I think the rest of the developed world would cheer on if the US just copied any of the dozens of other models for universal healthcare that produce better outcomes cheaper than the current US system.
What we find shocking is that the US appears uniquely unable to fix these things among developed countries despite the vast wealth and resources. There's a level of political dysfunction that is really hard to watch, but also incredibly hard to ignore.
EDIT: To give one example that I personally find shocking: That Medicare has restrictions on the extent of its ability to negotiate drug prices. I get your point that this is in part due to entrenched interests as seen with the attacks on the recent attempt to fix this issue by using powers under the Inflation Reduction Act, but that even chipping away on things like that is proving as hard as it is, is bizarre seen from the outside and the new ability to negotiate prices is still ridiculously limited.
Check out the tsunami of white American kids refusing to get even the most basic vaccines (because Jesus) ... polio and other long-forgotten diseases are about to make a big comeback.
NY Times had a big story about this.
"Insane" doesn't do it justice. We need new words.
> "Insane" doesn't do it justice. We need new words.
Norwegian has another US-inspired term for crazy: "Helt Texas" ("completely Texas") [1]
(Though to be fair, that is mostly used for a hyperbolic allusion to the Hollywood version of the wild west, and translating it as something being "wild west" would perhaps better carry the meaning, but I still find it funny)
> I think the rest of the developed world would cheer on if the US just copied any of the dozens of other models for universal healthcare that produce better outcomes cheaper than the current US system.
"Just pick one" isn't actually a method of choosing when different people disagree on what should be done. People don't even agree that "universal healthcare" is the right target, rather than e.g. a market-based system with actual price transparency that would introduce competition for non-emergency care.
This is also ignoring many of the factors that make the US system so expensive. For example, the AMA has lobbied for regulations that require doctors to do a lot of things that could reasonably be done by nurses. This has been exacerbating an existing doctor shortage, so then doctors get paid more (raising healthcare costs) while impairing outcomes (there aren't enough doctors to provide a high standard of care). This is a regulatory problem created by a powerful lobby.
It's things like that which in the aggregate cause the US system to be what it is, but you can't fix them by copying some different part of the system from another country. You have to fix that problem in particular regardless of what else you do, but fixing it is the thing strongly opposed by the lobbyists.
> To give one example that I personally find shocking: That Medicare has restrictions on the extent of its ability to negotiate drug prices. I get your point that this is in part due to entrenched interests as seen with the attacks on the recent attempt to fix this issue by using powers under the Inflation Reduction Act, but that even chipping away on things like that is proving as hard as it is, is bizarre seen from the outside and the new ability to negotiate prices is still ridiculously limited.
You have to understand the context for things like this. Nobody is talking about negotiating the price of aspirin, which is a cheap commodity regardless of who you get it from.
The issue is drugs under patent.
The way the patent system is supposed to work is that if you invent something you can patent it and then charge the monopoly price for a limited time in order to recover your R&D. The monopoly price is based on the value of the invention. You can patent some dreck and try to charge a million dollars for it and nobody will buy it from you. But if you cure some fatal disease, the value of the cure is very high, which allows you to recover the cost of developing the cure, which could also be very high.
This is obviously not going to be efficient when the drug is being paid for by insurance or Medicare. If the drug company patents something which is only marginally better than the generic, anyone paying out of pocket would just choose the generic and save a lot of money. But if the doctor prescribes the patented one, the insurance is now expected to cover it and by law only the patent holder can make it, so they can charge high prices even though the person choosing which drug to take isn't the person paying the bill anymore.
This is dumb but it's not completely crazy. Sometimes drug companies get away with charging a lot because they patented "existing drug, but with Tylenol" and then convinced doctors to prescribe it. But it also means they can recover their costs for actual life-saving drug research. It's not serving its purpose efficiently but it's still doing something of importance.
So now you want Medicare to "negotiate" these prices. Basically what you're saying is that you want to reduce the intentionally-created subsidy for drug research, or shift more of its cost from Medicare to private insurance and the uninsured. Which is bad policy, but is favored by people who want Medicare's numbers to look better.
