When I lived in San Francisco, I worked freelance for a number of years and had no health insurance. It was too expensive.
Over time, I started having sever pains that shot through my abdomen and groin. I could barely walk. I had tried to go to the SF General hospital, but it took about a month to be seen by a general practitioner. I finally did get seen and they thought it could be a hernia, but were unsure. They scheduled more tests, which was about a 6 month wait. (I should note that SF General gets a lot of unusual people and the staff gets slowed down from dealing with the more difficult patients.)
Desperate, I found a small hospital clinic and asked them to see me. I told them I had to pay out of pocket. Oddly, the doctor who saw me gave me a huge discount. He diagnosed that I had sciatica from bad ergonomics. Sure enough, changing how I sat improved my pain! I was lucky. Very lucky.
Now, my sister is currently struggling with a serious issue, and as a Medicare patient (being under the poverty level), she wasn't able to be seen for months, and even now they are unable to diagnose properly due to delays in getting her referrals or tests (CT scans, etc).
I can't stress enough how uneven and cruel the US healthcare system is. I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.
This is par for the course in the UK. Not saying it's good enough, but it's truly par for the course.
NHS budget in 2021 was about £135B or ~$180B in USD, which is offered to the entire UK population ~67M.
Medicaid budget was $458B in 2020, offered to part of the US population (~84M).
So we have
UK: $180B for 67M people
US: $458B for 84M people
The only difference is that $458B is provided solely by the 270M Americans who, in exchange for their medicaid funding, are banned from using it.
So basically, we have an NHS in America but it's only for the people who don't pay for it. Then we have an entire secondary subsidization going on with health insurance which some comments above have pointed out is often tens of thousands per year.
May be relevant to this, that money probably goes a lot further in the NHS than in US system. Staff are paid less, hospitals run on lower budgets, less unnecessary tests, no billing systems, less beaurocracy (NHS has its serious IT issues, but not probably to the level of US healthcare) etc . The NHS is badly under-funded at this point, and more and more Brits resorting to private healthcare to jump waiting lists, and wards in hospitals are not exactly posh, and getting appointments is harder, and you can see things creaking. But I think I'd still rather be treated by the UK's system than USA, unless I was extremely lucky with the right kind of US healthcare insurance, lived near a particularly good hospital etc... If the US would simply adopt our system that everyone deserves treatment no Qs asked, I think that would make life in the US a lot better, for everyone actually, not just low income people.
I live in Romania and often wonder why there isn't more medical tourism...a good way to have a holiday and get a diagnosis.. I've had surgery done here, maybe I was lucky because it was dirt cheap but the hospital stay was beyond basic but then again I didn't stay long... I stayed the winter in Egypt and heard the same thing, cheap prices, good service... wierd not many seem to be taking advantage of combining travel and doctors...
> I can't stress enough how uneven and cruel the US healthcare system is.
Yes, and there is no doubt healthcare is expensive. I won't rehash the reasons it's particularly expensive in the USA; they're well-known, though there isn't strong consensus. But:
> I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.
"Obamacare" tried to remedy this by capping healthcare costs at 8.5% of income. Yes, there are holes (in particular, before 2021 this only applied to those earning under 400% of the federal poverty line FPL) and healthcare is even more egregiously expensive in those special cities where 400% of the FPL is below the local poverty line.
But whether you get subsidized by the state, a union, or your employer, the thing to keep in mind is that the costs of healthcare are ultimately still borne by "you": really, we, collectively, employees, union-members, taxpayers -- yes some of us are privileged enough to work for companies that are not financially constrained, but for most employers an extra $1000-3000/mo going to healthcare (you did say "family-level premiums") just feeds in to their total cost of employing you. Offering that benefit to employees means the pay they can offer you as an employee is constrained by its cost as well.
If having employer-based care is the only way to survive, then what that really means -- since money is fungible, really -- is that having the privilege of being well-compensated is the only way to have effective healthcare.
>> If having employer-based care is the only way to survive, then what that really means -- since money is fungible, really -- is that having the privilege of being well-compensated is the only way to have effective healthcare.
Anecdotally, it seems to be the current and foreseeable future.
