There are a lot of people making a lot of money on the inefficiencies of the US system. They won’t give
up their revenue streams without a fight, and they are filthy rich on the backs of sick people. You better believe they will play dirty.
I saw Jim Clark (of SGI and Netscape fame) talk one time about his new healthcare startup (Healtheon). He said something insightful that captures a lot of why it's hard to get things done in general: one person's inefficiency is someone else's bottom line.
The flip side of Bezos' "your margin is my opportunity". But that's for competitive markets, not for heavily regulated multi-party setups with minimal competition. That's the real wonder of American healthcare, as it manages to neither be a good market, nor to have regulator mercilessly going after the largest profit centers. Near the worst of both worlds.
Actual healthcare delivery is a growing field because boomers are getting old and dying and advances in health care mean that people that would otherwise die (eg people with cancers) are now receiving treatments that keep them alive.
Note that this is a Good Thing.
The issue with US (and privatized) healthcare delivery is that there is an incentive (by insurers) to deny treatment, as well as an incentive for healthcare suppliers (hospitals, doctors) to over-deliver treatment, as well as incentives to use more expensive solutions.
Demand in healthcare is inelastic, no one is ever "too healthy".
Supply is always insufficient, so there needs to be a mechanism to resolve that.
In the US, that mechanism is money, or the cost of insurance etc to provide a restriction on demand.
In universal healthcare, that mechanism is a combination of subsidizing medications based on results and waiting lists for limited supplies, prioritized by need (eg surgeries).
Is there any reason to believe less healthcare professionals would be employed under a universal system? Insurance claims adjusters and call centre scripted finance deciders, sure. But actual health delivery agents?
No, if anything there will be more because some of the funds freed up can be spent on healthcare delivery.
But you will lose endless billing departments at general/specialist practices, hospitals etc, because actual consumers would not engage. Hospital administrations will be driven by the government setting reimbursement rates for services that are transparent, so the argy-bargy between someone paying cash, someone getting insurance etc will disappear (mostly).
I'm in Australia, and the billing departments, even at private hospitals are minimal. Ditto at general practices. Reimbursements for GP/specialists that are not "bulk billed" (ie paid at the government rate) are automated into a nominated bank account and are usually instant.
Medicare for All in the US would move the 2/3rds that are not covered by Medicare, VA, etc into the same systems, with the reduction in overhead from 10-20% to the 2-5% of the current government run health systems.
Allowing Medicare to negotiate both drug prices (as a large purchaser) and health services will also dramatically reduce costs, because the government has the purchasing power to drive hard bargains.
The UK has a "universal system" as does Germany and the inevitable reality is that if administration does not limit/deny overuse of the system then it requires setting prices artifically low to limit costs. --> Causes Doctors to earn less wages and be overworked (many med cases). Ultimately, less doctors. =(
Alternatively, the government starts relaxing legal requirements on medical schools with the intent to flood the market with doctors. This not only severely depresses their wages, it leads to unemployment and indirectly to charlatanism and quackery as people try to make ends meet. Better hope the future AI doctors are good.
Alternatively alternatively the government could subsidize medical school for doctors and nurses reducing financial barriers and allowing more medical professionals without lowering standards.
Subsidizing existing schools merely makes it easier for existing medical students. It does nothing to increase the number of doctors entering the jobs market per year. You need to make more schools to increase that number.
You can't just conjure up a medical school out of nowhere though. That's extremely hard and expensive. You can do it if you relax your standards. Maybe by making the "hospital" part of the school optional or something. Students won't see patients but what does it matter.
Except this process is independent of whether there is overuse. It's always a pressure to lower costs, whether they are appropriate or not.
Medicare, Medicaid and Tricare are all basically universal systems for segments of the population. None work well. And all are subsidized from what people with private insurance pay. And the UHC proponents rely on a stacked deck--UHC is "better" in a system that makes 20% of the score "fairness". That is, UHC. And one of the other yardsticks is life expectancy. Sounds fine--but dig deeper. A big factor in lowering life expectancy is infant mortality. Again, sounds fine--except you see a big difference in infant mortality across the developed world that is not reasonably explained by differences in their medical systems. But you see an inverse relationship between infant mortality and stillbirths. Most of what you're really seeing is whether the doctors consider it a live birth that promptly died, or consider it a stillbirth. (And, yes, we are still an outlier--but by only 1/3 of the amount claimed.)
Show me it's better without your thumb on the scale!
If someone shoots some more CEOs, they'll have a change of heart.
(A lot of people are going to be very mad at me about this comment, without having the awareness to understand that this is the inevitable conclusion to, "You wanna play rough, ah?!"ing people's access to life-saving treatment. Please grok that we can preclude any more assassinations by cutting profits and letting people get the care they need.)
I'm skeptical. It will be cheaper to hire a couple security guards and buy a couple armoured cars then turn away profits.
The reaction was short lived while the insurance companies figured out how to bolster security and return to the usual.
Look at what's happening in California with the proposed wealth tax.
>Page’s co-founder, Sergey Brin, has poured at least $45 million into the Building a Better California Super PAC specifically dedicated to blocking the tax
The reason more CEOs getting shot might make a difference is that many CEOs care about status and being able to mention it in the right places. Historically many people love it so much that they call themselves CEOs and Presidents of companies that are small businesses.
If these same people can no longer be open about their role and status, which they value, there will be some kind of change. I'm not sure what it is, but security guards don't restore their freedom to feel thoughtless about their role and lifestyle.
Whereas with taxes... Maybe some people brag about dodging them or their suspect filings that get them big refunds. But they're mostly not public and not tied to identity the same way. And even the wealth tax isn't remotely the same as the public being vocal at large.
For it to be comparable we'd have to have modern highwaymen and Robin Hoods somehow stripping the wealth, not the tax man.
Because the weight of any changes or perceived need to change come from the social burden that public violence would create in the shooting case.
And that doesn't seem to exist near at all with the wealth tax.
>It will be cheaper to hire a couple security guards and buy a couple armoured cars
This is still a possitive outcome brought from the presence of a threat to their lives. Not as positive as the healthcare thing, but it's still jobs and a "tax" in that they are forced to purchase the vehicles which do have to be built and driven by someone not in their tax bracket.
If it were only the CEOs that were at fault you might have a point. Hundreds of thousands if not millions of Americans benefit from this system and the leaders are accountable to them - the shareholders, employees, and on down the chain.
Congress is our only hope, along
with a president who signs reform.
The people are in charge of congress, and they consistently show they do not support socialized healthcare systems. It will never be a politically viable path for the u.s, regardless of the economics. Even if it somehow passed, opposition would quickly sabotage and dismantle it.
Obama had a generational mandate and couldn't even pass a public option which, is far more moderate than a single payer approach. Even the abomination of the ACA that actually got signed into law was subsequently gutted to the bone in the following years.
There is room for more tweaking, but the system we're living with now is pretty close to what most voters prefer.
If people voted for universal healthcare we could get it done. The issue is that there’s a sizable, significant voting population that votes against it
I have wondered if an option would be to have a state make it law that every 4 or 5 years they open the bidding for a health care insurance provider for the entire state. A state committee then takes the bid with best premiums to services ratio and they do the job for the contract term.
There would still be the option of people and businesses to buy 3rd party "extras" like private hospital rooms, vision care etc. on top the state plan, but some level of basic health care would be provided to all people paying into the state plan.
No, overwhelmingly more people support a single payer healthcare system. The issue is that the people in Washington won’t make it a “votable” decision.
> The issue is that the people in Washington won’t make it a “votable” decision.
Sorry, that's ridiculous. Universal Health Care policies are an almost 100% partisan issue. I can literally count on one hand the number of federal lawmakers who cross party lines here.
The real problem is people like you refusing to vote for the people with the policy you want, as often as not as part of a bothsidesist stance designed to get more upvote in peer forums like HN.
The two party system may be flawed and unjust, sure. But people who want single payer are still democrats.
I already have universal healthcare here in Canada. I just feel sorry for people living in the US who could have it too if it wasn’t for stupid political shenanigans and ideological stubbornness. Health should be a right, not a commodity sold by private corporations to those who can afford it.
> The real problem is people like you refusing to vote for the people with the policy you want, as often as not as part of a bothsidesist stance designed to get more upvote in peer forums like HN
That's a lot of words they didn't say. It is a true statement that Congress did not give the USA single-payer healthcare nor even a public option.
Nothing about that says anything about who voted for whom, where anyone even lives for that matter, or anything about political parties.
To say this is the fault of "people like you" is out of line.
> That's a lot of words they didn't say. It is a true statement that Congress did not give the USA single-payer healthcare
But that is what they didn't say! They said it wasn't "votable", in the sense I took that means that this isn't an issue you can get by voting. And it is, clearly. And was, in 2010, when they were within one senate vote for a "public option" in the ACA. It 100% boggles my mind that you'd look at that once again incredibly partisan voting result and decide "Oh well, I might as well vote republican" (instead of "damn Joe Lieberman").
> It 100% boggles my mind that you'd look at that once again incredibly partisan voting result and decide "Oh well, I might as well vote republican"
Who said any of this? "I" said nothing of the sort
I don't think you're going to convince anyone of anything this way. If anything you'll probably end up turning people off who otherwise would have agreed with you
> Who said any of this? "I" said nothing of the sort
You quite clearly came in to defend someone who did, though. This is the second time you've tried this end-around strawman. Please engage with the discussion as it is.
> You quite clearly came in to defend someone who did, though
> "I already have universal healthcare here in Canada"
I don't think I'm the one misreading the discussion as it is.
If you take a deep breath and re-read, maybe you'll understand the point I've been trying to make is you're jumping down people's throats that aren't disagreeing with you, which at best does your own arguments a disservice. To put words in someone's mouth and say this is the fault of 'people like you' is out of line.
Please don't tone police on HN. If you agree with me but think I'm an asshole, the polite thing to do is just to keep quiet and not troll a discussion by convincing me you disagree.
But I'm very happy you agree that health care policy in the USA is among the most directly partisan issues and know who to vote for given those priorities.
If you think I'm merely "tone policing" then you still miss the point. I don't agree with your translation of "Washington didn't make it a voteable decision" to "both sides are the same" (with the added irony of accusing others of strawmanning).
Edit: and even now you still put words in my mouth with your edit (so that's every message in this thread that does so). Best of luck to you
Oh, come on. That edit was a clarification added like 40 seconds after the post. Really, it seems like you're the one getting bent out of shape. Again, I thought (and still think) you agree with me on the partisan nature of the issue, right? That's not putting words in your mouth, that's your opinion.
You just don't think I shouldn't have engaged with advocacy around the issue or taken offense that you and upthread commenters feel that this isn't something that can be... I guess "achieved by voting"[1]. I think that's a weird thing to troll a discussion this deep about, but OK.
[1] Does that match your understanding of the point? Genuine question! I think it's bonkers and wrong, but you seem attached to it and I'd like the opportunity to convince you.
I do believe it's mostly partisan. I don't believe it's exclusively partisan nor the most partisan
In the 2020 debate, Joe Biden said he would veto Medicare for all*. Just this week, Hakeem Jeffries said he did not support Medicare for all and wouldn't vote for it. You already mentioned Joe Lieberman
None of what I just said implies "it's not partisan" nor does it imply "both sides are the same" -- multiple things can be true at the same time
It sure does, however, reinforce the original, plain statement: "The issue is that the people in Washington won’t make it a 'votable' decision."
*By April 8, 2020, Biden was the "presumptive Democratic nominee" -- at that time, 22 states still hadn't yet held their primary elections. As such, for those 22 states it was quite literally not a votable decision
That being said: the whole thing is a complicated clusterfuck. Someone's health care spending is someone else's income. If one just snaps their fingers and enacts whatever ideal healthcare plan, what happens to those now-redundant workers? How does provider capacity ramp up to match the increased demand? I can understand why politicians might be hesitant to jump into such a woodchipper
As the joke goes, "how did God create the universe in 7 days? No installed base"
Oh for... Joe Biden was literally the tiebreaker vote in the senate when the public option was still part of Obamacare and was stumping for it like crazy. MfA is one particular proposal from one particular faction of the party. We aren't talking about MfA specifically, and that's quite clear all the way upthread.