What you really want to do here is one of two things. Option one, give up on the model of patenting drugs and then having insurance cover the cost and instead just publicly subsidize drug research and immediately put the drugs into the public domain. Option two, make the patent system work as intended by exposing some of the cost to the patient, e.g. by having a 10% copay for prescription drugs. Patients would then avoid drugs which are extremely overpriced relative to their benefit and you wouldn't have Medicare paying high prices for "existing drug, but with Tylenol" anymore.
> "Just pick one" isn't actually a method of choosing when different people disagree on what should be done. People don't even agree that "universal healthcare" is the right target, rather than e.g. a market-based system with actual price transparency that would introduce competition for non-emergency care.
>
> This is also ignoring many of the factors that make the US system so expensive. For example, the AMA has lobbied for regulations that require doctors to do a lot of things that could reasonably be done by nurses. This has been exacerbating an existing doctor shortage, so then doctors get paid more (raising healthcare costs) while impairing outcomes (there aren't enough doctors to provide a high standard of care). This is a regulatory problem created by a powerful lobby.
>
> It's things like that which in the aggregate cause the US system to be what it is, but you can't fix them by copying some different part of the system from another country. You have to fix that problem in particular regardless of what else you do, but fixing it is the thing strongly opposed by the lobbyists.
The point is that pretty much every other developed country and a lot of developing countries have managed to figure this out, the first over 130 years ago, and they've all had to figure out how to get agreement, overcome the objections to having it at all, overcome lobbyists, overcome medical associations wanting to keep tight control, and so on. Not one thing of this is new.
This US exceptionalism is a bigger part of the problem than each and every one of these objections. You're just not that special other than in believing you're that special and stubbornly refusing to learn from what has worked.
> You have to understand the context for things like this. Nobody is talking about negotiating the price of aspirin, which is a cheap commodity regardless of who you get it from.
>
> The issue is drugs under patent.
This is not news. Every other country also has to deal with it. However, unlike the US, they have chosen to deal with it by negotiating best possible prices, usually by putting together portfolios of different drugs to negotiate over, and then deal with any perceived need to subsidise R&D into drugs that pharma companies aren't doing enough to address. The US is near unique in effectively letting pharma companies write public healthcare policy by making it a game of how to extract the most money from taxpayers.
It is, however, amazing how quickly the American belief in the free market collapses when someone suggests that Medicare should just act as one more actor in a market where the are already hundreds of other buyers negotiating the best possible prices.
> So now you want Medicare to "negotiate" these prices. Basically what you're saying is that you want to reduce the intentionally-created subsidy for drug research, or shift more of its cost from Medicare to private insurance and the uninsured. Which is bad policy, but is favored by people who want Medicare's numbers to look better.
The outcome is that you're misrepresenting the cost of providing care per patient by making the per-patient cost appear ridiculous when a huge bulk of it is an R&D subsidy that the entire world benefits from, that you're choosing to carry even for the half of the top 10 pharma companies that aren't even American, and that does not need to increase if the number of patients increase. If you want to pay that subsidy that's awesome, but when you're lumping it into Medicare it becomes an argument for not extending cover to more people because it artificially inflates the per-patient marginal cost of providing care.
> What you really want to do here is one of two things. Option one, give up on the model of patenting drugs and then having insurance cover the cost and instead just publicly subsidize drug research and immediately put the drugs into the public domain. Option two, make the patent system work as intended by exposing some of the cost to the patient, e.g. by having a 10% copay for prescription drugs. Patients would then avoid drugs which are extremely overpriced relative to their benefit and you wouldn't have Medicare paying high prices for "existing drug, but with Tylenol" anymore.
Or you can do what pretty much the rest of the developed world does: Publicly subsidise R&D (which the US also does - NIH grants for FY2023 are around $50bn) and negotiate best possible prices, so that you avoid creating perverse incentives to chase drugs to optimise the expected ratio of R&D expenses relative to ability to maximise costs to patients.
This willingness to actively defend a system that demonstrably is providing you substandard outcomes at the highest cost in the world is also fairly unique to American conditions.
> The point is that pretty much every other developed country and a lot of developing countries have managed to figure this out, the first over 130 years ago, and they've all had to figure out how to get agreement, overcome the objections to having it at all, overcome lobbyists, overcome medical associations wanting to keep tight control, and so on. Not one thing of this is new.