I had a co-worker a couple years ago that had an undiagnosed condition (lupus) for many years because he couldn't afford healthcare. Once he had insurance, he was able to pursue various doctors for help. This is the pattern I've seen.
>> the costs of healthcare are ultimately still borne by "you"
Yes, and always will be, but costs have ben obfuscated for years. For-profit health insurance is one of the big issues, in my opinion [1]. Profit-making is largely apathetic to patient outcomes. I have no idea how to realistically change this current structure.
> Yes, and always will be, but costs have ben obfuscated for years. For-profit health insurance is one of the big issues, in my opinion [1].
I have no kind words for for-profit health insurance, having been burned by the industry myself. Being for-profit definitely doesn't help, but the non-profit insurers in the US are not much better. The truth is, the incentives are terrible all around, including -- and you won't read this in Stanford Medicine's quarterly magazine -- the fact that we train far too few doctors, nurses, and other medical staff, work them far too hard while not using their time well, and pay them very, very generously.
Then again, the cost of higher education has grown tremendously too, without (that many) for-profits taking a cut, and that's an industry where we face no shortage of qualified professors, work them harder (oddly) the less they get paid, and pay the ones teaching the most classes, well, let's just say it's not "very generously".
Perhaps the major commonality is that the people getting the service are often not the ones paying (at least, up front) -- either insurers or lenders are? That and also these are both highly human-capital-intensive industries.
> Now, my sister is currently struggling with a serious issue, and as a Medicare patient (being under the poverty level), she wasn't able to be seen for months, and even now they are unable to diagnose properly due to delays in getting her referrals or tests (CT scans, etc).
This sucks, and I’m genuinely really sorry that you and your sister are having to go through this. I hope she gets the care she needs soon and that the delays don’t cause any irreparable harm.
Unfortunately, the current issues with access probably have more to do with the way the pandemic has crushed the health care system than with whatever insurance your sister is using. My experience has been that getting access to services right now is much harder than it was in 2019. I’ve had referrals take 3 weeks just to get a scheduler on the phone (plus 1–4 month wait times), physicians wasting their time chasing people up and doing their own scheduling because their support staff no longer exist or aren’t doing their jobs, labs that don’t return phone messages. I even had a clinic outright ghost me last year. It’s an absolute shitshow out there right now.
(Also, pedantically: Medicare and Medicaid are two confusingly similarly named but distinct things. Medicare is federally managed for old and disabled people; Medicaid is state managed federally assisted for low income people. You can be on both Medicare and Medicaid at the same time because Medicaid will pay costs that Medicare doesn’t, but they aren’t the same thing.)
> I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.
I’m not sure even this is a long-term solution. A friend of mine who works for a very large financial institution as a software architect has had their premiums increase by 200%, OOP by 300%, and deductible by 400% over the past three or four years. They had to figure out how to absorb almost $10000 in new health care costs this year after the company eliminated everything except for some high-premium high-deductible plans.
We are currently hosting Ukrainian refugees and one of them was suddenly struggling to breathe. We brought her to the hospital two days ago and they made her sign a single sheet that says "you can request the social services on my behalf". Since then she's been transferred to another hospital, has been CT scanned and they did at least a dozen different tests on heart, lungs, etc. all it took was a few hours of waiting and the power of Google translate to make her be understood. We expect that she will not have to pay a single Euro.
Honestly I don't even need to tell you which country that is as that's what I would expect in any western or northern European country (except maybe Switzerland, which is its own capitalist hellscape).
The US is still the richest country in the world. That you are suffering is not needed. It is not a necessary feature of the system. It's a policy choice.
If your poor and in certain US states, Medicaid is pretty comprehensive.
Medication including PrEP, Metformin (for diabetics), sleeping meds and such are free, and you won't pay a single dollar for going to the emergency room or going to see your doctor. Dental coverage even exists too!
That being said it is a fragmentary system where those that do not qualify for Medicaid in states with good coverage essentially only have more expensive and varying quality options available. The quality of said options can be difficult to evaluate as an outsider to the medical industry as well.
I think Switzerland is not bad in this respect. There are several health insurance companies, but the basic plan's coverage and price is set by the government and it's quite comprehensive. Those who can't afford it get it through social services.