This kind of dissembling and trickery is what's driving me crazy in this thread. You just don't seem to be arguing in good faith. No, Joseph Biden Jr. is very clearly not opposed to government-provided health care, nor is any democrat in office right now that I'm aware of.
I wandered into a stupid thread that said "single-payer healthcare." The article/study that spawned this thread is about single-payer healthcare
Public option is not single-payer/universal healthcare. Medicare for All is generally used as a synonym for single-payer healthcare in the US. The article stated it models the results of implementing a plan like Medicare for All
"Public option" still results in a vast bureaucracy of "paying for healthcare machinery", and so is scarcely comparable. Note: that does not mean a public option would be a bad thing. But it is not the same thing
I've already wasted way too much time on this, against my better judgement. I tried to leave twice, but third time will be the charm. Be well
Oooph. So this is all down to dithering on whether the public option qualifies as "single payer"? Like, is the "single" applied to everyone or just to the beneficiary? I'll point out that Medicare (the global archetype for this kind of coverage!) isn't "single payer" by this definition either, as senior citizens exist with private coverage or self-coverage.
Indeed you've wasted too much time on this. And I still have no idea what it is you really are trying to argue about. You agree with me on everything I've tried to pin you down on, and want to dither over tone and jargon when challenged.
-The US has had a lot of success by letting businesses run pretty free. This has produced some of the largest and most powerful companies on the planet.
-The conservative party traditionally has been suspicious of a powerful, centralized government
-In the US, there is a common thread of "government workers are impossible to fire" as well as a common thread of "government moves at a snail's pace".
In light of just that, there are many people who would prefer that healthcare is run by a private industry, as private insurers are enormous companies in the US. Everyone knows Blue Cross Blue Shield, Aetna, or Kaiser Permanente. Many people give a benefit of the doubt that companies are doing things efficiently. Additionally, health insurance companies in the US have a requirement to spend a certain % of their revenue each year on medical care, and will sometimes send out small refunds when they simply cannot suppress costs in certain other regions of the company enough to keep their spending at the right rates.
Beyond this, states may provide additional benefits, and many do (some with the help of federal funding, even). You may find someone in one state where they are suffering greatly, while someone in an identical economic situation in another state is not suffering at all. It's easy to convince the first man to vote for a better healthcare situation. It's hard to convince the latter.
I could go on for ages, but this is getting long. There are like a billion reasons.
> there are many people who would prefer that healthcare is run by a private industry,
The grammar is a little ambiguous around this, but you seem to be claiming that this is a majority position. It isn't. Single payer polls over 50% basically every time it's tested (the exception being some spun partisan reframings you occasionally see pushed), and has for decades.
The people who vote are old. The median age of primary voters is 65, regular voters 54. This is why you get a gerontocracy - old people vote for their interests, and young people don't vote. It's also probably why the median age of politicians has risen to 58 and 66 in the house and senate, respectively. With an 80-year-old president.
The solution is to have both a) mandatory voting and b) a voting holiday. This is done in many other democracies around the world, and it works. Personally I would prefer term limits and age limits for congress, the president, and federal judges. Diane Feinstein, Ruth Bater Ginsberg died in office. Mitch McConnell is working on it. We have age limits for lots of professions that require high performance - political leadership should not be an exception. But of course to make any of these changes young people have to vote, but they're mostly busy being poor and doomscrolling to block out the pain.
1) In the immediate aftermath of Thompson being shot, policies were deliberately briefly softened. Anecdotally, people were helped to live longer by this. It didn’t last long.
2) The response to Thompson’s assassination was the closest I’ve seen to a class consciousness almost forming in the US, as people from across the political divide who had suffered at the hands of the healthcare insurance companies found common ground.
I acknowledge their bloviating as I would a tough-talking teenager: with a wariness respectful of their capacity for violence, paired with an understanding that, 9 times out of 10, they're not going to do jack shit.
Probably important to point out here that leftists are looking to see a threat to a corporation's leadership change the behavior of a corporation, whereas right-wingers are looking to see a threat to a government's leadership change everyone's behavior ("overreaching government" in a democracy being the will of voters). They're not the same thing.
They've lost all credibility under Trump with the massive amounts of overreach. It becomes apparent they only care when the other party is seen as overreaching.
"Healthcare costs have been rising faster than inflation, and a staggering share of that spending is consumed by administrative middlemen, soaring drug prices, and emergency care for conditions that should have been treated earlier and for less"
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It's a n-tuple-whammy. Co-pays and deductibles discourage early diagnoses by preventing most people from visiting doctors for issues that aren't serious. The painful process of claiming the small amounts that would cover preventive care discourage people from getting it even if they've seen a doctor and been told to. Preventable conditions balloon into things that are very expensive and unpleasant. This process takes years though, and there are many, many insurance companies, plus people change jobs and coverage frequently. Odds are, the company denying preventive care won't be on the hook for the heavy costs down the road. If they are, they have ways to wriggle out of it. Also, with more people waiting until conditions get bad before seeking treatment, the whole system consumes more resources to keep people less healthy, on average, than if the system pushed preventive care effectively.
When governments assume responsibility for medical coverage, incentives start to be much less perverse. You pay taxes while you work. You work while you're healthy. So, the government wants you healthy. The government wants to do that as cheaply as possible, so they're incentivized, not just to provide preventive care, but to make sure you take advantage of it. I live in Canada. I have a genetic condition that could cause me problems if I don't get preventive care. One of my relations had those problems, so they tested her and found the problem gene. The government then tasked a genetic counsellor to seek out everyone related to her. I had the gene, so they now book me for the care I need to manage it. I don't have to pay for this. I don't have to fight insurance companies to prove I need preventive care. I just do what they ask me to do and I get to live longer. This is the kind of stuff that happens when the incentives are right.
Insurance companies need to be cut out of the loop entirely. They know they're what's wrong, so they employ expensive lobbyists. Americans need to realize this and start making it an election issue.
_______
EDIT: TIL that preventative and preventive are used interchangeably in the context of medicine, so I changed my very inconsistent use of them to just one.
You’re blaming it on lack preventative care, but the truth is that there is very little preventative care that is shown to be effective at anything more than burning money. The few things that are effective (e.g. vaccines) are largely inexpensive, and don’t require “insurance” as we know it.
Most of the things that are predictable and lead to long-term bad outcomes are behavioral (i.e. diet and exercise; smoking cessation; quitting drugs), and therefore both largely unaffected by medical care, and heavily confounded with socioeconomic status. Your doctor cannot make you eat better and exercise and quit smoking.
In the developed world, if you don’t die at birth or succumb to diseases of lifestyle (diabetes, heart disease, addiction) or accidents, you basically then die of cancer. The lifestyle diseases cannot be prevented by a doctor, and we have essentially no ability to prevent cancer. It’s all just acute treatment.
North Americans in particular hate to hear this, because they have an almost religious faith in doctors based on decades of bad TV. Honestly, though, doctors are pretty impotent when it comes to prevention of illness, and it is ironically this desire for treatment that is helping to balloon costs.
GLP-1 drugs do seem to help people change their diet (or at least intake), even in this environment of unhealthy, hyperpalatable foods that we have created.
No ability to prevent cancer? Ever heard of the HPV vaccine? I had polyps removed from my colon 10 years ago. There's a decent chance those would have developed into colon cancer by now. Prevention is a major part of reducing deaths from cancer. See also the effects of increasing taxes on tobacco products or restrictions on the use of asbestos.
Those are the exceptions, not the rule. But also, you're wrong: most polyps would not become cancerous -- only 5%-10% ever do. As a preventative intervention on otherwise healthy people, colonoscopy is one of the most effective things we do, and it's not that effective [1].
You've also included vaccines (which I explicitly mentioned) and "taxes" (which are not medical interventions), so you've completely missed the point.
[1] The NordICC trial found an impact of 0.03% on risk of death from colorectal cancer, which was insignificant. It did find an 18% risk reduction for getting colorectal cancer, but this didn't translate into a survival benefit.
Not just the wealthy people on top. All the administrators and suppliers, and all the machinery of pharmaceuticals and insurance brokerage, even HR benefits specialists in corporations are all tied to the current system. That’s a massive block of voters to be overcome.
This is a top-level example but you do not have to look at the top, really. The whole private insurance system is a scam at every level. I mean: I immigrated to US couple years ago, and I can tell you that any hospital visit, or a diagnostics, such as CT scan or ultrasound are 15-20x more expensive here than in my home country (which is in the EU).
Funny thing is: if you tell the hospital that you do not have an insurance they will charge you a price that actually sounds reasonable, say $700 for a CT scan (which is still like 2x more than in my home country, but then the US is a high cost of living place), but if you do have insurance they will try to extort as much money as possible from your insurer: initial bill will be like $10k, and then they will settle for, say, $6k.
>The whole private insurance system is a scam at every level.
All for profit insurance must by definition bring in more than it pays out. From cars to homes to health to pets.
If instead of paying all your premiums, you'd be far more likely to be able to afford the services that the insurers are supposedly paying for. Like, yeah, there's a chance you need a new engine, and a small chance that all of your monthly car insurance totals up to less than the cost of the engine, but the entire point of the company is that they know that it is far more likely that you will end up paying more for their service than you'd have actually payed for turns out the only thing that ever went wrong was a small crack in your windshield.
On car insurance, you have a competitive market with actuaries trying to identify actual risks, and that, with their prices, modify bad behavior and purchases of cars that are expensive to repair. So all in all, you can end up with very narrow margins, and end up ahead only on the float between receiving premiums and paying out. Health insurance, especially how it works in the US, with no public system williyto cover all the expensive stuff for catastrophic situations and chronic conditions, would compete by trying to fail to insure risky people. But since most insurance is handled by employers, all the levers for that fail too, so it's an especially bad insurance system. Home insurance, car insurance, normal life insurance... all more competitive and more beneficial economically, as their efforts lower costs overall.
Why can't they just charge higher rates to more risky people. If you are a risky driver you pay more, and if you have a risky body you should also pay more.
>...Funny thing is: if you tell the hospital that you do not have an insurance they will charge you a price that actually sounds reasonable, say $700 for a CT scan
That has not been my experience. Insurance negotiates lower rates and without insurance, the full fare price suggested price has always been higher.
Providers are contractually forbidden by insurers to show you the much lower "out of pocket+ price schule if you have insurance. It's why the first question posed to new patients is always " do you have insurance?"
I'm clueless about healthcare economics, but this sounds fishy to me. Why would insurers go along with that? In fact I would expect insurers to be in a much better position to bargain with a hospital than a private party. Actually it's if the hospital were billing the govt (not as motivated as a private party) where I would expect that overcharging to creep up and up.
Insurers can only spend 15% of premiums on admin spend (e.g. salaries, etc). That means if the CEO (and everyone else) wants more money, they need to pay more money to the hospitals, so their 15% cut grows.
Also, for beyond that, unspend premiums have to be refunded, which also cuts into the potential admin spend bucket, so it's best to always ensure your paying as much as possible in claims.
Plus, patients hate denied claims, because typically your forced to sign paperwork saying your responsible for anything insurance refuses to pay.
And with most health insurance spending being locked to employer benefits, the big market is the group market, which means your stuck with either getting your job's option(s), finding a new job, or not getting insurance basically.
In other words, you don't have a price choice as an individual in a group.
It's even worse when they claim to be "in-network" and they make you sign that. To me, the entire point of being in network is I shouldn't have to worry about the provider filing claims correctly on my behalf, and if there is an issue, it should be on the "network" side, not my side.
Hm, seems to be a bit of a contradiction between what you’re saying in terms of “insurers want to pay more” and the infamous tendency of insurers to deny claims as much as possible?
Well, they also need to ensure they aren't spending past their premiums coming in...
Alot of insurers the past few years have actually gone bankrupt from ballooning costs and claims.
So, they want costs to go up, so the next year they can up the premiums, so they can then up their admin spend, but the costs still need to below the premium. And they can't just up the premium without an associated rise in cost, because groups are owed their premium money back if it isn't paid out.
