Consider most physicians are hundreds of thousands of dollars down in education debt and have been training in healthcare settings for almost a whole decade, and that significant time has been invested in a previous undergraduate course and to pass the MCAT. I think they are paid accordingly for their investment, and only 8% of that healthcare spending [1] accounts for physician personnel salary.
What is most baffling to me, as someone who isn't from America, is how expensive even the most basic tests are.
A CT or MRI (which are admittedly expensive machines) scan shouldn't cost >$1000, and it probably doesn't anywhere else in the planet.
I spent 11 years at university and came out with a medical degree and a couple of others for ~100k AUD, whilst also receiving government assistance whilst studying. The for profit education sector and price inelastic nature of demand have a lot to answer to
Unfortunately, it's a matter of where you get it done. Getting literally anything done at a hospital is highway robbery. That said, i get two MRIs a year at not a hospital and it's a couple hundred dollars, not a a couple thousand. It's not cheap, but it's a about 1K expense twice a year, which you can budget for.
I feel like this is the crux of the US's issue. We have medical care deserts and for many people the hospital is the only way to get something taken care of. This is where the US is different from many other wealthy nations. We really don't get economies of scale at all. We have cities, but a lot of our major cities juet have nothing like the population of other nation's major cities.
> We have cities, but a lot of our major cities juet have nothing like the population of other nation's major cities.
I don’t think this is it. European cities aren’t that big compared to American ones. So Spokane is larger than Geneva. The problem is there isn’t much in terms of healthcare between Spokane, Boise, and Minneapolis.
That's only if you look at the population of the named cities themselves rather than the population of the city plus the surrounding populates areas.
In Geneva's case, it is composed of several different named cities/towns/etc and those taken together are bigger than Spokane plus the municipalities that comprise its urban area.
Spokane metro is 579k. Geneva metro population is 633k. So Geneva metro has slightly more people than Spokane metro. Of course, the metro areas are wall to wall (so Geneva metro is adjacent to Lausanne metro) but they both have their own healthcare systems and aren’t gaining much more from scale than American metros.
And Spokane is a small case. There is nothing comparable to the Seattle metro in Switzerland. The closest you get is Paris in France or Milan in Italy.
On the chance this may be helpful, I recently used Radiology Assist [0] to self-pay for two 3-Tesla MRIs. Each MRI cost $375 - total - and included a radiology report and a copy of the MRI images. I have health insurance. It was cheaper to just pay for it myself. Also, Radiology Assist was able to get me in on the exact day and time I wanted, on short notice.
I have no connection to the company other than as a satisfied customer.
In Canada the typical MRI waitlist time is several months outside of emergent issues. You could go privately but it's tougher than you think to pay for this, as it's not well integrated with the public system and your family GP (if you have one). I guess I'm saying, cost is definitely one factor but our exclusive public-only system has got problems too
Canada has extremely few physicians, like USA. For healthcare to work well you probably need to reform your system to get more physicians, I don't think any system works well when you have too few physicians. You can see the countries with good public healthcare has twice as many doctors as Canada and USA does.
>> Well, physicians have to be paid accordingly for their time and financial investment... Baker estimates that the salaries of the roughly one million doctors in the U.S. account for about eight percent of total healthcare spending.
This is exactly the attitude as to how American costs are out of control. If American healthcare budget was halved (which is still much more per person than other nations), then physician salaries would be 16% of the total. If American healthcare budget was a quarter of its current total (in line with many other nations spending), then physician pay would be 1/3 (32%) of the entire spend!
Clearly, if American healthcare is going to see a 1/2 or even 3/4 cost cut as the proponents of universal/single payer healthcare predict, then physician pay must take a similarly massive cut.
Just as you can find reasons why physicians cannot take a pay cut, so too can every slice of the pie claim that their slice is valid and uncuttable.
Even now becoming a doctor is a dubious financial trade off in the states. Medical school and residency is going to take a huge toll, you’ll be underwater a long time before that $350k comes in. However, a SWE can make that without such an investment and without such a crazy work life. So now reduce that to $200k but with all the same medical school debt and stress requirements.
A lot of areas already have trouble attracting doctors at all because they can’t compete with the money offered by bigger richer cities. If you want cheaper doctors, something else will have to give, or supply will just plummet.
> Well, physicians have to be paid accordingly for their time and financial investment
Most of those doctors European doctors probably got their degree with almost no tuition paid. If I wanted to become a doctor I could start now, and finish in 5 years with zero debt. It wouldn't be an "investment" in any more than my own time and effort.
But I think this shows that the healthcare is just one part of a large interconnected system of things. It's not easy to change into a french or UK or scandinavian healthcare model with great savings if doctors expect to make $300k/year because they made an investment. So single payer universal healthcare might need more doctors and nurses trained with tax money? But when I go to a university to get my tax-funded MD, that university is most likely a public institution too. You wouldn't have a university taking a huge cut of that money.
OK I'd be a "physician" within 5 years (if I didn't fail). A "doctor" would be after a couple of more years, but those years are done working, with a salary, and the rest of the staff still calls you 'doctor'. Just like there are no unpaid internships for attractive jobs in law or finance, there also aren't any unpaid or extremely underpaid healthcare jobs.
On the other hand: a US resident dr makes what, $60k? That's comparable to European doctors. I wouldn't make $100k for quite a few years. The first "residency" period here would proabably be more like $50k or even less. But with zero debt that doesn't sound horrible.
> Well, physicians have to be paid accordingly for their time and financial investment. Consider most are hundreds of thousands down in education debt and have been in training for almost a decade
> What is most baffling to me, as someone who isn't from America, is how expensive even the most basic tests are.
If you understand the former, then why is the latter baffling?
So physician pay is a complex topic related to cost of education and artificially restricted supply, but pay itself is not as big a driver of healthcare costs as people imagine it to be. Estimates I’ve seen put it at around 10% of healthcare spending in the US. Interestingly, this research in 2011 found its estimate (8.5% in this case) to be comparatively low among western countries with universal healthcare systems: https://app.texmed.org/tma.archive.search/507842859111472161...
The US also spends frankly absurd amounts on drugs and devices. In my country, generic drugs are the norm and you essentially need special permission to be prescribed most drugs that are still on patent. I see a lot of Americans grumbling about their high out-of-pocket costs for drugs, but a lot of the drugs they're paying for simply wouldn't be routinely prescribed in my country on cost grounds.
I think it's basically a fantasy to imagine that the US could have affordable healthcare if only the system was reformed. Rationing of various kinds is the norm in single-payer systems, because everyone wants the insanely expensive new drug when it's their health and someone else is paying; I don't think that America can do much to control their healthcare spending if they aren't willing to engage in a serious conversation about what they don't want to pay for. Even Medicare covers tons of stuff that I wouldn't get from my universal single-payer system.
They're that. There is also the massive inefficiency of of having non-universal system, due to administrative operational complexity cost and marketing spending.
France is one of the less efficient in europe due to having a dual system, the universal part is very efficient (5% of budget spend on operational costs), the other part, operated by competing organisms, loses up to 20% of their budget on marketing, plus the general operating cost of having a multi tier for insurance coverage.
The US is a "Fee for Service" model, the more sickness, the more fees, the more profits for the medical system. In a "Value Based Model" you would get paid to keep people healthy.
maybe one of the reasons, but imo, not even close to the biggest reason - look at the diet and weight and sedentary lifestyle of the average american - that is likey a HUGE reason that people are not healthier - not because they didn't get go to a doctor enough.
and doctors don't even try to solve that problem anymore - they just push pills to counter the bad diet and bad lifestyle.
Built environment causing sedentary (and socially atomizing) life and cost of care seem like the two biggest issues. I think we should just start solving both instead of debating which is 1 and which is 2.
According to the research it’s mostly diet (what we eat) and the sedentary lifestyle. Less than 10% of people eat healthy. Most people I know daily eat food’s causing them harm (not neutral)
The US isn’t the only place people eat like shit, though.
The french and Aussies and English and Germans and Italians all have some unhealthy food habits, or excessive butter/cheese, or elevated alcohol consumption levels, etc.
You can point to activity levels, but weight is about food consumption, not activity levels, and (eg) Aussies are a pretty car-reliant culture too. Pretty much any way you can argue that the US is "unique" - it's not, we are a culture exporter and some other place has inevitably picked up some of our habits.
Americans aren't even uniquely fat anymore. There are other populations (like aussies) that are getting close to our obesity levels and they still don't 5x their healthcare spending. And the idea that obesity makes up even a simple majority of total healthcare costs (as it would need to be for this to be the factor that 2-5x's healthcare spending) is generally ridiculous.
(also, paradoxically, a lot of things that we think of as unhealthy actually reduce total life healthcare spending, because US care is heavily weighted towards end-of-life care. It's cheaper to die of lung cancer at 40 than to have three knee replacements and spend a month in the ICU at 80, and US health care is heavily weighted towards the latter because of medicare, everyone else struggles to get affordable access to the system.)