The difference is the structure of the US government. The original constitutional framework envisioned a weak federal government with limited powers, with this sort of thing instead being handled by the states.
The populist movement in the 20th century didn't like this, so they removed some of the most important safeguards ensuring that that remained the case -- but those safeguards were the only thing preventing the federal government from being captured by industry.
So now that's what's happened. It's a structural problem because we broke the constitutional safeguards originally present to prevent it. The problem is the change is sticky because to undo it you need the votes of the people whose undeserved power you're trying to take away. This has been a problem for much more than just healthcare, but nobody has managed to solve it yet.
> However, unlike the US, they have chosen to deal with it by negotiating best possible prices, usually by putting together portfolios of different drugs to negotiate over, and then deal with any perceived need to subsidise R&D into drugs that pharma companies aren't doing enough to address.
You have a patent monopolist selling to a bureaucracy which is the sole provider of coverage for a large number of patients. That isn't a negotiation. If the buyer isn't allowed to refuse to buy the drug then they have no leverage. If they are then the government is just setting the price and saying take it or leave it.
> It is, however, amazing how quickly the American belief in the free market collapses when someone suggests that Medicare should just act as one more actor in a market where the are already hundreds of other buyers negotiating the best possible prices.
A patented product isn't a free market, it's a government-granted monopoly. The entire point of the patent is to allow the seller to charge a monopoly rent for the duration of the patent term.
If you don't want to pay the monopoly rent then there shouldn't be drug patents to begin with -- but that doesn't get you out of funding the R&D in some other way instead. TANSTAAFL.
> The outcome is that you're misrepresenting the cost of providing care per patient by making the per-patient cost appear ridiculous when a huge bulk of it is an R&D subsidy that the entire world benefits from, that you're choosing to carry even for the half of the top 10 pharma companies that aren't even American
Yes, this is exactly the problem -- other countries "negotiate" (i.e. the government dictates prices) and thereby pay less than their share of the drug development costs. The US could do the same thing but then nobody would be paying for it and the world would have less drug R&D.
It doesn't matter where the drug companies are headquartered. They all use the money to develop drugs that patients everywhere then benefit from.
The ideal solution would be for other countries to pay their fair share of the R&D instead of the US having to pay disproportionately, but in the absence of any way to force them to do that, what should we do? The thing that causes more people to die because there is less funding for drug development?
> and that does not need to increase if the number of patients increase.
The more patients receive the drug the more valuable its development is and the more incentive you want to provide for that.
> If you want to pay that subsidy that's awesome, but when you're lumping it into Medicare it becomes an argument for not extending cover to more people because it artificially inflates the per-patient marginal cost of providing care.
The cost isn't artificial, it's amortizing the cost of the system being used to fund drug development over the patients who use those drugs.
Maybe that system could be more efficient, but just reducing its funding without changing its overall efficiency is only going to result in less drug development.
> Or you can do what pretty much the rest of the developed world does: Publicly subsidise R&D
That would be the first option that I listed?
But there are disadvantages to that. The patent system is imperfect but it has a different set of incentives than a grant system and consequently results in different kinds of research. It's plausible that we're better off with both than one to the exclusion of the other. In which case we shouldn't be so offended at not slashing the funding source for the one of them.
> This willingness to actively defend a system that demonstrably is providing you substandard outcomes at the highest cost in the world is also fairly unique to American conditions.
America subsidizes the rest of the world and then the rest of the world criticizes us for it. Are we really being lectured for not being selfish enough?
What we find shocking is that the US appears uniquely unable to fix these things among developed countries despite the vast wealth and resources. There's a level of political dysfunction that is really hard to watch, but also incredibly hard to ignore.
EDIT: To give one example that I personally find shocking: That Medicare has restrictions on the extent of its ability to negotiate drug prices. I get your point that this is in part due to entrenched interests as seen with the attacks on the recent attempt to fix this issue by using powers under the Inflation Reduction Act, but that even chipping away on things like that is proving as hard as it is, is bizarre seen from the outside and the new ability to negotiate prices is still ridiculously limited.