Switzerland locks you into obligatory health insurance, starting at around 200$ a month but with 2k franchise which you pay before you get covered or more like 400$ a month and then you're still liable for 10%of the bill...it's a capitalistic hellscape allright...sure you can get government subsidies...not sure what each cantons requirements are... the irony imo is that under the guise of competition people pay multiple management organizations of different health care companies a good cut ... they tried 7? times to vote by referendum to amalgamate them all but ¯\_(ツ)_/¯...
Also I've been through their "Urgences" triage in Lausanne with a menisque problem and they were incredibly inefficient and then had the gall to charge me 100chf and bill me for painkillers I didn't want...
As noted in this article, it’s insane that the wealthiest country in the world doesn’t have universal healthcare. I know Medicare is complex and not nearly as straightforward as I think too many people assume
Toward the end of the article, to quote:
> At any rate, when it comes to medical care, what’s wrong with socialism? The existing American system, with its dazzlingly inefficient mix of public and private insurers and its legions of redundant paper shufflers, is not a persuasive argument against it. Canada, which does have universal health care, spends roughly half as much per capita as we do, yet has better outcomes, including an average life expectancy that’s more than four years longer than ours. In fact, according to the World Health Organization, the U.S. ranks just fortieth, worldwide, in life expectancy at birth. That’s a little bit better than Ecuador and Poland but a little bit worse than Turkey and Croatia.
I agree wholly with this. Arguably when one of the most complex government programs we have in the US is better than average than the options left with private insurance, even after all the political machinery that messes with Medicare and our system as a whole, it should be obvious by now we are doing it wrong
Medicare, the little socialized medicine we do have, is unusable if you go abroad too. No vouchers, no treaties with foreign healthcare systems, no tax exemptions. You will pay in to Medicare your whole life and be required to burn air fuel flying back to the US to redeem any care whatsoever. The worst part is that often it stills ends up cheaper with medical tourism or getting local care.
I don't think that's a reasonable criticism of Medicare. Most other countries with universal healthcare do require you to be in the country to get that care. Europeans don't get much benefit from their universal healthcare when they leave Europe for example.
The EU is not a nation state, yet roaming in Europe between nation states they get universal healthcare. As do visitors from treaty nations outside the EU.
There are no good bilateral health treaties with the USA For a reason. As an Australian, I have private health cover for longterm services like physio, optical and dental services. For life threatening emergencies I go public and can do so in bilateral treaty countries.
That's how I understand the problem. Happy to be corrected.
I had Medicare on a temporary visa in Australia and had to go to the ER. I don’t think I ever got any bill at all. It was really amazing all the way around.
The contrast made me feel ashamed to be an American, to be honest. I grew up in poverty, and have internalized not going to the doctor for any reason besides an actual, literal life threatening emergency. My folks were volunteer firefighters and first responders, as we lived in an isolated rural area on dirt roads, so we were the closest emergency services, now that I think of it.
I’m back in USA now, and I still have to live that way, as I’m unemployed and trying to start a business. I have no assets and am nearly homeless. It’s no American Dream for everyone.
I wrote a bit about my Australian medical emergency here:
My healthscare is an admittedly unusual one, but it applies globally - with a single country exempt. I can get treatment in Sri Lanka, Greece, Moldavia, North Korea, Ghana or Iran and they will cover it. But not the US as ithat system is the most broken and most expensive in the world.
Canada's system doesn't cover you once you leave the country. Well, Ontario (each province is different), will give you $30/day if you're hospitalized but nothing more.
It's insane that it took Obamacare to finally push for the rollout of electornic health records. Before this, less than 20% of hospitals were doing it:
EMRs have been a handout of a fistful of dollars from actual doctors, to the software industry.
Its insane that anyone would think that politicians could be wise and mandate something that an entire industry rejected, and have never needed since the advent of medicine.
Result. Doctors spend time on screens instead of, seeing patients.
The emr is basically an accounting system for insurances to receive claims in a format they can process.
Anyone that tells you otherwise is making money from selling an emr to you or doesnt work in healthcare
Yes but rich people in the US live far longer than the average american. We have to keep that dream alive, the dream that if you just work hard enough and/or buy enough lottery tickets anyone can live a long and healthy life. And access to company-provided healthcare is almost as important to workers as thier wages. Fear of losing healthcare motivates workers to work harder. Take that motivation away and they might quit or demand more money. The stock market cannot afford that sort of hit.