Like it would be interesting to see an attribution of what specifically americans are eating so differently vs everyone else, and the caloric/macronutrient balance and total inflow/outflow, and total life expectancy (and total spending) changes. I suspect it's just a "how much of it" more than anything, but the "gosh americans just eat like shit, that's why!" really doesn't justify 5x per-capita expenditures on the face of it, in the way people try to use it. The rest of the world drives cars and eats like shit, and eats too much too, in varying proportions.
But to go back to spending - it's really hard to argue that it's any one thing. It's everything. Everyone at every layer is bleeding everyone else. Americans are a bit unhealthier, but we also have for-profit hospitals (even non-profits make a "profit", it just goes into real estate investments), for-profit insurance, doctors who make $400k because they need to pay off $300k of loans from for-profit education, drug and device manufacturers who have no cost containment before approvals, a political system that tolerates evergreening and similar practices, an "access problem" for delivering basic care before it escalates into expensive problems (even "preventative care" often still ends up costing), etc etc.
That is really the problem and why the system cannot be reformed. Medical care is at the nexus of every single "unsolvable problem" of the US political system, from patents to education to farm-lobby and environmental regulation, and it involves a million taking hands that after a true reform will no longer be able to take. There is a lot of people who have become reliant on the revenue streams from this rent-seeking/unproductive activity, and they will lobby heavily to make sure they can keep taking.
The point can be made that interventions into these types of lifestyle's would have to come from somewhere. Probably a doctors visit could make a big difference in this type of lifestyle for some portion of the population. Maybe we need an Auxiliary location that's just full of dieticians and lifestyle coaches or something. Get people involved in a community, know their neighbors. These problems are systemic and the system is intractably large, but it's gotta start somewhere.
People wake up, go to an incredibly stressful workplace and use up all possible productive hours of the day, come home extremely tired, pop on the incredibly stressful news cycle and get permanently angry as they eat their TV dinners, then fall asleep in their chair as the news continues to unsettle and disturb them even in their most peaceful moments. I've seen this over and over again, it's how a lot of people live here.
There's a million places a resolution to this type of issue could start, but damn it's gotta start somewhere!
> Probably a doctors visit could make a big difference in this type of lifestyle for some portion of the population.
Most doctors are never taught to deal with lifestyle. It’s sick care with things like medications and surgery. Doctors office visit won’t address this for most.
Most people live lifestyles that lead to conditions. For example, most high cholesterol that cause people to use statins is caused by diet. Less than 10% of Americans eat a healthy diet. Doctors almost never deal with that and usually aren’t even taught that in school.
What if people just never had most of those issues that require treatment?
As far as I know, the link between diet and cholesterol was a myth that caused many of the bad diet choices people make today, such as replacing animal fats with (bad) plant-based fats like palm oil.
In a healthy individual, cholesterol intake is not related to blood cholesterol levels (beyond some reasonable threshold, like not eating a tub of lard in one sitting).
Americans visit the dr about as often as other oecd countries, it's just that every interaction costs about 5x in comparison due to crazy tangled insurance/regulatory overhead.
>> Holy cow, really? Is this a case of over-diagnosing things, or are virtually half of Americans legitimately struggling with multiple health issues?
There isnt much incentive in the US to prevent disease, doctors make their money from visits fees, procedures, etc. Not saying they purposefully make people sick, but I think there is some Darwinism in a system like this -- a hospital system that keeps people healthy would wither and go bankrupt because hospital systems dont get paid to keep people healhty, they make most of their money when people get very ill.
Over 1/3 of US adults have cholesterol levels that cause them to use or qualify for a statin. High cholesterol which leads to cardiovascular disease (leading cause of death in the US).
what usually causes this also causes a bunch of other chronic issues. So, yeah.
Life expectancy rates in the US were going down before COVID. Chronic illness.
The numbers aren’t looking good. Unless you’re trying to make money on healthcare. Healthcare income goes up when health goes down. Capitalism.
Far more than a super majority of those with high cholesterol are due to lifestyle. At my least yearly doctors appointment I asked about the genetic case. My doctor, in his mid-40s, said he had only had a few patients with that in his career. I've listened to lipid PhDs lecture and they talk about it being rare but present.
We cannot change the genetic case. But everyone else can be affected.
I was talking with someone recently who changed her diet. In a matter of weeks her LDL cholesterol dropped 50 points.
Oh wow, it sounds like my understanding is off considerably. I was under the impression only 15% decrease is possible with lifestyle changes!
Can you provide any basic literature on how large of an effect can be achieved through lifestyle alone? It sounds like my vaguely recalled ~15% is way, way off.
(I do wonder how statins are so easily justified if lifestyle is so effective, but pharma profits/lobbying may explain that.)
So 25%, which is well above the 15% effect I’ve seen, but you could just be an outlier. Also possible that such research suffers from self reporting problems, and many who claim they’ve made lifestyle changes are not reliable in those self reports. Fwiw, my experience is similar to yours. Lifestyle changes (weight loss moreso than diet) improved my “bad” cholesterol and glucose.
It's probably worth noting that I went from fatass to healthyish (about 50 pounds lost) so that's fairly drastic as well. We are certainly each unique medically speaking, but I'd still think that the single biggest change for the better you can make in your health is to try and kick the obesity. While BMI might be far from a perfect measure, I'd still like to get to at least the top end of the normal range.
not to mention the varying obesity rates - USA is almost double that in France - solve that problem and a lot of the health problems and costs will be solved as well.
Instead we as a country are glamorizing obesity, which has become a bizarre and deadly trend in the USA, we should attack it like we did smoking.
Even my local doctors office is advertising how you can be 'healthy at any weight' - talk about gaslighting, no you cannot.
Without a doubt the 'healthy at any weight' campaign is directly or indirectly funded by food companies and drug companies - neither of them which want thin and health populice.
Huge parts of the money are going to middlemen who do nothing productive at all (gigantic health insurance companies hiring armies of paper pushers that cause a need for more paper pushers in hospitals and pharmacies etc). Another large chunk is the enormous profits of drug manufacturers, who, entirely uniquely in the world, can set prices however they want with no government negotiation - ending up in madness like insulin being an expensive drug in the USA.
While obesity is a huge issue and a huge cost factor, there are more obese countries with nevertheless a tiny sliver of the US medical budget - even after adjusting for life expectancy.
Careful with “without a doubt” thinking when presenting a strong argument without facts to back them up. BMI is the foundation of a lot of health studies and it is increasingly called out as a bogus standard to base people’s healthfulness on. Science changes.
The body positivity movement, plus sedentary lifestyles, plus the increasing cost of healthful foods, the time it takes out of your day to exercise, almost mandatory amounts of sitting in a car daily… there’s a lot of factors in modern American life that are just bad for our health. It’s not just the money spent on healthcare.
if you follow the money, it is pretty easy to connect the dots - ask yourself - who benefits the most, and makes the most money keeping people fat, and on lots of drugs?
it gets even more paradoxical when you consider total healthcare spending, and how the US system tends to weight this far more towards end-of-life care than other systems.
in many cases, when looking at total life spending, things that kill you earlier actually can reduce total life spending (smokers are a great example) because it means you don't incur the three knee replacements and bouncing in and out of hospital for the last 2 years of your life and spend the last 2 weeks dying in an ICU. Having a heart attack and dying on the surgical table is pretty cheap in terms of total healthcare spending.
Obesity is still cost-positive, but it's a lot less than you think from numbers like "X% of total medical funds spent on obesity" - you are going to substitute around 50-75% of that cost in cancer treatment and knee replacements instead (see table 2).
anyway, one of the problems is that obese people are massively stigmatized and shamed. they are already treated worse (and receive worse medical care, etc) than others, for every moment of their lives, they have constantly-reinforced negative body image, which is psychologically unhealthy to impose on people. And the point of "healthy at any size" (when not taken to an absurd extreme) is to get people to at least feel like they aren't so far gone that it's pointless to make better choices, because starting to make better choices are the foundation of starting to climb out.
This is usually met (even here, in past discussions) by some variety of "good, they should feel bad", and "well, I was fat and it helped me!", but that's basically a riff on "my parents spanked me and I turned out fine". Not only is that probably not a medically-supportable opinion (stress and fear are themselves powerfully negative causative factors that place actual physical damage on the body over time), but not everyone's brains work the same in the first place. What inspires you to improve might just reinforce someone else's depressive spiral, a lot of obese people have very negative body image ("good", says the peanut gallery).
Black Mirror wasn't wrong, people love having an underclass to look down on, and obese people are a very visible and very socially-acceptable underclass to punch down on. A "steelmanned" view of HAES, when not taken to ridiculous extremes (and I'm not saying nobody does!) is that it's simply asking that we not go full Black Mirror on shaming fat people, but frankly I think a lot of people don't even agree on that much, or that it would be a good thing. "It's for their own good" etc.