This is largely misunderstood. At the time the government went after many hospitals for what it perceived as "fraud" in a politically driven campaign. The hospital group he led was the largest at the time and targeted as such. While there are/were bad actors in the system is extremely complicated so try not to generalize.
https://pmc.ncbi.nlm.nih.gov/articles/PMC1115078/
They absolutely will, but I've been on the provider side of healthcare for over a decade and I can assure you there are lots of organizations who are EAGER to move to single payer and will absolutely help the fight. If you told a healthcare CEO that in 6 months they could let go of 90% of their RCM staff and 100% of their benefits verification staff, they'd be THRILLED.
And the PE firms getting in to healthcare delivery space will take up that fight too, so they can keep more of what they make.
We're also at the point that if there existed validated evidence that 'Universal Healthcare' made everyone rich and happy and beautiful and able to freely stroke kittens at will then we would still vote against it as a socialist conspiracy benefiting weak, lily livered failures.
Right.... but it is also an industry that provides an insane amount of (often well paying) jobs to a large amount of people to do "make work", admin tasks.
Reliable details are hard to come by, but some estimations are that more people in the industry are doing admin tasks than instead of providing care, admin tasks that will be reduced drastically once the industry is streamlined.
Once we get affordable care there will be less people who can... afford.
Feels like their job is mostly to enrich the corporations profiteering from these inefficiencies, they're doing admin fighting the sick and dying who also gained the job of admin of fighting them (a job thrown at them to - in a lot of cases - literally save their lives, financially and physically).
> Once we get affordable care there will be less people who can... afford.
This just plainly isn't true. The US is unique in the way it doesn't have affordable public healthcare, but the rest of the western world doesn't have an affordability problem because of less bean counters scamming patients.
I'd like to believe this, but the study makes a bunch of really hasty assumptions.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
>> Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
> Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
Would this go away, though? Instead of fighting with insurers they would be fighting with the government insurer?
I am very pro universal healthcare, I just don’t want to pretend there aren’t still going to be fights over what should be paid for.
No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
The way a lot of other countries deal with this is that the government calculates out a benefit vs cost assessment for every new treatment and only covers ones that come out ahead. But, that ends up with things like new targeted chemotherapies being unavailable for years after their initial release, vs in the US where they are available to much of the population once the right prior auth is filed. There is also more top down management of costs, such as long term life support for people in vegetative states.
All of this was branded as "death boards" in the American healthcare debate.
People hate it when faceless bureaucrats decide that some health care expense is too expensive for the large faceless bureaucracy to cover, when they have a medical issue that they would like the large faceless bureaucracy to spend money on. Perhaps in that world, some insane guy with a back injury who's unhappy about the quality of his care assassinates the Secretary of Health and Human Services, rather than the CEO of a medical insurance corporation (and hey, a lot of people hate RFK Jr. anyway, so maybe that assassin still becomes a folk hero for doing it).
This is already how Medicare works and it covers 70 million Americans. I’m not aware of any of these hypothetical violent outcomes being a huge problem for the program.
> Instead of fighting with insurers they would be fighting with the government insurer?
1. I'd rather fight the non profit-motivated entity
2. We can probably compare to VA and Medicare and even other countries to see what the fight will be like. I'm willing to bet it will be a big improvement.
> No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
Government insurance has a service motive. Private insurance has a profit motive.
What hospitals makes has nothing to do with physician pay - those are separate categories. Hospitals aren’t going to magically start giving some of their profit to doctors to help cover their lower fees.
OP makes a good point. The studies assumes two diametrically opposed things will happen - doctors will take a 50% pay cut but access to primary care physicians will increase.
Why would we solve the primary care physician shortage by cutting their pay?
Those are two real effects, but together they wouldn't compensate for the rate cuts.
About 8% of the population is uninsured. The uninsured population skews younger, with less healthcare utilization (Medicare already covers everyone 65 and older).
Another comment in this thread estimated billing overhead at 8.5%. Medicare for All would eliminate some, but not all of this, since Medicare is still a claims-based system. You would remove a lot of overhead around prior auths, which I agree is a good thing, but could be achieved with more focused legislation.
> .. 8% of the population is uninsured. ..
this is Bogus, one of the first argument hospitals make for inflated pricing is that they have to cover the cost of uninsured. if the uninsured doesnt exist then the whole line of BS argument falls.
> 2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
This layer won't go without a fight. Maybe it _is_ the layer we're fighting against. The owners will still make profit, the providers still have jobs.. but the middle layers are useless bloat. They don't have skills to provide care, they don't operate at the capitalist layer. They are useless today, and even more useless tomorrow.
And that is likely useless layer is millions? of jobs.
How would this change solve: "Hospitals eating the cost of the uninsured..."?
Wouldn't it just transfer the cost from the hospitals to the universal coverage agency? This would make the financial picture even worse for the proposed system.
>>> Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance.
The hospital can be paid less without reducing their margin if they can remove a cost from their balance sheet. It does not make the system cheaper overall, but it means the hospital does not have to bear those costs directly. They may not have to bear them at all, because hospitals are not the only things in the system.
Healthcare reform isn’t actually hard. Every advanced country has done it bar the United States.
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Yeah, and they all generally get there by paying practitioners much less than the US does (by integer multiples). Single-payer, which this working paper equates with "universal coverage", is in fact not the norm among universal systems; besides using Medicare to ration the supply of practitioners, the original sin of our system is employer-based coverage, not payer structure.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
Why do doctors need to be paid integer multiples more in the US than every other country on earth? This is not rhetorical, I mean it sincerely.
And I’m aware that medical debt is a big issue, but it seems like a chicken-or-the-egg type problem. Of course you can charge $500k for a medical degree when the doctor can make it back and then some in 5-10 years.
Nurses are also highly-paid in the USA (relative to other developed countries), and they make up a large part of the wage expenditure in the system. This may not make a difference to your point, but it is important to note that doctors are not the whole problem.
For those that have never looked it up, the median RN salary in the US is about $100k a year. Germany and the UK are more like $60k.
It’s funny, because it’s a career that feels both overpaid and underpaid to me. I went to a college where almost half of the students were going for nursing - and you certainly don’t need to be especially intelligent.
At least to an outsider, some nursing fields seem damned easy. The nurse that sees me before my GP? Pretty easy job.
Other specialties? Like the nurses that needed to clean up my wife after she massively bled during/after a c-section and they had to give her medications that also caused all sorts of other fluids to intermingle with the blood? Or the nurses that had to stand there for 10 minutes squeezing our infant daughter’s heel in the NICU to try to get enough blood out while she screamed as hard as a little baby can?
$100k doesn’t seem like enough. Odd occupation. For $60k I’d rather work at Costco, that’s for certain.
No, that's not why. Doctors also make drastically more than the median wage. Doctors make so much in the US because we have artificial scarcity of doctors.
No it isn't! The median wage for an electrician in the United States is about $65,000. It's nowhere near $200,000. The median general skilled wage is lower than that.
"Gen Z electricians making $240-280k in data centers" was a viral ploy by Mike Rowe on a podcast to promote his trades-training hustle.
> "The electricians that I interviewed and met two months ago in a data center in Plano, Texas, all under 30 years old, all making $240,000 to $280,000 a year, all with as much overtime as they want, none with any debt, all three of whom were poached three times in the prior 18 months," Rowe said ...
Google AI summaries then pick up wealth/finance grifter social media clickbait about it and parrots it as a fact.
There are contract data-center electrical jobs paying $55-65/hr (some with signing bonuses, per-diems, and benefits on top), but they only come close to $200,000 takehome by working 12/7 with generous overtime. And these are 5+ years of experience, OSHA 30, journeyman license, bring-your-own-tools. They're also exceptional; most are still $25-40/hr.
They don't! It's a huge problem! It's probably the problem in US health care, which, despite my own belief that single-payer is bad policy, is in fact a total shitshow.
We have numbers for this, we don't need to derive them axiomatically. Practitioner compensation is the largest component of health provider spending. Liability coverage is the second largest component of admin spending, which is 25% of provider spending.
“We have numbers” is always refreshing, especially in a shell game.
Cost of all licensed medical practitioners? Or overweighting incomes of outlier CEO physicians?
25% is a steep tax on health in any case.
Fair enough, but it is a political topic, and there are different and more confusing slices of the healthcare system exposed to patients than org spending breakdowns. Not sure how many of this thread's comments could hold water if falsification were universally applied.
Just so that people reading this thread know that there is the medical expense version of the Bureau of Labor Statistics, and it lives inside Medicare (CMS), and it publishes data. Most things people are trying to derive axiomatically on this thread, you can just look up.
It's really easy now with Claude and GPT5; just ask them a question and tell them to answer it for you, with cites, from the NHE. (The data I argue from precedes widespread LLM research; I built a site for this a couple years ago and didn't bother to update my data, because I assume it didn't get much better.)
Funny how one of the arguments against Medicare in the 60s was that providers wouldn’t accept it.
Turns out when you have the choice of accepting lower payment per patient for Medicare or having a lot fewer patients, you choose the lower payment per patient.
I would expect the same situation here. Doctors would grumble, but no one would force them to accept patients on whatever “Medicare for all” would be called. Nothing other than market forces.
A number of things would probably have to change, including the cost of medical school. But the system right now is expensive and essentially unsustainable. So change is inevitable.
Nope. More and more providers are dropping out of Medicare, or imposing limits on the number of Medicare patients that they're willing to see. It's tough to sustain a financially viable medical practice on Medicare rates, especially for primary care in HCOL areas. Medicaid is even worse. There are a lot of patients who nominally have coverage but in practice are functionally uninsured because they can't find a local doctor to take them on.
I think for the math to work you have to consider the bigger bulk of work that could be eliminated by universal healthcare: the payer industry. Insurers, PBMs, and all the smaller sectors that support them. The utility provided to society is fairly low — basically, just selective claims denial.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Truly. Aetna, United Healthcare, Anthem, etc are examples of industry that does not need to exist, and exist only to serve the status quo.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
They do perform one useful service: forcing a hospital that tries to issue a $100,000 bill that should be $10,000 to reissue it, and not leave the patient saddled with a giant debt.
(Medicaid & Medicare claims processors do the same thing. Medicaid claims processing is mostly handled by private, third-party insurers now, and seems to be able to do so more efficiently and cheaply than when it was being run directly by states; the savings is mostly in the area of catching fraud.)
Companies do this because it's massive song and dance by everyone. Hospitals issue big bills to insurance companies knowing they will want a discount so there is plenty of wiggle room. Also, it's free marketing for insurance companies because people see 100k, see all discounts for their insurance and are happy it's only 10% of true cost. It's like car buying except with your healthcare.
Medicare is much cheaper because they have fixed rates and hospitals know what to bill.
A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
They are not taking any losses; they just charge the regular price with a very tiny profit margin. US healthcare costs are heavily inflated. Insurance is a scam that lets the rich get richer. All insurance should be non-profit.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
It doesn't matter what they charge if the patient doesn't pay it; which is what often happens with uninsured people showing up at the ER.
> Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary
Under the ACA, excess money in the pool must be rebated to policy holders. In practice, this worked for a few years, but eventually insurance companies ended up increasing cost in order to increase the absolute amount they were allowed to keep. Maybe this is still good (more claims approved), but it is counter productive to the goal of reducing healthcare costs.
It often happens with insured people showing up at the ER as well. Many patients don't pay their bills, either because they can't afford it or are just deadbeats. As overall healthcare costs have increased, insurers and employers have shifted more costs to plan members through higher deductibles / co-pays / co-insurance. So hospitals end up with a lot more bad debt, and this in turn causes further price inflation.
Carriers and providers don't make this easy, either.
I had a recent doctor's visit, with very good healthcare coverage, that was an in-network facility but an out-of-network provider. Coverage would have kicked in if I had a referral from my PCP, but my PCP recently retired and I was advocating for my own health for a small dermatological issue. They said it was cosmetic, my old PCP said it was not. I got a stack of 10 bills over many months all stating different things -- everything from $0 EOB to over $2k in uncovered expenses. No one would take ownership of sorting out what I was on the hook for. No one I talked to was empowered to actually solve it. It wasn't an affordability problem over $2k (but would be for my elderly grandparents on fixed income). Even asking "If I give you $2k does that resolve the debt?" was answered with "we won't know until we apply the payment" type non-answers.
