prove successful...

There are very extensive studies done on non-patentable lifestyle choices/activity/smoking which have had similar results over the last 70 odd years. These include the nurses study [0], the bus drivers/conductors study [1] and also the [2] Farmington heart study. The overarching findings here: maintain a healthy BMI (weight), maintain a healthy blood pressure, be active like 10k steps/day active, don’t eat too much processed foods. This will cut incidence of chronic disease a lot, although there will still be the outlier of a healthy 25/yo runner that does of pancreatic cancer due to genetics bc this is inevitable. This has been known forever, however no one wants to follow it because we have fat and sugar in everything.

Of course if we cared about preventive healthcare in the United States we could also greatly reduce the incidence of chronic disease and free up $$ for actually researching interesting aspects of disease and not just putting out fires.

[0] https://en.m.wikipedia.org/wiki/Nurses%27_Health_Study [1] https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2027... [2] https://en.m.wikipedia.org/wiki/Framingham_Heart_Study

They could even do double-blind studies on things that are not ingestable, like sunlight, doing enough exercise, getting enough rest, etc., etc.

Is there any great mystery as to the health benefits of each of those items you mentioned that has gone unanswered?

Undoubtedly resources are commonly committed where there is opportunity for a return on that investment, but there are decades of research (and plenty of anecdotes too!) on each of the items you mentioned. I just don’t think they are packaged in a way you like.

I think of myself as a skeptic when it comes to healthcare and healthcare professionals - mostly because of the bravado and certainty healthcare professionals exude regarding the actual utility of what they think they know (which is, embarrassingly, not much much more than your average self-aware and discerning Joe or Jane Public). But even as skeptical as I am, I think you characterize healthcare, healthcare professionals, and the business of healthcare too cynically.

> the healthcare profession could do the same double-blind studies they do on drugs -- but on substances that are not patentable

But... they do? Pretty much everything you mentioned is well studied, although a lot of times it’s hard to get conclusive evidence when the effect size is small.

Why are those things not prescribed then?

Why are only pills, pills with which pharmaceutical companies (and usually doctors, via commission payments) make money, prescribed, and nothing else?

Maybe it's not the Doctors' fault however.

Perhaps the mindset was taught to them via most Medical Colleges and Universities, who accept large amounts of money from big pharma to teach that prevailing, patented-pharmaceutical-drug-centered mindset... and perhaps it was regulated into them by well-meaning, yet exclusionary and limiting government regulations...

I hold Doctors harmless... but they could prescribe less man-made products for profit, and more that are made by nature for free, or pretty close to free...

Because prescribing them doesn’t improve people’s health very much.

How would this be known, without conducting double-blind studies?

Again, pretty much everything you mentioned has been studied quite a bit. Yes, even with double blind studies (e.g. [1] to pick one at complete random). Some of the things you mentioned (diet, exercise, sleep) literally have entire subfields of medicine devoted to them.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514135/

If it's been studied a bit, and it helps people's health, then why isn't it prescribed?

When the evidence says they help they usually are. Losing weight, sleeping more, prenatal vitamins, etc, are all regularly recommended or prescribed by doctors. But, again, the issue is that most of the time the evidence is either inconclusive or says they don’t help.

That’s what universities and government are for.

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