The whole reaction to the idea of HAES, itself, is a microcosm of the social problems around obesity and self-image - how dare you feel good about yourself? Why aren't you going through every day in a haze of shame like you deserve to? It's for your own good!
Also there's a big difference in the quality of pretty much everything, from the chairs in the waiting rooms, to the medical technology and equipment used. In US everything looks a lot more newer and fancier - at least from the patient's point of view, but I think doctors would agree too. Also US doctors are far more willing to order extra searches and tests, while in many EU countries doctors have limits on how many lab tests or medication they can prescribe monthly, which affects the quality of service that patients receive. And still the medical system is in huge problems in many EU countries, e.g. in Croatia where I live the quality of service has been really devastated in the last 3-4 years, there's a lack of everything including the medical staff - doctors've been emigrating to countries with better salaries (Germany and yes, US).
So, just keep in mind with these types of news, it might be more economical system overall when you look just the numbers, but it's not like everything is working great in EU either...
1 million active physicians in the US. At $352k/ year that is only $352 billion in physician compensation, or less than 10% of total healthcare spending.
This appears to be a random pseudonym account so it's unproductive to phrase it in this way, because it requires a lot more credibility to back it up.
A simple counterexample: I clearly think 10% is fine, and I've met at least a few dozen people who share a similar view. Which suggests it's a common enough sentiment among HN readers.
Never seen somebody so aggressively wrong. Just take the L and move on, my dude. Surely you have better things to do than to try to boost your ego by “winning” internet arguments through sheer volume of responses.
There's almost no difference after 'winning' or 'losing', other than extra word count on HN. So if this bothers you so much, asking me seems pointless. Maybe try asking yourself?
You broke the site guidelines extremely badly and repeatedly in this thread—far worse than the other commenter. And it unfortunately looks like you've been posting unsubstantive comments and/or aggressive comments (e.g. https://news.ycombinator.com/item?id=37737463) in other places too.
If you keep doing this, we're going to have to ban you again. I don't want to do that, so if you wouldn't mind reviewing https://news.ycombinator.com/newsguidelines.html and taking the intended spirit of the site more to heart, we'd be grateful.
1. Average physician salary in the US: $352,000[2]
I have many friends who are doctors. There is the salary they make, and then there are all the extras. Some have used their salary to buy the equipment in their office, and charge thru for equipment usage (added money on top of salary.)
Some have used their salary to buy the building used for their medical practice, and charge thru the facility fee (added money on top of salary.)
I agree both are "investments" but it is a non-traditional investment where you have a huge edge and a ready customer.
Given that the source of payment is unrelated to the cost of the service or quality of service, the answer is probably elsewhere?
Also I don't think you can come up an example where transitioning from private to state operated enterprise has improved the quality of service. Tragedy of the commons/OPM etc.
I suspect some of that is due to 4 years of med school (at a cost of $200k-$500k) followed by 3-7 years of low paying residencies, when you could alternatively go into tech or consulting and have years of high income during the same period of time.
The cost of school is fairly minor in the reason's not to become a doctor. It's the massive increase in administration overhead that has reduced a doctor's time spent treating patients and practicing medicine significantly. EMR systems are slow compared to paper/dictation from a doctor's perspective, they also produce extremely verbose reports, so more time is spent sifting through records to find the useful bits. Doctor's need to perform X task that is often irrelevant to qualify for increased reimbursement from Medicare. Doctors have to justify why they prescribed X medication with prior auths and appeals just to get a patient the help they need. The additional scrutiny on opioid medications forces people to come in more often even if they've been compliant and successfully managed for years. Doctors that serve the neediest patient populations get rewarded with the most expensive malpractice insurance, because poor people are far more litigious than average, and often get paid less as Medicaid has some of the lowest reimbursement levels.
Let's not leave Big Pharma out of this. They charge the US 2.5x compared to countries with universal healthcare [1]. Why? Because Medicare and other large population sizes here are prevented from negotiating drug prices.
We also need to consider hospital, ER and ambulance costs.
In this case, having a single universal plan can greatly reduce those costs.
It’s not quite as apples to apples comparison. To employee someone in different EU countries the organization pay an extra 20-30% on top of the gross salary. And if we wanted to be more accurate we could factor in statutory time off.
You also factor in a percentage of their salary incase you need to exit them (maybe doesn’t apply to doctors). I’d assume the states is still ahead but not as drastic as the shared numbers
France has either free or heavily subsidized college for doctors and a large social safety net. I bet if you counted those things total comp would be a lot closer.
please explain why it would? The government essential funds colleges educations (through loan guarantees and grants etc) for tens of millions of students - has that driven down the cost of college? or did it have the opposite affect?
Universities are primarily businesses, and loan guarantees are effectively a state subsidy to those businesses.
If students were given grants, and universities were given grants, and that was all the money on the table, what pressure would there be to increase the cost of tuition?
None - and we know this because the more the system was privatised and deregulated, the more fees started shooting up.
Forced debt is slavery. Whether it's medical debt, educational debt, or rentier landlordism, it's the deliberate creation of unnecessary scarcity to reduce the personal agency of most of the population.
Well, look at all the other countries where universal healthcare has been implemented.
> The government essential funds colleges educations (through loan guarantees and grants etc) for tens of millions of students - has that driven down the cost of college?
Look at all the countries with free university. Yes, the cost is lower.
> or did it have the opposite affect?
Fixed fees and a single payer obviously would have that effect, like everywhere else it's been tried.
>Well, look at all the other countries where universal healthcare has been implemented.
Oversimplification. Most countries that have universal healthcare do many other things in addition that you aren't accounting for. The US healthcare system is not the same as Europe's but its not single payer.
>Look at all the countries with free university. Yes, the cost is lower.
See the above.
>Fixed fees and a single payer obviously would have that effect, like everywhere else it's been tried.
So now you're starting to get the idea. It's not just single payer. Never was.
Ah, so your argument is that a purposely sabotaged/neutered form of healthcare (that certainly wouldn't be universal) won't reduced costs. Well, yes, that's what the US has now.
Edit: I do love the deliberately obtuse comments from Americans on political topics like education, healthcare, gun control, etc. It's hard to believe intelligent people honest hold these absurd views.
Your argument is in bad faith and you're speaking from smug ignorance. That's not what I said. My point is that the US and European systems have more differences than just who pays the medical bills. And if you just address the payment without any of the multitude of issues in the US system you are doomed to fail. I think it would end up a lot like the college loan system has. Because the ones responsible for the high costs wouldn't have any reason to change what they are doing. For example, many hospitals and clinics in the US have been bought up in the last decade and are now owned by massive health care companies who have outsized power. They are able to eliminate competition not just for patients but also for healthcare workers looking for job opportunities. CHI is one such example. You need to bust them up. Every aspect of the US system will have examples like this.
I'm not saying single payer wont work. I'm saying single payer on its own isn't a solution because so much more is broken that isn't broken elsewhere.
There's a compelling argument that this is the result of Reagan cutting funding to colleges, resulting in once-free institutions pivoting to for-profit businesses.
USA has too few so it pushes wages up. That is what happens when you don't have a free market, lots of people who want to become doctors aren't allowed to creating artificially high wages.
The “allowed” terminology indicates they’re gonna suggest AMA licensing, etc. never mind that every country has those, and probably more restrictive versions.
One of the major reasons the U.S. has low physicians numbers is because med school is just so expensive. You either have to pay a ridiculous amount of money upfront, but more importantly, need to figure out how to pay for your existence for nearly your entire 20s where you’re studying and not earning, or you need to take massive student loans.
That’s just too much of a ln upfront burden or risk for large chunks of the population to take.
> AMA licensing, etc. never mind that every country has those, and probably more restrictive versions.
How can they be more restrictive when they are licensing way more doctors? USA is at the bottom of the developed world in number of physicians per capita but also pay the most. The only plausible way that can be true is if USA is the most restrictive in the developed world, like requiring way more years of schooling than necessary or limiting residency spots or limiting how many schools are allowed to educate doctors or making it hard for immigrants to become doctors etc.
Japan has less doctors, but they are also among the healthiest in the world so maybe they don't require as many for that reason. But USA is at the other end of the healthiness spectrum so you can't use that explanation there.
Lack of residencies which are funded by the government. Medicial schools in the US try to get as many students placed into residency as possible so they control admissions to match residency slots, because if you don't have a residency you cannot become a doctor and med school costs $200k-$500k so it's life wrecking if a student doesn't match. The side effect is that we have a lot of pseudo-doctors who have roles that overlap in capabilities with doctors like Physicians Assistants and Nurse Practitioners to fill in the gap.
High cost creates a barrier to entry. And it can often be an intentional one. See luxury goods as an example. Almost all luxury items are sold at insane profit margins and cost nowhere near that much to make. But the high price is the differentiator itself. Is a Gucci branded article of clothing that much better? No of course not. The value is indirectly signally to others you have the money to afford gucci. Poors not allowed. Other things can have their access limited by price in similar ways. Raising the price is a very effective way of keeping the poors out. Its not always intentional. But many times it can be.