A fully socialised healthcare system a la Canada won’t fly in the USA (this is obvious?). There are models eg in Australia where there is pretty good socialised care, and also a private system where you either pay up or have private health insurance (with a lot of extra costs). It kinda works, and gives some choice to the user. There biggest problem with this system is that private healthcare isn’t a great business, and the hospitals and insurance companies often struggle. They also don’t provide anything near parity with public healthcare. The most complex and sophisticated care still happens in the public system, which in turn means that the best doctors still want to work in the public system as well.
Is the canadian healthcare system even "fully socialized"? It's single payer, sure, but there's still private practitioners/clinics/providers.
>There biggest problem with this system is that private healthcare isn’t a great business, and the hospitals and insurance companies often struggle. They also don’t provide anything near parity with public healthcare. The most complex and sophisticated care still happens in the public system, which in turn means that the best doctors still want to work in the public system as well.
I've heard the opposite about public/private healthcare, at least in germany. Apparently there, the public insurance pays a pittance and is regulated, whereas with private insurance they can charge the market rate.
Life expectancy is a crappy way to measure how effective your health care system is. It's way to blunt a tool and has many confounding factors that have nothing to do with your healthcare system.
Anyone trying to picture a US “universal healthcare”, I want you to think back to your last trip to the DMV. The experience dealing with almost any aspect of our government is fraught with paperwork, delays, forms to fill out, “oh you want this other department” circular loops. You can put up with this torture for the “privilege” to drive a car, but you don’t get to force me to deal with this so I can get healthcare when/how I want to.
A while ago I went to an endoscopy clinic, and there was a woman crying and pleading with the secretary because her husband has cancer and couldn’t get treated on the day of his appointment because some medicaid paperwork didn’t go through regarding his diagnosis and thus medicaid wouldn’t approve the procedure yet.
Instead of telling people to make dishonest comparisons to unrelated bureaucracies, I’d recommend that they instead find someone who has actually used Original Medicare[0] (not Medicaid, which is a different thing) if they want to know what it is like to use Original Medicare. The amount of bureaucracy on the patient side is basically zero.
My personal experience with Original Medicare + Medigap has essentially been this:
Step 1. Need some health service.
Step 2. Go get the health service.
Step 3. There is no step 3, unless the provider fucks up and tries to bill the Medigap insurer as the primary insurer—which is a problem caused by the existence of private primary insurers, not Medicare.
And with private insurers, this:
Step 1. Need some health service.
Step 2. Check if the provider is in-network.
Step 3. Check if the facility is in-network.
Step 4. Check if the service is covered by the insurance.
Step 5. Submit a prior authorisation or else the insurer won’t pay anything at all.
Step 6. Get denied for some asinine technicality.
Step 7. Appeal and submit more documentation until they finally capitulate. (Also, you’re doing this while very sick.)
Step 8. Triple-check with the facility that they are only going to use in-network doctors for things like anaesthesiology.
Step 9. Go get the health service.
Step 10. Get a half-dozen gigantic bills in the mail.
There are certainly issues with Medicare, but I can’t think of any that aren’t the result of for-profit insurers or government abolitionists doing everything in their power to make the system intentionally terrible.
[0] As mentioned in the article, Original Medicare is parts A & B. Part C—Medicare “Advantage”—is the government hand-out to private insurers.
I'm no fan of our current healthcare system, but your description of dealing with private insurance is very much at odds with my experience. It has always been very simple and easy for me. (Doctors are a another story)
I never had a problem either until you try to anything outside of the ordinary. My wife needed some special treatment it was a nightmare to get approved I wasted hours on the phone to be told that the procedure was through another insurance company my company hired for this special procedure. They made so many mistakes I had to call once a week. At one point I had a 4 way conference call between both companies and a special hr person from my company to get this shit sorted out.
That is what pushed me to socialized healthcare private insurers can get fucked.
There are a lot of factors that determine how hard private insurers are to deal with—the kind of plan you have, the type and intensity of care you need, and the quality of the providers in your area/network—so experiences will vary significantly. I am genuinely glad it has not been so bad for you, and I’d love to say my experience with private insurers is the outlier, but unfortunately I suspect it is the other way around.