Burn the whole stack down -or- earn enough you can operate on cash for the tier of care you want. Nothing inbetween seems to be working.
Aren't their profits regulated regardless? If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
There are many factors, e.g. amongst other things American doctors are better paid than just about anywhere else in the world.
Yes and no. It's sort of a weird thing where insurance is somewhat regulated nationally but also regulated in a piecemeal fashion state by state.
There's a non-government standards body called the NAIC which provided national guidance for insurers. Most (all?) states basically say that "if you follow NAIC standards, you are good".
> If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
It's a huge mess. It's not even really a profit vs non-profit thing but rather "what's the motivation". One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
This is a big part of why I think universal public insurance is a must. Basically the only organization that's motivated to keep costs as low as possible is the government.
> American doctors are better paid than just about anywhere else in the world.
This is a problem, but the bigger issue and why doctors are paid so well is because becoming a doctor is one of the more costly and hard to do things in america. There are limited spots, schools, and residency requirements that severely restricts the number of possible doctors we add per year. That drives up the their salaries.
I have a nephew going to medical school in Idaho of all places, and he's looking at $500k in debt by the end of the whole ordeal.
> Basically the only organization that's motivated to keep costs as low as possible is the government.
Unfortunately, this isn't true for the government either.
Source: personal experience of me and literally dozens of people that I know. I've briefly worked with my country's government, and in that time I personally experienced and got dozens of stories along the lines of "the government spent tens of thousands of dollars of aggregate government employees' time because a single employee booked a hotel that was less than one dollar above the approved rate while traveling".
There's a good reason for this, of course: bureaucracies' policies are mostly "scar tissue" from high-profile cases where a bad actor did something they shouldn't have but wasn't specifically against policy, and then a policy was written for that case and stands for the rest of time. And, bureaucracies are risk-averse, especially democratic governments, whose leaders are elected based on optics almost as much as policy.
But it doesn't change the facts. Not only are large bureaucracies inefficient, but government bureaucracies specifically are incentivized to optimize for optics and structure rather than improving that inefficiency, and anyone who has actually worked for a large government can tell you that.
> One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
Investors care about margins, not absolute dollar figures. If your non-medical costs are capped, the incentive would be to reduce your other costs to preserve or maximize profits.
So the 80/20 rule is unlikely to have caused anything. More likely it's too low, and the profit ratio that can extracted and passed to investors is still higher than most investing alternatives, which is why it keeps attracting more investment. Without the 80/20 rule we would have seen the same thing or worse, though perhaps slower premium increases but less treatment delivered.
Really this all points to structural problems in the market. Naively we might presume there's not enough competition, and there could be many reasons for that--over regulation, lack of transparency. But it's more complicated than just that because medical treatment, particularly the most costly treatments, presumably have very high price elasticity [citation needed]. Over the long term, investors are just gonna keep trying to draw as much from the well as they can. The problem with public single-payer is that the basic demand curve dynamic doesn't magically change, so rather than complain about high prices people complain about shortages, OR the government just keeps borrowing to maintain satisfactory treatment access until they can't borrow anymore.
Maybe the only solution to rising healthcare costs is to slow down the pace of medical advancements. People love to point out how cheap care is elsewhere, but the most advanced and costly treatments usually become available in the US first, taking years or even decades to spread. (Note, higher prices on pre-existing tech subsidize the cost of bleeding edge treatments, so comparing MRI prices isn't very helpful.) Moreover, people elsewhere don't really know about them so it doesn't detract from their perception of the quality of care they receive. If you're dying and the doctor says there's nothing he can offer you, then that's that and no ill feelings toward the medical establishment. If he says there is something but it's gonna be crazy expensive or there's a shortage/waiting list, now your pissed.
The bigger factor in the American system is taxes. If everyone in the healthcare industry stack, from suppliers to nurses, is exempt from federal and state taxes, healthcare costs could come down by 70%+.
I'm not necessarily opposed to making all health plans non-profit, but that's kind of a red herring. Many of the largest insurers, like most Blue Cross Blue Shield Association members and EmblemHealth, are already non-profit. They generally don't charge plan members any less than their for-profit peers.
Not really accurate if you look at the closure of rural and smaller city healthcare facilities. They don't have the base to charge "regular price" to make up for the aging, less healthy, rural populations.
We all pay for it, but some pay heavier costs than others.
No, this absolutely does not explain the US's wildly off-base per-capita expenditure because uninsured people still go in the denominator of the per-capita figure! I'm sure the per-insured-capita figure is worse but that's not what we are comparing!
Americans are constantly trying to exclude uninsured people from their statistics (and, worse, from the care itself) but the comparable countries don't do this so it is utterly ridiculous to propose that the correct statistical comparison is one in which the US excludes the undesirables while other countries don't.
The fun part is when you break those numbers down between government and non-government expenditure. You’ll find that US governmental spending on health care per capita is higher than every other country’s entire (gov and non-gov) spending per capita.
Per capita stats are computed based on population, not per treatment or per person eligible for treatment. The US spends more per head on giving only a fraction of them subsidised healthcare than other nations manage on universal health, [more years of] education, [more generous] welfare payments etc. Some of that is down to medical professional salary discrepancies, but some of it is down to a terrible system...
>"Per capita stats are computed based on population, not per treatment or per person eligible for treatment. "
Your point is correct, but since the majority of healthcare spending occurs in the last 18 months of life, and the vast majority are on either Medicare or Medicaid during that time of their life (either due to age or ailment-related incapacity), it doesn't make a huge difference.
The spending per capita, unless I’m mistaken, is just “per person in the country” not “per person insured by the government”.
That means that even though government insurance in the US only covers a relatively small percent of the population, we pay more than other countries that cover the whole population.
That number seems hard to believe? Specifically that non government spending would be this low. Presumably "compulsory" includes way more than direct government spending.
According to the world bank it's closer to 40:60 (government spending still being the majority). So that puts it behind Switzerland but still more than combined spending in just about any other country.
In that link, government/compulsory for the United States seems to indicate times when an insurance company covered it. Voluntary/Out of Pocket is when insurance company wasn't required to cover and did or person paid out of pocket.
Even if it's US Government only per capita with people the government insures, it makes sense it would be so high because only people on government insurance are the poor/disabled AND old. Two groups that have extremely high utilization.
That claim is at odds with the working paper's methodology, which gets a good chunk of the $1T in savings it discussed by assuming very sharp cuts to practitioner compensation.
It also means that emergency rooms can be used just for emergencies and ongoing and preventative care can happen in clinics. Cheaper to operate and preventing preventable emergencies lowers the load.
Here's what happens in my locale. If you show up in an ER, they quickly decide whether you need emergency care, or regular urgent care, delivered in the same facility. And medicine is anything if not statistical, so they know the amount of each kind of service that they need to plan for.
My jimmies are hard to rustle. I'm fortunate that I have flexible hours, and can leave work if I need to visit a clinic. If either of my adult kids gets sick, they start making calls to find someone who can take their shift. So I suspect it boils down to individual or family circumstances.
A lot of the rest of the reasons are carrying the deadweight of administering regulation, and dancing with the existing and prospective malpractice suits that randomly benefit the system sometimes, but always cost everybody, and warp the practice of medicine and patient healthcare experiences.
So what's the solution? Some states have already limited malpractice liability but that hasn't done much to hold down costs. When patients are harmed by preventable medical errors they should be compensated.
The solution is NOT to decide on one problem at a time to all agree on solving by incremental compromise, or trust free market competition driving what is in reality a non-free market.
Most patients never file a lawsuit, even if things don't go well, and most injuries that aren't deaths or newsworthy are not worth the trouble to an "overburdened" court system itself imposing a lot of burdens.
And the quality life years lost waiting to share a verdict with attorneys ought to count for everyone affected, not just those who spearhead a trial by catastrophe.
I think the solution is to make the practice of medicine more scientific, and less dominated by competitive incentives, but as long as research and development, reform, or even consumer choice, is strictly a cost, that will be considered "too expensive", if not "too risky".
That's a non answer. The medical profession is already embracing evidence-based medicine as well as specific tools such as checklists and EHRs to reduce preventable errors. But there will always be some providers who are simply sloppy or incompetent or even malicious. Nothing else you proposed is actionable, just vague complaints and hand waving.
When patients are harmed by quacks, it is a true problem and those quacks should be incarcerated and never allowed near medicine again. If there are too many quacks, then this is a systemic problem that needs to be addressed completely separately from malpractice and professional insurance.
When patients are harmed by medical errors caused by non-quacks, that's just tough luck. Not everyone can be saved. Creating a gigantic medical malpractice insurance industry so that a few hundred surviving families per year can have lottery jackpot settlements isn't a solution in any way, and has done very little to incentivize fewer errors.
That's a silly comment. There's a huge difference between establishing civil liability versus a criminal conviction, and rightly so. The quacks aren't going to be incarcerated.
I think instead of my comment being silly, it's just difficult for you to understand because your Overton window only allows people who agree with you but differ on how much compensation should be allowed and the particulars of how that compensation is decided and doled out.
You can search for more reports, because they do vary based on methodology. But the median hospital in the US makes between -1% (yes, negative, they lose money, because a huge percentage are non profits) and 4% depending on the source.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
It is a system where all prices and costs are so far detached from reality for multiple reasons, that looking at any current profit margins is not going to be very realistic either.
Really need to step back and start from first principles.
When I go to urgent care I get 15 minutes with a doctor who on average makes about $300K and maybe another 15 minutes with a nurse assistant who might be making $100K (or less). So that is less than $50 in doctor+nurse salary. Of course there are then all the overhead of rent, utilities, etc, etc but those are not so different from any other business in the same strip mall. So let's say total cost for my visit is maybe $100. But I'm charged $500-$600 for the visit. Someone is pocketing a lot of money and it is not the doctor nor the nurse.
We could do the same exercise for surgery, the costs for surgeons and anestethicians is much higher, but you'll be hard pressed to find any realistic scenario where the cost of a two hour surgery is more than $100K.
> a department to argue with insurers, etc cost the hospital?
My surgeon friends routinely complain about the inordinate amount of time they personally need to spend fighting with insurance, in the form of filling endless forms that insurance insists must be filled and signed by the doctor. This is in addition to whatever time/cost the hospital staff wastes fighting with insurance paperwork.
The surgeon time is not cheap, but the insurance companies expect these doctors to do all this paper pushing for free on top of their day job.
The old saw about the engineer who says that the $100,000 bill was $1 for the bolt, and $99,999 for knowing which bolt it was... that's just funny AND true!
But if it's a team of nurses, doctors, and other healthcare specialists rushing around doing checklist work to make sure you get that aspirin, that's just evil.
The principle is only applicable to our industry and closely adjacent industries.
How do the salaries of administrators at such hospitals compare to for profit hospitals? How do they compare to non-medical institutions of similar size? Without a lot more information, your statement doesn't mean anything.
It's the salaries. That's where all the money is going. So that 37$ asperin, the profits... most of it is going to pay salaries. Not just of the doctors but administrators and all that.
Audited financial statements of all kinds of hospitals, both non-profit and for-profit. Here’s data from Moodey’s a credit rating agency: https://www.chartis.com/insights/hospital-margins-trend-high... (“This month, Moody’s credit rating agency released its annual not-for-profit and public healthcare median financial report for 2024, showing that overall hospital performance continues to improve. The median operating margin increased from 0.5% in 2023 to 1.5% in 2024.”).
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
Insurance pays the higher of their negotiated rate or the billed charge. Medical facilities set their billed rates so high that they’re guaranteed to be higher than all negotiated rates, ensuring that they get paid.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
All healthcare systems have administrative overhead, including completely nationalized systems. The US discourse on health care overestimates the administrative overhead by a large amount. We could remove all insurance company profits and adjust our administrative overhead to be in line with countries with nationalized systems and it wouldn't change health care costs by an appreciable amount.