The cost of employee is around an additional 22% of Salary in France but around an additional 140% in the US [1] (401k, SSA, Health Insurance, etc), which brings the total spend much higher in the US.
The page that you've linked for France says: "Total cost for the employer: 4970 EUR (142 % of gross salary)", so it's a lot more than what you say...
Those 22% you mention is extra cost for employees, on top of the gross salary (in Croatia that's called gross1, while the actual total amount for employees is called gross2)
As expected, the preponderance of comments claim US exceptionalism: why somehow it’s a unique snowflake and it just wouldn’t work there. Another comment with the classic “we pay for drug research“ fallback (ignoring that accounts for a vanishingly small percentage of the expenses).
The US population is so indoctrinated with baseless propaganda that it will take a century for it to move to a better model.
I've lived in Canada with its vaunted universal healthcare system. While it sounds great on paper, in practice it means you'll wait forever for appointments.
Long wait times are a potential problem of public healthcare systems. The thing about private though is that if you don’t have any money (perhaps because you are too sick to work), then there isn’t even a wait time - you just don’t get treatment.
How long does it take to get you appointments here? I have waited months for simple items. I'm already waiting as long as my Canadian friends for simple things, but paying way more.
Our better model (in Canada, Quebec) is increasingly disliked by our population. The private sector is getting more popular, enough so that our government is thinking about banning it.
Many European countries found a compromise where both public and private health cares coexist.
The overall point though is not to sit on the laurels and try to hammer in "one right way" of doing it, but to iterate until you find a legislative healthcare framework that works for your country and benefits most.
The lack of progress in US on health care front is an indictment of its political rigidity first and foremost.
Universal healthcare isn't guaranteed to work well. The point is that it at least can work well and you can see examples of countries where it is working well. I suspect that people would feel very differently about private healthcare if it was their only option rather than an additional option for those with the money to spare. For example, in the UK I am glad to be able to make use of private healthcare for small things when I need to, but I would hate to be in a situation where it was my only option. (And that's not because the NHS in the present moment is a particularly shining example of universal healthcare done right.)
I use to work with a lot of Canadians and multiple of them traveled to the US for medical procedures in the year or so I worked with them. One older co-worker broke his arm while visiting family in Quebec and literally drove hours to cross the border to have his arm set there b/c of the wait time. I won't pretend to say I understand the systems in place in Canada nor have insight into why they did this, but I always found it really interesting.
Why do you think that's happening? It is just a huge propaganda campaign by moneyed interests or is there some actual benefit? Maybe just the grass is greener
> The US population is so indoctrinated with baseless propaganda that it will take a century for it to move to a better model.
I used to be one of those people. We immigrated to the USA when I was very young, so as I grew up I went extra Right/libertarian, thinking that would make me "more American" somehow. I now realize that this is very common in US immigrants.
It was the US health system that showed me the undeniable faults in pure libertarianism. It all seems so obvious now:
In a government run health system, dollars put into the system which do not end up going to patient care is called waste, it is seen as a negative and we work to minimize it.
In a privatized for-profit health system, dollars put into the system which do not end up going to patient care is called profit, it is seen as a positive and we work to increase it.
It's that simple. For-profit-all-the-things is not ideal. The main lesson I learned is that stubborn ideological purity is fraught with issues, no matter the ideology.
Not to be pedantic, but the majority of US healthcare hospital systems are actually non-profits, so they milk profit a bit differently since they aren’t allowed to have any (instead it goes to administration salaries and overheads).
Even some of the insurance systems are non-profits. It doesn’t take shareholder profit motive to make money evaporate.
Pedanticism is one of my favorite things about this website.
In this case... while my specific terminology may be lacking, if we zoom out and just compare the US healthcare system to other countries' systems, we demonstrably see lower per-capita spending and better patient outcomes. [0]
If we could agree on those facts, can you help me use the correct words to describe the issue?
Oh we are in total agreement in the outcome. But misidentifying the problem as a pursuit of profit might lead to a reform that doesn’t really fix our system. The issue is a lot of vested interests getting a cut of healthcare money, and without reforms to streamline that, we aren’t going to make progress in coming up with something better.
I wouldn't call myself a libertarian, but I do find it bewildering when people caricature libertarianism like this.
For one thing, if you go through the exercise of examining the parts of the healthcare system and ask yourself "how much is the state involved in this", I think you may come to a different conclusion. I don't know what to call our trash heap of a system, but libertarian seems obviously not it.
OK, this is interesting. Please help me correct my terminology.
On my part of the exchange, might I suggest that what you see as government involvement could also be called "regulatory capture"? [0]
What I mean is that the monied interests now have major influence on the government which regulates them, so they create "regulation," with the goal of perpetuating their own profit centers.
How can I do better from your point of view? If not libertarianism, what should we call the ideology or ideals that led to this healthcare system with an ever increasing chain of profit centers?
Like I said, I don't know what to call it. Crony capitalism probably fits, which goes along with your link.
Libertarianism is about liberty, or individual freedoms. Are you free to purchase any drug or test or service or device that you want from whoever you want? Of course not, the state is heavily involved in making these decisions for you.
Ok, so one of the killer apps that I have discovered with LLMs is to further my own personal political depolarization. ChatGPT will always make a solid argument for most any other side.
To help identify what the heck I am talking about here, here is ChatGPT Classic's take on "libertarianism vs capitalism vs crony capitalism vs anarcho capitalism" [0] I found it very good reading.
What I realize now is that I was only holding on to one aspect of "libertarianism."
> Free Markets: Supports the idea that a market free from government interference naturally leads to efficiency, innovation, and wealth creation.
If I may be introspective for a moment, I believe that the reason that I may have used libertarianism instead of capitalism, is because how polarizing "capitalism" has become in the US discourse. I feel like readers would assume that if I am making light of capitalism, then I must support communism or some equally obsolete ideology.
Sadly, you are 100% correct. Once our American brothers wake up the down-votes will start pouring in.
The numbers are inflated because you get charged hundreds of dollars for an aspirin tablet in an emergency room and thousands for a 10 minute ride in an ambulance. What is particularly sad is that to the rest of the world this is absolutely insane but if you try to explain this to Americans they'll tell you they don't want no stinking communism. It's fascinating how deeply indoctrinated this nation is.
Where does all this extra money actually end up? Who benefits?
Is it all shareholder profits? Employee salaries? Re-investments into research? Marketing and sales budgets? Defending from liability lawsuits and liability insurance? Taxes? Construction workers that charge more for building hospitals than they do in other countries? What the hell is going on here?
The fact that the US spends more on healthcare isn't very interesting to me on its own. It doesn't really say what the US can do about it, moving to a single-payer system can reduce prices due to the government's bargaining power, but it can also increase prices and decrease quality due to no competition and no reason for anybody to care about efficient spending. If consumers have no choice, they will choose the option you provide, no matter how bad it is. A breakdown on what exactly the US spends more on would be far more enlightening.
If more money flows into the healthcare system, more money must flow out of it, and where exactly those outflows are is a far more interesting question for me.
In my experience working the tech side of the healthcare industry, every aspect is inefficient and most players are doing their best to extract as much wealth as they can from it. There is a lot of room for improvement in terms of cost and efficiency. I've given up hope for a political solution. Nobody seems to want to talk about why everything is so expensive. They are too focused on who is going to pay for it.
I don't mean inefficiency in the bureaucratic sense. I mean it in the economic sense. Where stuff costs more than it actually should. There's a lot of rent seeking and middle men in the medical world that inflate costs.
so roughly 20% goes to insurance company overhead (marketing and hiring people to deny claims and argue with doctors). another bunch goes to extra hospital administration (billing patients is expensive). there's also a bunch that goes to private equity companies that run ambulances, hospitals, and the rest.
If cycrutchfield is correct (in https://news.ycombinator.com/item?id=38719752), all the doctors put together get 10% of the spending. Insurance overhead gets twice as much as the doctors? That's insane. That's a huge amount of overhead that could be dramatically reduced with single payer.
Still, that's only 20%. Would single payer reduce the other 80%? If so, how?
The US doesn’t typically spend on health care. It spends on sick care targeting things which can be dealt with via medications or surgery.
For example, most doctors don’t help people avoid heart disease. Instead they watch for it or things they can treat with drugs that can lead to it. Then try to help people manage it that. I’m not blaming doctors, it’s the system.
If we targeted health care and generally good health over the course of our lives, cost could radically go down. And people would have far fewer issues.
That assumes high chronic diseases from other things causing high health care costs. What if we got rid of most chronic diseases? Most are caused by lifestyle but they’ve become topics we just don’t talk about. They’re taboo.
Totally agree. The biggest failings in the US are around public health. In the US, the path of least resistance is to drive everywhere, sit at a desk and eat fast food. It’s really hard as an individual to overcome these forces.