Every US-based friend or family member of mine has at least one horror story about a surprise bill, a Kafkaesque nightmare of denials and prior auths, being unable to afford their medications or doctor visits, unrealistically low annual visit limits (Depressed? No more than 12 visits per year to a therapist should cure that!), “copay accumulators”, and on and on. The podcast An Arm And A Leg[0] offers a disturbingly wide variety of stories of this bullshit and all the things you have to learn just to protect yourself from getting completely screwed in America’s privatised health care system.
It’s endless, and it’s exhausting, and it’s even more exhausting when folks like the OP show up to make baseless claims that government-run care is somehow going to be like going to the DMV because they’ve swallowed this “government is the problem” bullshit. I’m not going to sit here and say governments are infallible, or that Medicare is perfect, because they aren’t and it isn’t. But do you know which insurance plans in the US have the highest patient satisfaction ratings? The government-run ones[1]!
"Anyone trying to picture a US “universal healthcare”, I want you to think back to your last trip to the DMV. " - I think the truth in this, is the USA needs to solve the meta problem of having well-run government systems, before it can attempt universal healthcare. For various reasons, while the USA is excellent at many things, its poor compared to other countries, at running public services. It seems like a self-fulfilling prophecy to me. Americans don't believe gov't can run things well, therefore they don't even try, therefore it doesn't happen. When Ronald Reagan famously said the 9 scariest words were "I'm from the gov't and I'm here to help" , that message would have landed flat and made no sense to Europeans and Canadians, but in the USA that fits with people's experience. One big thing is the lack of an independent civil service in the USA. If I understand correctly, in the US when a new administration comes in they effectively fire all the managers and put their own people in charge. Whereas in the UK for example, there's an independent civil service who operate by a code of unbiasedly serving whatever administration is in and implementing their policies. While this means that sometimes there same people in their career implement one thing, then roll it back, then re-implement it, as governments change, and this may sound inefficient, in practice this means the public services carry on running reasonably well despite the wins and crazinesses of certain politicians that come and go.
So everyone gets Medicare A (hospitalization) who qualifies for Medicare (~40 quarters of SSI taxes).
You get Medicare B (hospital or physician administered drugs like chemotherapy) if you pay the premium.
Everyone should get Medigap, as Medicare A + B only pay 80% (or 90%?) of costs, so Medigap covers most of your obligation under A+B. Those with very low incomes can get a LLS (low income supplement where the government covers the gap).
Medicare C is Medicare Advantage is HMO Advantage. It's basically the government paying premiums to an HMO Medicare plan instead of providing the benefit directly themselves. It covers Medicare A+B+Medigap.
Medicare D is prescription drugs (drug you take home and give yourself). Your premiums are paid by the government but offered by private insurers. The choice here (and there are calculators) are more complex as there are multiples plans to choose from and they are updated each year and it depends on what drugs you're on or think you'll be on.
But it computes nothing for us. We all like to plug in our personal socio-economic numbers of what we have and get result … rather instantly. This here is the Internet!
Not everyone is good at math. Much less on SSA/Medicare/HMO policy and procedures. (But I am, as I compute this labyrinth for my senior citizen family members, each, repeatedly)
Over time, I started having sever pains that shot through my abdomen and groin. I could barely walk. I had tried to go to the SF General hospital, but it took about a month to be seen by a general practitioner. I finally did get seen and they thought it could be a hernia, but were unsure. They scheduled more tests, which was about a 6 month wait. (I should note that SF General gets a lot of unusual people and the staff gets slowed down from dealing with the more difficult patients.)
Desperate, I found a small hospital clinic and asked them to see me. I told them I had to pay out of pocket. Oddly, the doctor who saw me gave me a huge discount. He diagnosed that I had sciatica from bad ergonomics. Sure enough, changing how I sat improved my pain! I was lucky. Very lucky.
Now, my sister is currently struggling with a serious issue, and as a Medicare patient (being under the poverty level), she wasn't able to be seen for months, and even now they are unable to diagnose properly due to delays in getting her referrals or tests (CT scans, etc).
I can't stress enough how uneven and cruel the US healthcare system is. I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.