The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system. No politician wants to propose reducing the salaries of doctors, surgeons, or even researchers making new medications. The only acceptable villains are the administrators and insurance companies, but even in this inefficient system that's a much smaller slice of the pie chart than most people imagine.
One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
> The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system.
Well, the salaries of medical personnel only account for about 20% of total healthcare spending. So even cutting those by half wouldn't change much.
> One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
If that was a major reason, then those who don't pay would balance out those who pay and the grand total of all healthcare spending in the US would be pretty average despite individual premiums and out of pocket costs being sky high. But in reality, the total healthcare spending is just as sky high (several times more per capita then median OECD country).
That number might be true across all health spending, which includes hospital plant, home health care, all public health work (including animal control), and medical equipment. But if you zoom in on clinical and specialist practice, the parts of the health care equation where payer-structure actually enters the picture, compensation for practitioner shoots up; it's the dominant cost of running a health provider.
It’s more like a politically palatable Rube Goldberg machine for transferring costs to those (well-insured through their jobs, the Federal government, rich supporting institutions and donors) able to pay.
> The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
The comparison you make between a bottle of wine vs a glass is not the right one. It's two different stores selling the same product. What's different about hospitals?
This is like that thing about about $15,000 toilets at DoD. What's actually happening is a cost allocation function where an agreed-on list price for a whole project is getting distributed pro-rata over as many different line-items as possible.
Sure, it's more expensive, but is it thousands of times more expensive? That $5 bottle probably has 50-100 pills in it. A single dose for $37 is 740X more expensive. And its not just that the apsrin is expensive to cover salaries, EVERYTHING is similarly inflated.
Hospital billing practices are often terrible or even fraudulent, but stories about the $37 aspirin are generally misleading. Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
To be clear, they are billing for all the coded line items at the listed prices, it is just that the agreements with the insurance company will disallow many of the line items in favor of other ones. They bill everything, because they may accept some insurance that has not negotiated a day rate, and in that case, the day rate code would be disallowed and some of the other line items will be paid at relevant negotiated rates instead (with others still likely disallowed). It needs to be the same bill in both cases, so they need to include everything, and the list prices need to be greater than or equal to what any insurance would pay, or they might lose out on the difference.
This is one of the areas where more standardization would certainly help. If there were more standardization of which codes disallow which other ones (which can currently vary wildly by plan even with the same insurer, must less across insurers), then a lot of line items could actually get removed as truly redundant, vastly simplifying the bill.
>Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
Yep. Hospital "bills" are a fiction. On one occasion I was presented with an "Explanation of Benefits" for a hospital stay where I was "charged" for being in two hospital rooms at the same time. As if that weren't enough I was also "charged" with having a "Pap smear"[0], even though I don't have a cervix.
I complained bitterly and after making a big stink was informed by the hospital my insurer that the items weren't actually "billed". Rather, the insurance company paid $1500/day regardless of the treatment provided.
I have the best health plan available (as a lifelong heart patient) from my provider, which owns the hospital. I've been charged 250$ for a covid vaccine, which was administered when I was recovering from a surgery to stop Sepsis. My hospital bill was itemized and I called to verify it.
I would be able to dispute a double room billing, but I was sedated and dying so I took whatever they offered, assuming good faith.
On the occasions that I’ve watched a hospital go through the actual process of selling a small amount of inexpensive medication for a large amount of money, there is a ridiculous amount of ceremony involved. I can easily imagine that it costs that hospital 2 cents for the pill, $5 in amortized capital plus operating expense for the facility that stores that pill, plus $25 in labor and IT expenses to get that pill to the patient.
My wifes a doctor and i can assure you they are gouging you. What it is is that the insurance companys are really in the purchase processing business. So what they do is institute fees on every possible charge and the hospitals in our area mark everything up as a result. Thats part of the problem.
Yes, but can you personally allocate four people, two computers, a wristband, a HIPAA-compliant database, a HIPAA-compliant data entry system, and at least two barcode scanners to get an aspirin out of the bottle?
I’m making a serious point here: medical overspending is not just gobs of money ending up in a single pocket. The US medical system really is incredibly complex, and the money is moving all over the place and being spent on many things. Most of those cost centers may all zero or even negative value to the patient, but that doesn’t mean they don’t exist.
Ever hear of loss leaders? Some parts of a typical hospital make money while others lose it hand over fist. The overall margin isn’t across the board, it’s after everything hopefully balances out.
ER’s for example are money pits, but society really needs them.
Exactly this. They need to offset the areas where they lose money. And we have federal laws (justifiably so, IMHO) that ERs must provide stabilizing services regardless of insurance and ability to pay.
And while that law is obviously humane and reasonable, my only gripe is that the rest of our system is so backwards that it increasingly forces people to leverage that. There was a story about a woman who needed dialysis but had no insurance. So basically, she had to wait every couple weeks until she started breaking down, go to the ER, get emergency dialysis, get sent home. Rinse, repeat.
I don't blame her but really just the system that made this her best possible option.
There was a story about a woman who needed dialysis but had no insurance.
And who was in the country illegally so she couldn't use Medicare or Medicaid. Still a terrible situation, but not representative of the typical American.
Nationalized healthcare might help with certain things but it can't create capacity out of thin air. Just because the government theoretically covers everyone doesn't mean that services are actually available when needed. In general the countries with the highest levels of nationalization also have the most problems with shortages. When everything comes straight out of the government budget there's always a political tendency to cut costs by reducing provider payrolls, imposing waiting lists for expensive treatments, or refusing to cover certain treatments at all.
> In general the countries with the highest levels of nationalization also have the most problems with shortages.
Do you have any citations for this? I've heard this rhetoric before, but every time I look into it, searching around for studies on google scholar or the web, I can only find studies and reports indicating that health outcomes trend better in countries with more universal coverage. There are think pieces with anecdata of course, but no actual peer reviewed publications I can find.
> Among patients undergoing cancer surgery, waiting times to initiation of first-course therapy have steadily increased since 2012, particularly at high-volume academic centers and among patients referred for definitive care. With continued consolidation and expansion of health systems, system-level strategies are urgently needed to monitor and mitigate delays in the delivery of surgical care for cancer.
> Delays were more pronounced at academic compared with community hospitals and among patients referred for care. Predictors of longer waiting time included Medicaid insurance (5 of 6 cancers), lowest-quartile income (6 of 6 cancers), Black race (5 of 6 cancers), increased travel distance (4 of 6 cancers), care in the West region (6 of 6 cancers), and treatment at academic institutions (6 of 6 cancers). Receipt of robotic operations was linked with longer waiting times for nonbreast malignancies (5 of 5 cancers).
Those studies have all, to my knowledge of them, shown no system mode that is better or worse than any other. The USA for many categories of care has often in those studies had worse wait times compared to nations with fully nationalized healthcare.
Heck when I went to college in Ohio's capital, the recommendation on how to get psychiatry or therapy as a new patient was to call the suicide helpline and claim that you were suicidal. That would get you a new patient appointment within 72 hours versus over 3 months on average for patients looking to get into care through normal channels.
Interesting you weren't able to find any examples. Here are some quick ones for CT scans in US Canada and UK.
The US maintains the highest hardware capacity of the three nations with roughly 43 scanners per million people and performs around 245 to 290 scans per 1,000 residents per year. non-emergency wait times are 1 to 7 days. The UK has 10 scanners per million people and ~100 scans per 1,000 residents, using centralized triage to keep non-emergency wait times between 1 and 6 weeks for NHS targets. Canada does 160 scans per 1,000 residents and 14 to 15 scanners per million, with wait times of 5 to 9 weeks.
When you consider that the US population is not fully covered by insurance, the number of scans is even higher
Okay, but that again seems to just be a few selected data points, rather than an actual trend, backed by peer reviewed study? Japan, Australia, and Iceland all have CT units per capita that exceed the US (~ 112, 70, and 50 /MM respectively), and all of three have universal care, two are full on single payer.
That's true, but obscuring the true costs through hidden cross-subsidies isn't helping anyone in the long run. We would probably be better off with state and local governments setting requirements for ER capacity in each region, and then running an annual reverse auction system where hospitals can bid on maintaining that capacity in exchange for cash payments.
It comes from the fact that lots of the charges they bill (both of the patient share billed to insured patients and of all costs billed to uninsured patients) end up written down or off because they are uncollectable.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
Medicare has been playing a shell game with reimbursements for decades. They cut the base rate for an office visit or hospital stay to below the cost of the actual service, but allow for separate charges for various things that make up the difference so that doctors don't just stop accepting Medicare in mass. That's why you get billed $37 dollars for aspirin, $15 for drug administration, $50 for IV placement, $10/bag for saline drips, $75 for vitals checks, etc. That way the hospital can make up the money lost from the actual visit charge, this also requires more administration overhead, to both keep track of all the additional charges, and to make changes as the rules change.
Hand-waving numerous details, but - That $37 isn't the price in the hospital's gift shop. It's n=1 pricing, hand delivered to your bedside by a nurse with a whole hierarchy of higher-level medical & admin staff behind her, and documented out the wazoo. Aspirin could be free & unlimited at the hospital pharmacy's receiving dock, and it wouldn't affect the @bedside price.
... and in other countries, medical administrative costs are far lower because they don't need to build entire divisions around correctly coding the same condition and procedure 11 different times before insurance approves it, because the insurance is universal and self-consistent by comparison to our private fractured mess.
It ain't just the insurance crap that drives up medical overhead costs in the US. Our health care system is treated as a money farm by plenty of other industries and interests.
All of which are willing to fight tooth and nail to preserve "their" fat slices of the obscenely bloated pie.
And on top of that you've got synergies like the horrific cost of housing in the US - which drives up the cost of every employee, no matter how essential they might be to providing actual medical care.
You understand that hospitals have more costs than just aspirin, right? Depreciation, amortization, utilities, rent, taxes, maintenance, salaries, etc...
Hospitals, now that private equity is involved, do this weird cost shifting accounting BS with shell companies etc, as such their books aren’t straight forward and the 2-5% thing is likely greatly underestimated given the amount of understaffing PE has driven in that space and how much gouging there is from PBM etc.
Even if universal health coverage lost money it would be better than the current system that is based on a "causing cancer is better for the GDP than curing it" mentality.
The US has top-tier cancer survival-after-diagnosis outcomes. We spend too much to get there, and other countries in our cohort would "argue" that we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar, but if you're going into these debates with "the US private health care system causes cancer deaths", that's a pretty rebuttable argument.
That overlooks the 27 million uninsured Americans. Uninsured cancer patients are more likely to be diagnosed at a late stage, less likely to receive treatment, and have substantially higher mortality than insured patients.[1] They also have worse survival, even after accounting for cancer stage.[2] So excellent U.S. outcomes among those who access care don't rule out preventable deaths caused by barriers to accessing it.
This is a cherry picked statistic. We still have lower life expectancy, high infant mortality rates, and one of the highest rate of preventable and treatable deaths among developed countries
The unfortunate truth is that if you break life expectancy out by ethnicity, it tells a different story. Generally Asians, Latinos, and Whites are above while Blacks and Native Americans are below and pull down the average: https://pmc.ncbi.nlm.nih.gov/articles/PMC9256789/#S12 If you break the groups out and individually compare against countries of similiar ethnicity, the US is often ahead.
For infant mortality specifically, in the US we count every baby with a sign of life, regardless of the age. In many developed countries, they simply don't count too premature (under 22 weeks or 500 grams, iirc) and therefore don't consider them in the metrics. It makes for an apples to oranges comparison.
You're right on "preventable and treatable deaths" with heart disease and diabetes being the biggest contributors. The question for that comes down to "is that a result of systemic issues or individual choices?" because we can do lots about one of those.
Statistical hustling is common, but the most usual form is that the US excludes uninsured individuals to make itself look like it belongs in the developed country cluster.
This means that the average life expectancy of white Americans is actually slightly below the average life expectancy of all Americans.