Many would argue that this very clearly shows the US gov is unable to provide cost effective healthcare, if they’re already paying through the nose and not even covering the entire population how would adding a single payer system be more efficient?
This is a misleading clickbaity headline. Those 6 countries added up equal about the population of the US, so it's not like we're spending 6 times other countries on a per capita basis. We spend more and get less than other countries, but you don't need to mislead people to get that point across.
If they have the same combined population, then it’s not misleading. There are no other first world countries with 300 million people, so it’s pretty obvious that the comparison is with the combined 6 countries.
Yes it is - they could have done it on a per capita basis but they didn't. Also, if you read the headline, it's very easy to think we spend 6 times per capita than comparable countries, which would be wrong
This does not make sense. If spending is much higher for a similar number of people, then spending per capita will be higher by the same factor. Normalising per block of 300M people or per person is exactly the same, that’s not misleading at all.
The headline says exactly what it seems to say. It does not imply any normalisation per capita.
>Those 6 countries added up equal about the population of the US,
Yes, that's exactly the point: to compare the US with a similarly sized block of nations.
And from that we can conclude that this block of nations can service universal healthcare to 330 million people without additional private healthcare insurance.
So for less TAX money than the US they get universal healthcare for the same amount of people, while US taxpayers pay more but still have to buy insurance on top of what the government spends on healthcare.
Sure, the article makes that point, and it's reasonably well made (although not the case that there isn't any private insurance in those countries at all). My point was that the article's title is misleading and clickbaity and does not convey the point that the article makes well
> This means the U.S. government spent more on health care last year than the governments of Germany, the U.K., Italy, Spain, Austria, and France combined spent to provide universal health care coverage to the whole of their population (335 million in total), which is comparable in size to the U.S. population of 331 million.
I’m not sure how the headline is misleading in any way.
Second of all, reality isn't that the US spends 1.5 times the money. The reality is that the US government spends 1.5 times the amount that these other governments spend.
But somehow in the US people still need to buy private insurance. Even though all people in the other countries get universal healthcare for less public money than the US already spends on healthcare.
It's meant to illustrate how cost inefficient the healthcare systems in the US is.
I don’t know how to discuss this because I have no idea how you came to that conclusion.
It seems like a totally straightforward headline to me. There’s no mention of per-capita, no mention of some sort of multiplier.
It actually seems like quite a generous headline to me, given that it is talking about just the US government (when most of our healthcare system is privately paid).
The US federal public spending being cited here is for Medicare and Medicaid only. They are nowhere close to providing healthcare for the entire population.
> Between direct public spending and compulsory, tax-driven insurance programs, Germany spent about $380 billion in health care in 2022; France spent around $300 billion, and so did the U.K.; Italy, $147 billion; Spain, $105 billion; and Austria, $43 billion. The total, $1.2 trillion, is about two-thirds of what the U.S. government spent without offering all of its citizens the option of forgoing private insurance.
Is it fair to include Germany here? I thought the German system required everyone to have private insurance through their (breadwinner’s) employer. But I’ve only heard this via self-employed people complaining of having to pay €300 a month in health insurance. To me it sounds more like the American system than the UK one of everything just being free and state-funded. But as I say, I only know through hearsay.
This is false. As a regular employee, the system is fully regulated by the state. You can choose your "state-regulated" healthcare provider (gesetzliche Krankenkasse, but the differences between those are only in extras, which are neligible - something like rewards for going to the gym, living healthy). You and your employer pay monthly fees to the healthcare provider. You never get to see the employer's part, and you never see the money that you have to pay, because it is deducted from your monthly salary before your net salary is transferred to your bank account. The monthly fee is regulated (https://www.bundesgesundheitsministerium.de/beitraege). If ylur gross salaray is lower than about 62.000€, it is mandatory to stay in this state regulated system. With higher salaries, you can choose to opt out into the private healthcare system.
If you are self employed, you can choose to stay in the regulated system. However, since you are now both employer and employee, you have to cover both sides of the fee. For many self employed people, switching to a private healthcare provider saves them money, because there the fee, depending on some factors, is usually lower - it does no longer depend on the gross salary, but on the insuranced person's personal circumstances. However, private healthcare provides are to some degree also state regulated; there is a minimum set of service they are required to provide.
The cases of regular employees that don't go with state regulated healthcare providers are low. The cases of self-employed people that don't go with private healthcare are low. If you make enough money, you can start calculating wether switching to the private sector is benefitial to you. But it is impossible not to have health insurance, and it is impossible to go bankrupt because of health related costs in Germany.
Private insurance in Germany only applies to those self-employed or, optionally, those employed who are above a considerable yearly salary threshold. Otherwise, it's public, and the cost depends on your salary.
If you're employed, your company pays for half the insurance cost, be it private or public. This means that it's expensive for self-employed people.
In addition to what’s already said in other comments, in some cases in Germany you don’t even pay for your insurance. It can go as part of your unemployment benefit, included in the insurance of your spouse at no extra cost or payment can be suspended while you are on parental leave and have no income.
Most employees are part of the public health insurance system in Germany. People who are not employees and people with an income above a certain threshold can (or sometimes must) choose a private health insurance.
This should be GDP adjusted, since most of that money goes back in the country, paying healcare workers. Both the US and Europe employs people in the pharmaceutical and medical equipment industry, and research. So really, gross numbers don't make much sense for the sake of comparison. People in high GDP per capita countries are better paid, duh.
And here, if you adjust for GDP, the effect disappears. And in fact, in rich countries, it is normal for healthcare expenses to go up in proportion to GDP since health is a basic need and not a solved problem. That is, rich countries can give food and shelter to their entire population but there is no panacea.
It doesn't mean it is good for the US, but it is a dubious statistic to pick when you want to highlight a disfunctional healthcare system. Try life expectancy instead.
It's a lengthy title that didn't fit into the HN title limit. I've edited it to include the word "combined" although the result is still a little unwieldy.
And the point is that those countries have combined population roughly equal to the US, they’re not, say, the Nordics. A technically correct but almost useless title.
So many interesting non-technical threads get flagged these days. This post appears to have been flagged by administration as I cannot vouch for it. Or, is that because I already commented?
Sometimes I completely understand, sometimes I somewhat understand, but in this particular case? There is a good exchange of ideas going on.
Yes, I know the first rule of HN club, but this is a deserving topic.
I do live in country with universal healthcare - Poland, and
On one hand when my mom had eye problem that required spending 2 weeks in hospital and surgery, she didnt have to pay for it except for some simple things that were cheap
On the other hand im paying not small amount from my every salary for health care and due to wait time or quality I still often go to private med (except for basic sickness where doc can give me a week or two "sick leave")
Also Ive been pissed off when I had serious surgery (at private med) and my insurance didnt cover it (but ok, thats insurance not univ. health care)
All of that makes me feeling like im paying a lot for mandatory health care and things like insurance
And at the end of the day I must go and pay for private health care. At least my mom didnt have to pay.
I feel like im getting scammed. I'd rather manage my own money and how I want use it
I don’t understand how anyone manages their money and how they want to use it when medical expenses are concerned.
Your “how I want to use it” is completely out of your control and based on when you fall sick, get injured, need advice, etc. Nonenof which are choices you make. So even an extremely efficient entirely private system doesn’t allow you to either manage your money nor allow you to choose how you want to use it.
You could take insurance, but again, you’re neither managing your money nor choosing how to use it.
Medical expenses are not like buying a toaster that you can decide to put off or buy whenever you want or never if that’s what you prefer.
Also, in any modern decent society, if you choose never to eat toast no one is concerned. However, if you’re dying on the street because you aren’t paying for medical care society will step in. So there’s also a burden you’re imposing on society based on your choices that are not involved in most non medical situations.
>Medical expenses are not like buying a toaster that you can decide to put off or buy whenever you want or never if that’s what you prefer.
Some.
Not all medical cases need instant contact. Proof? Months or years long wait times.
Also for me 99% of the medical expenses are around 10-20% of what I pay every month. Meanwhile those medical expenses arent regular.
>Your “how I want to use it” is completely out of your control and based on when you fall sick, get injured, need advice, etc. Nonenof which are choices you make.
So how people do it with cars?
Cars break often, especially when poorer people must use used cars
They often rely on them to get to work, so they not always can delay fix endlessly
You just have backup of just in case money.
>. However, if you’re dying on the street because you aren’t paying for medical care society will step in. So there’s also a burden you’re imposing on society based on your choices that are not involved in most non medical situations.
The system you describe is common for Europe and it is not perfect, but you would still pay more if the American model of healthcare would be in place. European system can be fixed by some country-specific tweaks, American system can only be replaced.
Once more, with feeling: it's not the lack of spending or taxes or too many billionaires that make healthcare difficult in the US. It's the unholy system created by generations of governments over there.
The original title finished with the word "combined". Even still is not clear what they're saying until halfway through the article.
> This means the U.S. government spent more on health care last year than the governments of Germany, the U.K., Italy, Spain, Austria, and France combined spent to provide universal health care coverage to the whole of their population (335 million in total), which is comparable in size to the U.S. population of 331 million.
They lumped together six countries to get something with a similar population and use that as the comparison. Of course you may argue that the US is too exceptional to compare, this wasn't addressed.
Population density relative to population. The US is not dense. There are legitimately strategies that will not work for us given some of our "large population centers" are actually pretty tiny when considering hpw developed we are. This is also why the US has 3rd world problems like issues getting water and electricity to some citizens. The population density in some states can drop very very low and we have a lot of people on those low density areas. It becomes a horrible last mile problem.
Honestly, I'd like to hear from Canadas and Australians about the rural experience. They have the same density problems and I think their solutions are nore relevant. That said, I'm not really a fan of the outcomes from Canada, so who knows maybe high population, low density is just a bad hand for a country in this context.
There is no such thing as "universal health care" in a country, in any meaningful sense. Every country with government run health care rations with limits on availability, wait times, excluded treatments (mental health, dental, vision, drugs, acupuncture, etc), and often by personal clout/connections (this is the case in Canada, where I lived for many years).
Note this is in no way a defense of the US system, which is messed up six ways from Sunday.
And yes, there is. At least in comparison to the US system: "Universal" means everyone gets a basic level of care.
... Rations? There are no set limits, though they might not build another MRI machine if the existing ones aren't being used enough. It isn't like health insurance doesn't limit your care: They just tell you they won't cover x or y. And your denial of care will be different than what your neighbor gets in the US instead of everyone being treated nearly the same.
My drugs are covered in general. And when I purchase them, most are fairly cheap compared to the US.
Wait times definitely exist in the US as well, especially if you are waiting on a specialist, who likely isn't in your area unless you live in a big enough city. At least when I have wait times here, I get paid time off work if it is necessary.
Mental health is included.
Acupuncture isn't actual medicine.
Dental and vision aren't included here: Vision isn't generally too expensive (my partner and I both wear glasses) and dental has a discount. I think these should be included, though. Still better than dental insurance in the US - at least i can afford a dentist here. The dental is included in some systems (looking at you, Brazil).
In short, the complaints are the same in most places. Especially in the states.
Modern medicine also had plenty of practices along the way that we now disagree with. Cherrypicking two examples to discredit the acupuncture is a terrible way to prove a point.
My argument wasn't that alternative medicines must be just as effective because they're old. My point was simply that hand waving anything that isn't western medicine is a very close minded view in a community that is so often pushing for equality and open mindedness above all else.
> Wait times definitely exist in the US as well, especially if you are waiting on a specialist, who likely isn't in your area unless you live in a big enough city.
That is simply untrue, the only thing reminiscent of "wait time" is the actual scheduling of an appointment - ie call the office and they pencil you in for next Thursday or something. Or if you actually walk into an ER with something trivial.
"The average wait for an appointment with a physician for new patients is 26 days, according to a 2022 survey of 15 metropolitan areas by the physician recruiting firm Merritt Hawkins. That's the longest it has been since the company began doing the survey in 2004"
Getting that first appointment for a specialist can definitely have a long wait time. It took me 1 year to get in with a specialist to see my daughter diagnosed. I was was several waitlists trying to see any doctor. Granted this is the worst it'll ever be because covid caused a backlog, but I'm told by other parents they had to wait 3 months. It took me 3 months to get that first appointment with mu specialist too.
Now after I've seen that doctor once? Now I can make almost same day appointments and I have access to staff nurses for basic questions, etc. But yeah the wait for specialists can be long. It's usually not for generalist specialists. Like I saw a neurologist within a week, but the really specialized neurologist I got recommended out to was a 3 month wait.
What an inane statistic. It looks like this is "news" because someone only come up with it now, but the reason someone only came up with it now is that it's so stupid. It would not be "news" that the US spent more on healthcare per capita then the UK, but you can actually compare and discuss the two healthcare systems, you can't compare "universal" and "non-universal" healthcare.
Also: if the gov't buys as a "single buyer" it has a lot of purchasing/bargaining power. The system in the US is (lobbied) to not give the govt any power, and put it all in the hands of the market (insurances, etc).
It's be said many times: never let a capitalist come near your healthcare system.
This article is unscientific garbage. As a Canadian who got healthcare in the US, I can say the quality of the service I got was much higher, and I waited 2 months for surgery instead of 2 years.
You guys want a free lunch, expect free lunch quality.
That's called anecdote. If you're a skilled immigrant working in tech, you'll probably have excellent healthcare coverage through your employer. This isn't the case for dozen of millions of americans.
I am honestly curious: how that was paid for in your case. I’m an American who has needed urgent care in Canada and I was not billed. How did the reverse work, especially in your case where it was clearly planned?
I worked on a TN visa for <big_tech>. I had a high deductible plan, so I paid up to X out of pocket. I forget the exact amount but I think something around $3000 USD. My surgery was sports related and non life threatening.
The US system does an OK job of serving well off people who need inexpensive non-life-threatening procedures, I guess? But I’m not sure this tells us much about what the policy should be.
Where are the data charts attempting to quantify quality of care? To me, this article reads, "French citizen pay more for a meal on average", but meanwhile the comparison is of a population eating fast food everyday. The article feels like an emotional argument saying "We pay 2x for the same service" but I'm highly doubtful of the "same service" aspect of it.
Don't get me wrong, the data I've seen showing Americans are one of the most unhealthy populations in the developed world is clear. I'm saying the article is unscientific, not that the American people are healthy, or have great health care service.
For those who will click directly into the comments:
The US GOVERNMENT (not the US as a whole) spent more on health care ($1.8 trillion) to provide non-universal healthcare than 6 European countries with a combined population similar to the US did ($1.2 trillion) to provide universal healthcare.
The article's premise being, it costs the government significantly more per person, and 50% more in total to run a non-universal healthcare system serving a subset of the population, than it does a universal healthcare system which covers everyone.
As a whole, the US spent $4.5 trillion (private+public).
We spend more via taxes than any other country spends total... and then we tack private spending on top of that. We've picked the least efficient, worst aspects of both types.
The US has a significant higher percentage of obese people[1] than the EU countries they combined. Obesity is known to be a significant risk factor for a large number of health issues[2].
Eyeballing an average of 25% obesity among the EU countries with the US having 36%, means the US has 44% more obese people per capita.
While that doesn't explain all of it, it surely is a significant contributing factor.
Not if those lives are ending due to extreme medical conditions. From a costing perspective there's not a big difference if you spend the last 5 years of your life in critical care at age 72 vs. 85
Reducing obesity is part of our public health goals in Europe though, so the fact we have lower obesity in universal health system countries is likely not entirely an accident.
Obesity is a failure of preventive healthcare - more like a consequence than a cause of inefficiency, lower coverage and higher spending. And prevention doesn’t start at doctor‘s office.
it's also a symptom of extreme poverty. Very few people in the US starve to death but they certainly don't get healthy diets, the capacity to exercise and the education & access needed to control obesity.
How does this compare to European smoking? In Europe there are a lot more smokers than last time I checked in the US. Smoking causes similar health issues as obesity, mainly cardiovascular events.
If the US could improve their food, or Europe could get rid of smoking, it would be a big jump in health outcomes for either.
I think obesity probably explains a lot of the cost difference which is why people are so excited about drugs like Ozempic. It may make financial sense for the government to cover the cost for everyone since it could end up lowering overall healthcare costs by a significant amount.
Surely food companies will just stand idly by as their revenues drop 20-30%
Surely they wouldn’t figure out a way to produce even less nutritious, less satiating, more flavorful (and therefore calorically dense) foods, would they?
Well i feel like that's only good up to a point right? We can legislate the extremely unhealthy stuff like we have started already. Public information campaigns are making more and more people vegetarian and vegan or at least some reduced-shit diet, healthy at every size and the fat acceptance movement fell flat on its face and was replaced with the much more healthy imaged body positivity movement. And what are they gonna do, make our chips literally dripping in bacon grease? Honestly might be better for us than the insane amounts of sugar they put in things these days. I hesitate to say this but, how much worse can it really get?
Removing food stamps and just giving people money instead is a good start. Poor people without food stamps are healthier than poor people with food stamps, so I don't see any reason to keep that system, it seems to just encourage poor people to buy too much junk food.
With hundreds of billions of dollars per year on the line? I’m certainly open to arguments as to how it can’t get worse, but that’s a pretty obscene incentive to make it worse.
No, but at some point there will be a reckoning just like with cigarettes and alcohol. Garbage food won't go away, but the individual and societal costs will eventually be recognized.
If we had pills you could take that would mitigate most of the downsides of cigarettes and alcohol, then no we wouldn’t. Then the question would be whether cigarette and alcohol manufacturers could innovate their way around those mitigations. I don’t know that’s possible with cigarettes, alcohol, or food, but food especially it seems very possible.