Incidentally, while a lot of developed countries do not track life expectancy by ethnicity, the UK seems to have a few some studies. (https://www.ons.gov.uk/peoplepopulationandcommunity/birthsde...) Though the data is very old (2011-2014), and the data is broken out by sex with no summaries, whites actually fare the worst. Black African females came out at the top, with a life expectancy of 88.9. I asked Google's search what the comparable black American female life expectancy was in 2011, and it gave me 78.2, along with a link. (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a8.htm)
Our overall ranking generally is below all "developed countries" that I can see, which range from Germany (~80) to the ~84 of "developed" countries like Japan, Switzerland, and Sweden (along with a few countries still classified as "developing" like Kuwait). It's not completely terrible, but considering how much the United States spends on health care, that's quite a poor value.
There are multiple identified factors for explaining life expectancy, but access to healthcare is identified as a very significant factor. In a system, like America, that is very expensive (likely due to highly inefficient, over-bureaucratic, overly complex, and over-quasi-monopolized systems) and without universal coverage, it follows that those who are poorer may not have the same access to healthcare and may succumb to entirely curable illnesses. So I don't think it's a coincidence that the racial breakdown above almost matches the median ethnic household income (the median white American household earns more than the median Hispanic household, but elsewise it aligns).
On infant mortality, at least one link I found -- https://www.healthsystemtracker.org/chart-collection/infant-... -- which adjusted data due to the reported difference, and still found significantly higher infant mortality in the United States. Though the data is a little old (2016).
Cite the source for "access to healthcare" as a "very significant factor" in US life expectancy? We have pretty good numbers on the mortality cause differences between the US and other countries and they don't align with this claim (unless you're doing some bank-shot argument about how access to health care makes our car crashes more lethal or something).
You'd want to be looking for a scholarly source that puts numbers on this. It's been done! As I noted elsewhere on the thread, the study we're commenting on is based on 1990s numbers about differing mortality of the uninsured. But here you're looking breakdowns of all mortality causes and tying them to insurance, a trickier proposition. Will be interested in whatever you come up with.
Our life expectancy and infant mortality rates are downstream of driving a lot of miles and unhealthy behaviors (mostly diet and exercise) of American mothers (i.e., obesity). Those are things it would be good to improve, but it isn't the fault of the ER or L&D departments or their billing models that people get in car accidents or mothers are obese.
Life expectancy differences between the US and other countries are dominated by just a few factors:
* Car accidents, because we drive much more and are much more spread out than other countries.
* Drug overdoses, though other countries are starting to catch up to us there.
* Homicide, because of our gun policy and the universality of firearms (which also bears on our suicide stats).
* CVD.
That last item sounds like an indictment of the US health care system, but it isn't. If you break CVD out by state, northeastern states like Massachusetts have outcomes resembling the Nordics, and Mississippi has outcomes like a developing country. But the structure of the health care system is the same in both places.
> Car accidents, because we drive much more and are much more spread out than other countries.
Somewhat off-topic, but I think this explanation of the car accidents misses the mark. It might be part of the cause, but car accident deaths were dropping in the US and Europe until around 2010 when they kept dropping in Europe, but flatlined and then rose back up in the US.
I don't think we were driving less and less and are now driving more and more. We changed policies. (I think it's mostly bigger cars, plus less focus on traffic infra/systems/rules that prevent fatalities.)
I'm sure there are qualifiers and rationalizations when comparing cancer survival statistics as well. As someone already pointed out, uninsured Americans aren't necessarily included. They cited sources, you rebutted without sources.
I believe a single payer system is a matter of when not if. It works just fine in other countries. In our country, the healthcare industry has evolved into extracting as many dollars as it can from the economy. This is because when someone is sick and needs treatment, healthcare providers hold all of the cards.
Uninsured Americans are in fact universally included in death statistics and in cancer survival outcomes; we have top-tier cancer outcomes.
Europe has several universal coverage systems without single payer. The original sin of the US system isn't private insurance, it's employment-based coverage; that's the thing nobody else has.
Again, you cite zero sources. Survival rates for lung cancer in the USA, the most common cancer in the world, are much lower than Japan and South Korea. South Korea is single payer and Japan has strict government regulation of healthcare costs.
The second most common cancer is Breast Cancer. The USA is "top-tier" but so is pretty much every other Western Country. Australia, also famously single-payer is a mere 0.4% behind the USA.
This is the only source of modern survival statistics by country:
Take note of two things: First, some states weren't even included in the study and second, there is no mention of insurance. The statistics are only tracking people who were diagnosed with cancer. It's reasonable to assume that some people who had cancer symptoms did not seek treatment because they didn't have insurance and died without being diagnosed.
I'm not saying that the US is better than every other country. I explicitly said somewhere else on this thread that there's a common critique of our outcomes that we just do detection better, and that our life expectancy outcomes aren't materially better.
What I am saying is that it's difficult to make a case that US life expectancy is materially altered by our health insurance system. You won't be able to use cancer to make that case, because the US has in fact quite good cancer outcomes. That's it: that's the whole argument.
Again, though: this repeated claim that "the uninsured aren't included in survival statistics" --- I don't know where that's coming from. It's not true.
I literally posted a link to the CONCORD-3 paper and made arguments using it and you rebutted it with "start with CONCORD-3".
I'll restate my argument so it's clear: CONCORD-3 does not mention insurance status anywhere in the paper. It does state that the statistics require diagnosis. It's reasonable to assume that if you can't afford healthcare, you're less likely to seek treatment or diagnosis.
You understand that CONCORD-3 is about tracking people who enter the healthcare system. Isn't it reasonable to assume that if healthcare is free or very affordable, there would be higher participation? And on the flipside, if it's outrageously expensive, there would be lower participation?
Sorry, I'm talking about US overall outcomes, which is what I thought you were arguing with all this breast cancer stuff. I am not taking seriously your axiomatic argument that the uninsured are systematically not captured by the US cancer statistics, and was not bothering to rebut that, nor will I.
Some good news is that ISH diagnostics manufacturing can go through 510(k) instead of PMA on Sep 16 onward, which should make those diagnostics 10x cheaper and twice as fast to get through.
>The US has top-tier cancer survival-after-diagnosis outcomes.
"Airplanes that get shot in the wing always survive" logic. People _do not get diagnosed and die_ because the US healthcare system is inaccessible to close to 50% of your population. A diagnosis easily reaches a few hundred dollars for the best cases (and several thousand if you need multiple tests/blood tests/operations like colonoscopies). And when you do get diagnosed, then you've just entered a world of having to pay hundreds of thousands of dollars.
>we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar
lmao no you simply don't diagnose people and they just "die of natural conditions" early because they couldn't afford the treatment even if they were diagnosed.
> US healthcare system is inaccessible to close to 50% of your population
So you have no idea what you're talking about. What is the point of making comments like this that are both verifiably false with about 2 seconds of online research and just sound incorrect based on anecdotal data to anyone living in the US.
There is a ton of ideology baked into naive-level analysis of this stuff.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
>Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
Did I mention the 100° summers or the fact that people usually live 20+ miles from where they work?
I agree with you generally on the incentives, but it took us 70 years to paint ourselves into this corner, and we’re not going to get out of it because of a third-order incentive.
Thats not every where nor is it everyone. Im not saying it will specifically be bikes but the government will be incentivized to have a healthier population. It could be higher tax on cigs, or sugars, it could be more annual leave it could be any number of wellbeing policies.
But it is many places. You can't just magically hand-wave away the fact that the demographics between these places are wildly different, and that changes the burdens on the systems in place.
From a political philosophy standpoint, this is exactly why many people oppose a single-payer healthcare system. When the government is paying for everything it creates a financial incentive for an intrusive nanny state. We can argue about the positives and negatives, and maybe we would be healthier overall, but many Americans simply don't want the government telling them what to do.
We are getting the "intrusive nanny state" regardless of financial incentives of a given healthcare system. That ship has sailed. It's a goal, not a side effect.
Right… my exact point is that it’s not a like-for-like comparison.
Take Europeans, put them in Kansas. Fund their healthcare as though they were in Europe, and watch their health outcomes take a nosedive because the environment here is non-trivially worse for you health.
Unless I’m wildly misunderstanding these studies, it makes sense that we would need to spend more for the same outcomes because we are starting from a more unhealthy position, so the same results require more resources.
We need to at least be controlling for the 10%+ differences in obesity rates, and the enormous differences in UV index. That’s before even considering weekly exercise minimums that most European get when just walking to a bar.
Then compare, say, Massachusetts to high functioning north Europe systems. You will shrink the lifestyle and climate factors down to a pretty minuscule difference, but you will still find that the spending is dramatically higher.
You're not wrong at all that the US has some systematic issues that place additional strain on the healthcare system, but it's a "yes and" situation here. Even accounting for those, we spend far, far too much because our system is extractive.
I don't think there's a whole lot to understand in this study; it's pretty wildly extrapolated and its savings numbers come from spherical-cow projections of what single-payer would actually do (somehow, it would drastically cut pay to doctors without chasing them all out of the field).
I think the important bit in all these discussions is that "universal health care" and "single payer" aren't synonyms. Single payer is one way to do universal, and most universal systems don't do it. But this article conflates the two.
One wonders what the lowered stress vis a vis healthcare concerns that a reformed system would take care of would do for our ability, as an electorate, to make better decisions in other arenas.
Yes, these cost savings would be a deflationary event. Most layoffs will come from insurance companies and administration necessary to satisfy them in hospitals.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
To be fair, my experience has been exclusively with hospitals running a specific EMR with a relatively new-ish (at the time) and difficult to configure billing system. Still, we were expecting to see shortfalls nearly an order of magnitude smaller than what we found.
That the hospitals didn't seem to notice the problem, and upon being told of it, often pushed back against moving to fix the problem, is what gave the impression that they must be running on much larger margins than advertised.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
>"fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care.
This is a hoot. There is an entire cohort of people who use the emergency room as their non-urgent clinic. This is not a small demographic, it must be at minimum tens of millions of people, if not going above the nine digit mark. They do this because their parents did it, and it's the only thing they know, and their parents did it because it's the only thing they knew, and they did it because their parents did the same. It is a culture that no amount of education and public service announcements will ever change.
Heaping one perverse incentive after another on top of this mess won't change it either, but will almost certainly make things worse for everyone.
>For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
My grandpa when he was still alive would have one new fraud story with every visit to the doctor, and he wasn't in great shape towards the end, so this was too many to count, every year for the last few. Diabetic, they ordered him compression socks at one point... a dozen show up instead of the two pair that was ordered. He'd come home and wait for a bill in the mail, and a few days later would see itemization for tests and procedures he never underwent. Over and over and over. He was sharp, argumentative, and as far as I could tell, less confused than most his own age. His experience, I think, wasn't atypical.
I don't think a price transparency reform would be hard. Other than in terms of political will. We did go part of the way there a few years ago, though it's not common knowledge yet.
The US' healthcare model is not unique, and almost no countries have zero-cost-to-consumer healthcare systems (and none of them are free -- they're just paid by taxpayers instead of consumers). "Free" healthcare is the exception rather than some kind of international norm you incorrectly make it out to be.
The first step to reforming US healthcare is actually understanding it, and understanding some international designs. Lying about it doesn't help.
The vast majority of those 8 billion people do not have single payer healthcare. A lot of Americans get confused on this, because we're the only country in the Anglosphere that doesn't do single payer, but it's far from universal globally.
I didn’t say they did. I said they understand that free healthcare is not literally free, but comes from taxes. Do not underestimate them, they understand very basic things.
No, they’re not false, you’re just misunderstanding. When people say “free” healthcare they do not literally mean all healthcare is zero dollars. They don’t mean nurses earn a wage of 0 dollars an hour.
No, they mean free at time of service, which they are.
Don’t believe me? Great, then ask them, without doing word gymnastics to try to trick them.
Should medical equipment cost 0 dollars to produce? Should doctors not earn any salary or wage? They will say no, 100% of the time.
> No, they mean free at time of service, which they are.
I don't think that's true France, Norway, New Zealand, or Switzerland. (And that's just developed nations. The GP's claim was every country other than the US.)
People wouldn't be externalities if healthcare costs money. Next thing you know you would have to pay attention to the environment or god forbid the food. It would eat away the budget for overthrowing countries and bombing children. Watch them elect a democrat to do the bombing next round and a new republican after that. It sounds like a joke but it isn't funny.
> Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Billing and insurance ("BIR") is reported at around 8.5% of revenue --- admin isn't just BIR, as you note. But replacing private insurance with Medicare doesn't drive BIR to zero; Medicare is also a claims-based system. Estimates are that you'd cut BIR by somewhere around 30-40% (of 8.5%).
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
Physician/nurse salary is not the major driver of the cost of healthcare. It's around 12-15% spending, depending on the methodology. Even if you force doctors to work for free, it won't meaningfully affect the cost.
It's really the overhead costs that are so Byzantine that they can't be quantified properly. Hospitals have teams of coders, insurance companies have teams of counter-coders, physicians have to waste their time on calls with insurance companies, etc.
"Medicare for all" would alleviate a _lot_ of this. It already works for the elder population, and pretty much every senior has health conditions. So extending it for everybody would result in savings. This is a no-brainer from a purely fiscal point of view.
Another way to fix the mess is to lean on the free market side: prohibit employer-sponsored insurance. Completely. All the health insurance plans must be sold on the open market to everyone.
I just don't believe that it's correct. The Kraken hides here: Hospital Expenditures - 31.2%
I have a bit of personal experience here. I had a partner working as an endocrinologist, one of the higher-compensated medical professions. They were spending at least 1 _hour_ every day on calls with the insurance companies for prior authorization instead of seeing patients.
Some things are also weirdly broken down:
> Net Cost of Health Insurance Expenditures - 6.2%
> Administration and Net Cost of Health Insurance - 7.4%
Why are they split?
I also suspect that they included some admin personnel cost in the physician/nurse salary. For my partner, their office employed a person just to deal with insurance. There is no easy way to break down these costs for small practices.
There’s essentially zero doubt that universal healthcare would save over $1T per year.
How do we know? The experiment has been done multiple times, all over the world. In the worst case (Sweden), healthcare is a bit short of $5K per capita per year, or around $1.7T. We’ve actually got a nice margin to achieve $1T, even if we remain the worst.
I agree health care reform is hard, though. We have a clear roadmap on how it can work a lot better. But what’s the political path forward?
As someone who’s actually fiscally conservative, single-payer universal healthcare is an absolute no-brainer, but, ironically, the people who call themselves fiscal conservatives will fight it to the death (well, not that ironic — at this point we all understand that, in politics, what groups purport to believe and what they actually believe have little to do with each other).
You can quibble with the specific projected savings, or the projected lives saved. But it kinda doesn't matter? If we can have net savings of half what this paper said, or a quarter, and still have more lives saved, that would still be a strong argument to do it.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
Are you saying that most hospitals have 50% profit margins, of which 90% are paid to the chairman leaving only a thin margin? That seems difficult to believe.
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
I'm saying if you think that administrative expenses (among others) can't be inflated for a profitable company, I would like to run your company and demonstrate what executive compensation can include:
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
Yes, I consider big numbers like this to be red flags.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
This is broken window fallacy. The $1T not wasted on healthcare inefficiencies would be spent/invested on other things, creating jobs there. Yes, there would be churn because a good number of people involved in the bureaucracy of private health insurance would lose their job and possibly their career. But these things get smoothed out. Social supports (should) exist to dampen the effects of such churn and keep the economy agile.
Only the American mind can comprehend leading to the deaths of tens of thousands of your own people for the sake of 3% of your economy. As long as the line goes up.
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
Sure, it's possible in principle. But the US also has a much higher GDP per capita than the UK. The UK is a (relatively) poor country and is increasingly being left behind.
The US is in a class of its own when it comes to health spending. The second highest OECD country (per GDP) is Germany which is 5 points lower than the US (and BTW these figures include public and private spending).
You are clutching at straws to discount clear evidence that shows just how ideologically driven the US System status quo is...
"'No Way to Prevent This,' Says Only Nation Where This Regularly Happens"
The money doesn't vanish. It stays in the hands of people. People who would spend it on other things, feeding it into the wider economy instead of the pockets of a small number of corporations. There's zero reason to think this would result in anyone rioting except maybe insurance company CEOs.
Yes, it will, but think about the supply side. If people spend $1T less on health, health professionals will earn $1T less, it means, as GP said, layoffs, cutting salaries, etc... Not just doctors and nurses but also drug researchers, medical equipment manufacturers, etc...
These people will now have to do the "something else" that will be spent on, let's say gardening. But you don't turn a nurse into a gardener just like that, that's the kind of "wide ranging repercussions" I mentioned, and the painful transition period where nurses become gardeners. "Nurse to gardener" is just a random example, it can be "drug researcher to petrochemist", and some transitions we may be happy to see, like "health insurance lawyer to burger flipper", but overall, many good people will suffer in transition, many powerful people too, which make such transition unlikely.
I don't understand why we always pay attention to only the jobs side of decisions like this. Why is the main concern always preserving existing jobs? The extreme version of that is obviously silly. The savings is real and lowers prices, increasing social mobility and spending elsewhere. How many people are locked out of moving for a job that matches them better, or taking some training for a better job and so on just because of medical debt leaving them no flexibility? And if we could save that trillion by eliminating jobs, doesn't that kind of imply those jobs (or at least the system requiring them) were terrible allocation of human capital?
I am not saying it is a bad thing. What I am saying is that when we are talking about trillions we are talking big changes, and big change doesn't come without suffering, and people don't like suffering.
Usually big change doesn't happen without a catastrophic event, like a war, a coup, or an economic crisis, or maybe more optimistically, a technical or scientific breakthrough. So when an article mentions trillions without hinting at such an event, to me, it is incomplete, or wrong.
The French revolution would be an extreme example. It is a win for freedom and democracy, but the period following it is called "the reign of terror", for good reasons.
Yes, but it's a different group of Americans, and the ones who are currently thriving in this broken system will fight tooth and nail to preserve their way of life.
I see. But I think that's kind of the same diffuse vs. visible problem that underlies a lot of impedents to progress. The jobs thing is one example. We focus on one set of workers because we can picture being in their position. We can't internalize and "feel" the diffuse but greater benefit of a more efficient healthcare system, which I'm 100% would be a net positive, just spread out over the whole population.
I don't know the solution, but do you agree that the problem is basically one of individuals not being able to accurately model the tradeoffs in their head?
We're quick to want to automate trucking, manufacturing, even knowledge jobs and say "ooh but the horse shoe maker became the tire installer" but the pointless middleman jobs making everyone's health worse seems to be the line in the sand for job automation.
You can't touch the legions of people who exist to make things more expensive.
I mean there's flavors of contributions to gdp. Spending money on make work for people digging holes still counts. I wouldn't mind 1 trilly being freed up for more effective use. I imagine we could get pretty good returns on it just paying it against the debt as a simple idea, effectively a tax cut.
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
Every country with nationalized healthcare systems has lower wages for clinicians. So the notion that this wouldn't lower salaries is just ludicrous. That might be an acceptable trade-off but let's not pretend it doesn't exist.
In practice what we would see under a single-payer system is that many doctors would opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
Those countries also just have lower salaries for all sectors. The USA is just exceptional in salaries for many professionals. Just look at software engineers pay in Europe Vs US....
Switzerland has the system closest to the US in my experience, but with universal coverage.
As individual, you buy basic insurance costing roughly $500/month with a $2500 yearly deductible (LAMal/KVG). Applicants must be accepted even with pre-existing conditions. Post-deductible, you pay 10% co-insurance capped at roughly $800/year (no medical bankruptcy). Insurers operate basic plans as non-profit. They make their profit on optional supplemental insurance (private hospital rooms, extra benefits...) The state subsidizes basic premiums for low-income individuals. A doctor's visit is a $150 minimum, similar to the US.
What was most surprising compared to here in the US is employers pay $0 toward premiums. Funding is entirely decoupled from employment. You don't lose coverage or change plans when changing jobs.
On the negative, basic insurance does not have dental, so dental stuff is out-of-pocket and expensive.
In terms of stats, the US spends 18% of GDP on healthcare vs. 12% for Switzerland and the gain is lower stress too. Not perfect but maybe the best of both worlds.
Yup. Premiums change depending on the deductible you choose[1] and your age.
[1]: If you have the CHF2500/year deductible, premiums are cheaper but you have to pay that amount out of picket before the insurance company reimburses your expenses
Isn't this how socialized healthcare works in every country? Whether they realize it or not the principle is generally the same, an amount (usually bundled under "social contributions") goes from people's gross salary to pay for the health insurance.
Thats too much trouble.
In India, there is a new scheme of "ayushman bharat"
500K inr which is quite a lot of money, per family.
No co-pay, you show the card in supported hospitals or government hospitals and you are in.
There are "problems" but overall it has had a net benefit with poor people who could not afford medical treatment just get it.
If you are having an emergency, they just do whatever is needed and you are golden.
I know hundreds of people in my neighbourhood who have had surgeries done on "card" and most could not otherwise afford it.
What I've read about government hospitals in India is that they're extremely overcrowded, with people crowding the hallways and waiting rooms to be seen while bleeding out or dying from illness, without even air conditioning in a lot of places. On the other hand, this was reported by a young Indian doctor that wanted to get to the UK ASAP, so not sure how representative his accounts are.
>A doctor's visit is a $150 minimum, similar to the US.
It's $20 to go to the doctor on similar priced insurance in the US.
Your $500/month is just a tax for healthcare. Your only advantage over the US is that it's not tied to employment. Ours is both a tax and a cudgel to force people to work.
We have the worst of all worlds because ours is a tax and a cudgel, but then we also have to pay tax to the state to fund the healthcare for others who can't or won't work. I wouldn't call yours the best of both worlds. It sounds like you're getting fleeced to a lesser extent, but still not great.
I thought you were going to say out of pocket costs are much much higher than that.
I’ll be lucky if I get a specialist for under 500 until I meet deductible of 3k+ for a family of 3. One emergency room visit and we reach it in one or two days.
We've been down this road. ACA was predicated on studies like this, to no avail (it turns out that intense opposition chips away at it over time regardless of these studies).
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
ACA has saved tons of lives. Due to the intense opposition, it was not structured in a way that could save money, but rather structured in the way that it could get through congress.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
>Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
ACA is horrible for the middle class. The only reason it retains any type of popularity is because the media refuses to associated ballooning cost to cost redistribution that it enables. Preexisting conditions? Middle class family picking that up. Subsidy? Middle class family picking that up.
This is unfair to the ACA and factually incorrect. ACA subsidies (median household size) [1] are designed to start above the 50th percentile (income) [2].
The details matter. If you're a single person living alone at an income of $70,000.00, you're below the median household income and "picking up" other people's subsidies, but that's not indicative of the country.
In a wealthy and civilized society we have a moral obligation to care for all of our citizens. Some of them have pre-existing conditions and can't afford to pay market rates, so the middle class is going to have to subsidize them one way or another. Whether that subsidy comes in the form of higher insurance premiums or higher taxes hardly matters.
Before I went indie, prior to ACA requirements I researched private insurance and found plans for around $3K. This year I’ll pay over $20K for a bronze plan for my family. 700% increase in less than a decade. Aetna left the marketplace input state and no pediatrician in a 10 mile radius takes the most cost effective ACA plan. The pediatricians we found are actually just GPs who have training in pediatric medicine, but we bring in the only minors they see. This is in a top-5 market based on population.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
I think it's generally gotten better for insurance companies, at the expense of both end customers and providers (with the exception of providers that have vertically integrated into the ecosystem, e.g. Aetna/CVS, etc. to capitalize on the advantages that brings).
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
If that’s the only benefit couldn’t that have just been made a law and left out all the rest? Healthcare system is worse than ever, I don’t know the cause but with its current prices I can’t imagine subsidizing it further being the answer
Without the ACA it would have been even worse. And by worse I mean that even if the premiums were lower, we would still have horrible limitations like maximum lifetime coverage amounts or exclusions for pre-existing conditions.
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.
You are paying more because a lot more healthcare is being delivered, to people who never used to either due to exceeding maximum benefits (we have the opposite today with out of pocket maximum), or being denied for pre existing health conditions.
So to answer:
>Who is it better for?