Also cigarettes and alcohol don’t crowd out healthier alternatives on retail shelves the way that unhealthy foods crowd out healthier ones.
People already take all sorts of drugs forever, and it's only designer today. There are other similar drugs in development, so cost will come down.
Drugs like Ozempic don't just work on obesity, but they look like they may also work on addiction in general. There's also the second order healthcare costs of obesity that people don't think about - knee replacements for example. I think you're underestimating how much money would be saved in healthcare by reducing obesity rates.
pure capitalism is not an answer to the USA, especially with the system which allows lobbying of any type.
lobby + pure capitalism is creating a system where anyone who has more money can push ideas to make even more money and use an excuse that this is a free market balanced by supply/demand, because pushing many millions to lobby their ideas is not trivial or almost impossible sometimes.
I realise that it is most improper on this here orange website to read the article, but this is _government_ spending, not consumer. No choice involved.
(Even beyond that, bizarre idea. “Oh, I think I’ll go for a _designer_ MRI scanner” said no-one ever; by and large, the expensive bits of health care don’t have a lot of choice involved.)
We did vote for Obama who gave us the ACA. And a number of states have banned surprise billing from out-of-network doctors. And hospitals are now required to post prices, but they ignore that
So there has been change in the last 20 years, but clearly we're spending more than ever.
That said, the US system is pretty much the best in the world if you're wealthy.
At the end of the day, it's completely in line with the American cultural norm of promoting the material success of the successful. It's why some of the world's best doctors are in the US, why people on this website think half a million USD "total comp" isn't that crazy, why the US has such a dynamic startup ecosystem, and so on ...
When you consider that, it all makes sense. I wish Americans were more upfront about this being their culture though, and others in the world more understanding that this is what they are collectively trying to achieve, rather than an abberation. I'm not passing any judgment, just observing -- though anyone is free to of course.
I often see americans looking with envy at european health care, or europeans bragging about it. Well in the UK, and a lot of west european countries, health care is in a state of collapse. Just do a short google search of hospitals around the UK and rad their reviews - there are literal human rights abuses being reported, all while hospitals have an official government rating of "good". It's unbelievable - when I was in hospital I had patients next to me that had to beg to see a doctor, while a teenager was screaming in pain and nurses were mocking him. The UK doesn't have a financing problem, or a understaffing issue. The UK has an underskilling issue. Private or public the doctors and nurses I had to work with had no clue what they were doing, and there always had to be 3-4 people doing the job of one simply to confirm that what they are doing is right, and the issues working on were basic. Not to mention that health care software systems barely work - buggy, missing obvious features, not used at all because staff has no clue how to use it, and so on.
All in all west european health care, particularily british, looks like east european health care used to - but indeed without the bribery and arrogance that plagued that system. At least not at the same level, yet.
Not to mention that it is extremely expensive. You pay for public health care and on top of that for private health care without a tax deduction. So if you are a worker you are likely stuck waiting in long queues only to be sent home with a misdiagnosis. Your employer provided insurance will cover at most one or two visits to a GP per year and that's about it.
YMMV here. I’m in and from the UK, and have family members who are hospital doctors.
The NHS is indeed collapsing, but my understanding is that this is a combination of (1) underfunding, (2) Brexit, which caused many healthcare workers from the EU to leave the country, and (3) an incompetent, corrupt, far-right government that hates public services and would like us to move to a monstrously inequitable but profitable US-style system (but know they can’t say that out loud).
Correct. And as a result of underfunding it's also underskilled. Not that those that have not yet left the system are not capable of performing, but rather those that are new are not the best - who would want to work in a system that underpays and overworks? Literarily all students I know studying medicine wish to stay away from the NHS and work in private health care. When speaking to foreign prospect students in my network I get the impression that studying in the UK is the running joke - both in pay prospects and tuition quality.
I really really wish the british public would reflect more on understanding how corruption works, because "government that hates public services and would like us to move to a monstrously inequitable but profitable US-style system" is precisely that.
Constantly demanding higher taxes to patch the system is one of the means the public is steered towards wanting it to be privatised, yet many fall for it.
> Brexit, which caused many healthcare workers from the EU to leave the country
Turns out european workers were not in demand because they were cheap, but because they had critical expertise. Allowing people to come in and work on equal terms and equal pay meant attracting the best and the brightest. Now the system attracts the desperate, willing to work for nothing and providing quality comensurate with pay.
And this is reflected in all areas of life in the UK, private or public. The number of times I had to correct my lawier, solicitor, doctor, mechanic, plumber, and electrician, is ridiculous. Take this as a cry for change as I love this country.
In the context of comparing total government spending, that's a really important caveat.
> (3) an incompetent, corrupt, far-right government that hates public services
Isn't that a problem with a fully government-run system in general? Preferences and motivations in leadership change over time. If the people are dependent on the government program to function they're also at risk of being helpless if and when the government stops running the program well.
It’s true that the UK health care system is a disaster, but that’s through deliberate actions by politicians both conservative and “new” Labour (I.e. the faction of Labour that are basically just Tories but in the Labour Party for some reason).
For example, instead of just publicly funding hospitals (you know how the Government can issue bonds at lower cost than private finance can borrow, before even thinking of profit margins) the Tories introduced Private Finance Initiative (PFI) schemes, which were then massively expanded by Blair, which up to 2017 (I think which is around when they finally stopped entering into new PFIs) the UK Government had paid private companies more than £308 billion for what amounted to £59 billion of actual capital investment.
Many of these PFI schemes were wildly profitable for the companies, and the public have to pick up the pieces for the ones that fail. At the same time, care quality was often inadequate, even for the ones making profits.
And that’s just one of the “privatisation by stealth” methods, there are a bunch of others (the NHS is too popular to overtly privatise).
I've lived in the UK for 10+ years. Had two surgeries, one life-saving visit on A&E and another one urgent medical intervention. That is on top of less serious medical stuff like dermatological issues or infections.
This was all with NHS and I have the exact opposite experience. The staff were always very professional and friendly and the facilities well equipped.
They are friendly and professional - unless you are a teenage boy that they can make fun of behind their back, or an old person that no one cares about.
The issue is that the staff that looked after you was probably 2-3 times more than what should have been.
My issue was also taken care of. So well that i will have to go private in a foreign country to fix the damage they did. At least i am alive and well. The smiles they gave were nice too.
Seriously, google reviews of hospitals and read the horror stories. Old people with bowel loops kept on chairs in waiting rooms for 26 hours are my favourite. I know how bad it hurts because the friendly, smiling, professional staff nearly caused my such issues.
While I am very enthusiastic about reforming our system to a single payer system, one fact about the US that is unique that a lot of people on my side of the issue need to understand better is that making our healthcare system more socialized will almost certainly not bring down the costs. It may even go up.
One of the big factors driving the lower costs of healthcare in other countries isn't the cost savings from socializing it, it's the fact that the US essentially subsidizes the entire drug research industry and the rest of the world doesn't have to pay for that like we do.
So even with single payer healthcare, we're still gonna have to be the nation that shovels all the money into the drug industry. I don't personally see a problem with that per se. We are a rich country. We should pay the lion's share. But the cost shouldn't be so directly passed on to consumers in the form of insane drug prices. Switch to a prize system in exchange for taking stuff off patent or something, e.g. the federal government buying the patent whenever something new comes out for an extremely high one time price, then let the generics market go nuts with it. That would bring down consumer prices without eviscerating drug company profit margins and destroying their incentive to innovate.
> the US essentially subsidizes the entire drug research industry
This isn’t entirely true. The US does pay more for drugs but a lot of this money isn’t spent on research. In fact pharmaceutical companies spend far more on advertising than research:
It's true that the US pours a lot more money into drug R&D, and I understand that a lot of push for more global + stronger patent law comes from pharmaceuticals. However, when medicines change owners, and then get 10x price hikes years after being developed (like EpiPens, or Generics that get a tweak + a new patent), the problem is not just repaying for the R&D.
The more serious problem, is that reforming the machine that is the US health care industry is going to cost a LOT of jobs. That is going to make any kind of meaningful reform very difficult.
The small tweak = new patent loophole is easy to solve with patent abuse reform. The sting of the reduced profit margin by stopping patent abuse can be offset by making prizes for making stuff generic bigger than the profits they would get from patent abuse.
The job loss from transition to single payer is a tougher problem, but I would rather just rip that bandaid off than keep a lot of unnecessary insurance jobs around.
No. The largest cost of healthcare in the US is all the admin associated with it.
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OECD Health Statistics data show the U.S. spent $1,055 per person on “governance and health system financing administration” in 2020, compared with the OECD12 average of $193 per person.
A 2021 study by McKinsey estimates hospital administrative costs at $250 billion and clinical services administrative costs at $205 billion, representing 21 percent and 27 percent respectively of 2019 NHE spending in these settings.16 A 2014 study by Himmelstein and colleagues comparing hospital administrative costs for the U.S. and five comparator countries found that the other countries spent 42 percent less than the U.S. on hospital administration.
the per capita health care cost is estimated to be around $11,590 in 2019, per the CDC for the USA.
Your $1,055 in administrative costs is not even close to "The largest cost of healthcare in the US is all the admin associated with it.", in fact it is less than 10%.
Salary and Wages for Physicians and Nurses: About 15 Percent
Prescription Drugs: About 10 Percent
Medical Machinery and Equipment: Less Than 5 Percent
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Administrative Costs of Insurance: $1,055 per person on “governance and health system financing administration” in 2020, compared with the OECD12 average of $193 per person.
Administrative Costs to Providers: A 2021 study by McKinsey estimates hospital administrative costs at $250 billion and clinical services administrative costs at $205 billion, representing 21 percent and 27 percent respectively of 2019 NHE spending in these settings [aka 48% in sum, troupo]
Profits are a strong incentive to innovate. We should subsidize those profits but not do it the stupidest possible way by making consumers pay insane drug prices.
all you need to do is look at the profits (and running costs) of the health insurance industry to see where a lot of Americans health spend is leaking to, completely ignoring the fact the government is already spending more! Not to mention Americans still have to pay out of pocket costs over and above what insurance is paying for as well. You could still fund the drug industry out of the spend and make massive savings. Better yet, you can make it so no ones incentivized to push drugs other than what is evidentially effective (given a non perfect world where you can't 100% guarantee such things).
I have looked and I don't buy it. I think any realistic transition to a single payer healthcare system in the United States is going to result in us still being the most expensive health care system in the world for lots of complex downstream consequences reasons. But that doesn't mean we shouldn't do it. It means we should just embrace paying the most to get the highest quality product instead of pretending that the goal should be to somehow be less expensive than everyone else while still getting the best care. It's unrealistic. You get what you pay for.
IMHO that's almost a meme: The US spending is paying for all the research other countries benefit of. Usually used to defend the US system against criticism. The arguement, by the way, isn't true.
Kind of like the argument Europe is benegiting of US military spending and would be overrun by the Russians if it weren't for the US...
And give up membership in the most powerful military alliance in human history, reduce US international influence and give up the most lucrative defence market in the world. This idea is so spund, even the Congress GOP voted for a law preventing the POTUS from pulling the US out of NATO on his own.
I agree so, that Europe should be less dependant on the US, we sure shoupd have a very solid and competitive defence sector supplying the various European armed forces.
Being a NATO member is not being a client state... And the thing I support is a stronger EU defence industry, not the US leaving NATO or whatever you read into my comment.
And yes, the idea of the US leaving NATO is so bad it is only loughable, the only ones happy about that would be Russia and China. US influence is not limited to Europe so, NATO activities stretch to Afghanistan (past tense), Iraq (same), Ukraine, Africa, the Balcans...
As bad as NATO intervention was during the war on terror period, and boy was it bad, tue alternative would be either Chinese or Russian dominance in those regions. And that would be even worse. NATO, human rights and all that is a different topic so.
And where is Europe dependant on the US for defence? NATO is an alliance, one that served, and serves, each member state quite well... Sometimes ignorant American exceptionalism is tiresome...
Clearest example is Iceland that doesn't even have its own military.
If NATO is such an equal alliance, why is US the only "partner" that e.g. has (a lot of) military bases, running on their own laws, in other "partner" countries.
Edit: And my point of view definitely isn't from American exceptionalism. I oppose my country's (Finland's) NATO membership and watch in horror how there's now going to be 12 bases in Finland that are essentially under pure US control (Finnish laws don't apply there, or even to the US personnel outside the areas, and Finland has no say in US military coming and going as they like).
Iceland as a nation has less residents the mid-sized German town I live in, guess what my home doesn't have a military of its own neither. What Iceland has is strategic importance, just google SOSUS.
Agree on the bases thing, some of the CIAs kidnapping flights went through Rammstein in Germany and nobody did anything.
Not much I can say about Finlands NATO memebership, I am actually neutral on that. Or rather fall into the group of people that see NATO expansion to former Warsaw pact countries as something Russia could be less than thrilled about. That being said, only the future will tell if NATO membership is agood thing for Sweden, Finland and co.
Being a NATO member defenitely doesn't make a nation a US vasal, se way EU membership doesn't make a nation a vasal of Brussels. And yes, I know opinions differ on that one as well.
Of course what is meant by being a vassal is up to definition and degree. But a foreign standing army probably is somewhere on that spectrum.
Brussels at least has the pretence of the member citizens having (some) democratic control, although I find EU so antidemocratic by design that this is indeed mostly a pretence. And EU e.g. sets quite tight limits of how the member countries can structure their economies.
> Edit: And my point of view definitely isn't from American exceptionalism. I oppose my country's (Finland's) NATO membership and watch in horror how there's now going to be 12 bases in Finland that are essentially under pure US control (Finnish laws don't apply there, or even to the US personnel outside the areas, and Finland has no say in US military coming and going as they like).
That's a very sensationalistic take. No military bases will be established. The agreement between Finland and the US is about prepositioned stockpiles for use in case of war. Since the stockpiles belong to the US government, it is natural that they demand unrestricted access to warehouses holding their stuff.
There will be areas which are under the rule of US military and can house weapons and troops at their will. What more would be needed for those to be characterized as bases?
Also a foreign country positioning weapon stockpiles is a bit questionable for sovereignty in itself, and I find it quite wild to use that as a rationale for giving up the country's rule of law in the areas. You think USA would be happy to have Finnish military areas within their borders because there happens to be Finnish weapons there?
When someone says "military base", then most people imagine barracks full of life, tanks and IFVs being worked on in garages, people coming and going, groups of soldiers doing their PT in the background like in establishing shots of Hollywood movies. Guarded warehouses in the middle of nowhere are none of that.
And defense agreements that establish exceptions from local laws are nothing out of ordinary either. For example, the agreement between Finland and Sweden stipulates that visiting forces are excluded from customs procedures related to weapons, explosives and other dangerous goods.
The Finnish-American one is much more detailed and goes into weeds like excluding vehicles transported by the US into Finland from car tax and VAT. :) It's common sense, but countries that are ruled by law must have these things written down.
Guarded warehouses in the middle of nowhere give at least as wrong image as military base. The areas are mostly next to Finnish military bases and USA will be taking over some Finnish military infrastructure. And the DCA allows for permanent US troops there.
My hunch is that the word "base" is avoided because the public opinion on even NATO bases is split at best, and I'm quite sure US bases are significantly less popular.
You'd be surprised how detachments from NATO militaries are treated at US bases. Pretty much the way NATO countries treat US bases and detachments. Obviously there are more US bases abroad than non-US ones in the states, but still.
US military dominance (in the form of NATO in Europe) isn't so much about defending the counties per se but to defend its interests in the countries by low key taking over their armies. You have a country quite well by the balls if their defence depends on you.
It takes a lot of money to bring a drug to market. Those costs have to be recovered and there has to be a net profit or no one would do it.
Pharma companies charge different prices for drugs in different markets. Markets with single payer systems usually restrict expensive drugs (either not permitting them or restricting their use to fewer cases) and/or cap prices. Some countries don’t honor pharma patents. Together these controls may make the drug unprofitable in many markets. Someone has to pay full price to make the drug research net profitable, or the pharma companies reduce research into stuff they lose money on.
It happens that the US market is favorable for pharma companies to recoup R&D costs by charging more than most anywhere else. This is possible because of the US regulatory environment and heavy lobbying by pharma.
This is what is meant when someone says that the US “subsidizes” drug costs for the rest of the world.
Note that I am not saying this is a good system; I’m just attempting to describe it.
> It takes a lot of money to bring a drug to market. Those costs have to be recovered and there has to be a net profit
A friend of mine who works in this industry explained how they come up with drug pricing and whether they decided to bring a drug to market. It's pure capitalism, of course--and why shouldn't it be?
It's a bummer, though, to think of the drugs that could have really, really helped some people but weren't lucrative enough to bother selling. Oh well!
> or no one would do it.
On the other hand, that's sort of like saying "There has to be a net profit in going to the moon or no one would do it" or "there has to be a net profit in selling flood insurance or no one would do it". Neither of those net a profit, but sometimes does it all the same.
There's a non-trivial amount of R&D being done with public funds (universities, and/or grants) that go to medicines that end up being locked up with patents and privately owned.
I lived overseas for work. I once went to the pharmacy and they said "4" -- and I was like "4 hundred?"
No, they meant 4. The same medicine I'd pay $25 copay (with insurance kicking in another $70 or $100) cost $4 out of pocket overseas.
This is because single payer systems overseas negotiate down prices. The US does. not. This effectively means that the US is subsidizing the drug industry.
Average physician salary in the US: $352,000[2]
That’s a big chunk of the difference. Simply changing who pays for your healthcare won’t close that gap.
[1] https://www.erieri.com/salary/job/physician/france#
[2] https://weatherbyhealthcare.com/blog/annual-physician-salary...