My 4 year old, who has received hundreds of thousands of dollars of cancer treatment, and will need a bunch more over the coming years.
> ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.
Then turn it into a tax and be done with it. I don't shop for my tax collector and I don't pay taxes to companies with the biggest buildings in the city. Companies that don't actually provide health care, but just collect their pound of flesh from patients and providers, driving up costs for everyone.
I'm glad your child has received care. I'm very much behind the idea that pre-existing conditions should not preclude anything from receiving _care_. I'm completely opposed to mandating a private 3ᴿᴰ party be between me and my provider.
Democrats tried, they did not get 60 votes in the Senate between Jan 2009 and Jun 2009. What we have is because at least 41 other legislators, including all Republicans, decided not to offer the US public this option, and since then Democrats have had nowhere near the numbers to enact any further reaching legislation, except the No Surprises Act in 2021.
I agree with you about the ACA (as an opponent of single-payer). Prior to the ACA, members of my immediate family were uninsurable on the individual market --- not insurable at a higher rate, not insurable with exclusions, but literally uninsurable: their only options were employer-provided group coverage or state catastrophic safety net coverage programs. The twist: neither has any chronic health conditions. The underwriting refusals were based on symptoms reported in previous engagements with the health care system.
And this is precisely why nothing will ever change. I tell everyone who will listen to me on my soap box, we will never get universal healthcare until we divorce healthcare from employment (by that I mean, make it to where businesses cannot offer benefits at all).
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
Funny enough there's a very good chance I'm a Lost Canadian. I filed my application for proof of citizenship in February and am still waiting to hear back. Hopefully soon.
Part of the reason why there is no effort to fix this, to keep you a slave to a job that provides healthcare. Imagine the reduction in labor supply and increase in labor costs if healthcare did not require employment. On can, in many cases (facts intensive), bail to a developed country with healthcare if you want to realize this dream earlier than whenever the US will achieve the outcome (and your life situation supports doing so). It could potentially takes years, if not longer (~5-10 years), for the US to fix healthcare as the situation continues to degrade for those who need affordable healthcare today.
https://relocateme.substack.com (a product of andrewstetsenko here, no affiliation, I just like resources that can help humans achieve their success criteria)
https://healthcareinfusion.org/ (for healthcare workers interested in Canada, likely does not apply to many here, but please share with others who might be seeking a path)
(i see this problem as a vulnerability management and exposure exercise to attempt to solve for, ymmv, no affiliation with any resources recommended)
That's not how this system came into being. It's a path-dependent quirk of the tax codes of the 1940s. We got into this predicament because of WW2-era wage controls (a dollar spent on health care by your employer was literally worth more than a dollar in wages).
This is one major reason why most of the world's universal systems make private insurance work, and it doesn't blow up the way ours does. But I don't think employers are any happier about it than you are!
You are of course correct on how we got here, I argue we are still here for many reasons, one of which is what I stated. I mean, there is no will to fix healthcare, but lots of will to spend $100B+ to go to war with Iran, right? I simply do not see anyone who cares enough to fix this exceptional mess, even taking into account the coordination problem of doing so. We could treat this as an emergency requiring a fix, but we don't. Why? We can certainly find this will for, "low ROI nation state actions".
Can we afford it? Doesn't stop trillions of dollars for DoD spending for middle east wars or tax cuts for the wealthy, so that isn't an argument, that's subjective cover for not fixing it, we do lots of things we cannot afford (current sovereign debt outstanding is ~$40T, as of this comment). Can't be done? Almost every other OECD country has solved this in some way. Therefore, as a scholar of systems, the root cause I am left with via Occam's razor is "This is an active choice to not fix this suboptimal system, where the fix would be both more economically efficient and humane, For Reasons while the electorate is lied to or paid lip service."
Employers, who supposedly are unhappy with their healthcare costs, could form a coalition and lobby for legislation and fund PACs to fund candidates who would fix this state by state with universal healthcare systems (Canda's universal healthcare system started in a single province as an experiment, for example). Why don't they? Are the costs not high enough yet? They can't argue they don't have enough power, they already, in many ways, bend the US government to their will. They have the power, they actively choose to not use it to fix this system failure.
The evidence shows we could spend less and deliver more within the scope of healthcare delivery (this piece). We actively choose not to. The Pentagon hasn't passed an audit eight years in a row, I hear little that "we cannot afford to keep funding the military at these levels and with such inefficiency."
I don't want to sound like I'm fundamentally arguing with you, because if I could swap our system with Germany's I'd do so in a heartbeat. But (a) the "money that should be going into health care and education is going to military" argument is highly rebuttable, so I'd be careful hanging my hat on it, and (b) everybody, literally everybody (except the AMA) agrees we're spending too much on health care --- the problem is that money goes to practitioners, so it's very tricky to talk about clawing it back.
What an idle comment - where is the AMA on record saying that we should spend more on healthcare? Here's all the work they do to describe our increasing costs:
Also, when people invoke the bogeyman of 'AMA' they treat it like the lobbies that tech companies belong to. The AMA is not enriching physicians or hospitals (which have their own lobby!) but generally espouses consensus perspectives among doctors while making money from administering things like a residency program application system.
It's frustrating for someone like you to make this statement which feels quite divorced from any fact when you would not do the same about a security topic.
The AMA orchestrated the capping of residency slots through CMS/Medicare, which is the primary structural impediment to increased supply. Doctors in the US make integer multiples of what they do in Europe in part as a result of this.
I have to say: you can go either way on the AMA, I guess, but it's a weird hill to die on, isn't it? They're a trade group, not a public health organization. They exist for the benefit of their members.
I really would love to see the sources you have on this. As someone who has been in medicine for decades now, I have never hears this. This may be the result of a game of telephone but I'll comment as I can:
> The AMA orchestrated the capping of residency slots through CMS/Medicare,
This has very little to do with the AMA, though it is true that in 1997 the AMA was predicting an oversupply of physicians. CMS funding is the role of Congress and the AMA has supported increases in residency seats since the prediction of oversupply was found incorrect.
If there's a problem with an advisory group suggesting that the US not overspend, then I think we'll not agree on much.
I take their 1997 position as one in good faith; the graduate training component of medicine is very resource-intensive (and honestly dangerous!) so it should not be expanded without good reason.
> Doctors in the US make integer multiples of what they do in Europe in part as a result of this.
Doctors in the US make mulitples of what they do in Europe because we do not have a single-payer. You even say this earlier in the thread!
> They're a trade group, not a public health organization. They exist for the benefit of their members.
I assure you, no physician feels their needs are reflected by the AMA. It's an odd duck that probably made sense in the era of PCPs owning their own firms. The AMA has several structural roles in medical training (they administer application programs, primarily) so they're not going away any time soon, no matter what I may wish.
It's weird to hear someone in medicine say this, because it was a big deal at the time and it comes up in many health care economics discussions (it's a commonly stated reason we can't just make more medical schools to create more doctors, and in that way bring the cost of medical education down). And: if you feel that physicians are alienated from the AMA, OK, why are you defending the AMA?
"Single payer" can't be the reason doctors make more here, because they make far less in systems like Germany which aren't single payer. There's a really widespread misconception on the left in the US that "universal care" elsewhere in the world automatically connotes "single payer", but most universal systems aren't single payer.
A quick caution: if you write to me as if I'm a defender of the US system, you're going to miss me consistently, because I am not that. I just think the reflexive position that the answer to our problems is to universalize medicare is bad policy. We could do guaranteed issue, community rating, price transparency, and means-tested subsidy and land essentially where Germany is without essentially ratifying permanently the perverse protectionist premium paid to providers.
No system that saves money can pass in congress: that's the real problem that we cannot actually avoid. Forget pressure from large companies: So many of US costs come from very high salaries, and a lot of bureaucratic positions that don't exist elsewhere. Every dollar we pay goes to someone, and it's not just some random mogul here or there that will be OK anyway. Reform that really lowers prices means loss of jobs, which them will be blamed on the politicians who signed the bill into law.
Yeah, since the ACA my coverage has remained the same while my costs have risen 10x; I'm in my 30s and my medical insurance costs 3x what my mortgage costs, and I still have $$$$ sized bills after a round of strep throat.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
Your blame is misplaced. Costs are increasing in spite of the ACA, not because of it. Pre-ACA your family insurance policy was likely worse in some key ways: it probably excluded coverage pre-existing conditions and had a lifetime maximum coverage limit.
But then the blame might be correctly placed? If he had no pre-existing conditions and was on a no-existing conditions plan, that plan might have saved him a lot of money.
Imagine car insurance regulations changing in such a way to force underwriters to blanket-assume everyone has had a couple speeding tickets this year. I understand why we do it. We are ok with speeders paying more for insurance, and not ok with someone born with diabetes forced to pay more for health insurance. But it is the end result in any case.
ACA also greatly increased costs. As an entrepreneur at the time, insurance premiums increased 25% overnight for the same plan. Many people had similar experiences.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
You are both sort of right and wrong; based on a quick analysis, knowing this isn't perfect due to how plans have different characteristics, and states had different characteristics..
in the 2000s (pre ACA);
* Employer plans averages 6-10% increase per year
* Individual plans averages 10-15% increase per year
Rollout (2010-2017)
* Employer plans averaged 3-5% increase per year
* Individual plans averages 0-10% the first couple of years, but spiked hard to 25%+ from 2016-2018.. with lots of volatility (one stat I found shows 130% increase between 2013-2019)
Post (2018 to today)
* Employer Plans averages 4-6% increase per year
* Individual plans were generally stable but with huge volatility; also expansion of gov't subsidies absorbed much of the increases for those earning up to 400% of fed poverty level
All the stories I've heard about that came from people with bad insurance (for instance: insurance programs that could rescind coverage if you were diagnosed with something serious, and that functioned mostly as billing processors for routine care, which is where ~none of the expense in the system is). The ACA did effectively regulate those plans out of existence, so if you had one, and relied on it, it raised your cost.
But when we talk about the ACA's impact on cost, we're always talking in a macro sense. Every program has individual winners and losers.
Insurance prices _dropped_ in NY after the ACA was enacted. Not "slowed down the growth" but actually dropped in absolute numbers.
That's because NY had enacted a coverage mandate even before the ACA, so insurance companies were forced to offer policies to everyone. This resulted in a runaway spiral where only sick people were getting insurance.
The ACA forced all large employers to buy insurance, greatly increasing the risk pool.
I don't believe you. It wasn't the "same plan". I guarantee that the plan you had before the ACA had a lifetime benefit limit, perhaps as low as $1M. Read the fine print. A single complex episode of care could easily blow past that limit and leave the plan member functionally uninsured.
I lost my individual healthcare plan, and I couldn’t afford the new ones. Remember when they said you could keep your plan? Yeah, that’s the one I lost.
Why do you believe that the ACA would have wanted such plans cancelled? There's a very straightforward public health reason that's reminiscent of why states require drivers to have car insurance.
> And for the record, it was not as high a deductible as most “silver” plans on the exchange currently.
The plan would have been in effective over 18 years ago. Does your internet plan look the same now as it did 18 years ago? Your cell phone plan?
> The plan would have been in effective over 18 years ago
This is such an important point. There's been ~40% of cumulative inflation over that period.
Also, anyone who was already buying insurance for years before the ACA knew the price has always gone up every year, often by double-digit percentages. Simple compounding plus the fact that insurance is always more expensive for people 18 years older are confusing a lot of people in this discussion.
You act like I’m an idiot. It was cancelled immediately when ACA was passed, and I couldn’t afford the new plans the same year.
My point about the current plans is that if you want to call them a “scam” because they are high deductible, you have to call almost all current plans scams.
It’s reminiscent of the screeching about how single payer healthcare would have death panels deciding who lived or died like that’s not a word for word description of insurance company actuaries or financial employees making the same decisions.
I'm curious as to how your experience actually using the plan for more than preventive coverage? IIRC, plans before the ACA had a ton of customer unfriendly provisions which made the insurance far less usable in practice. E.g. denying coverage for preexisting conditions.
Keep in mind, I made no value judgement on ACA at all, just suggested that we learn about its opposition and, as you rightly point out, the difficulty of passing such legislation that can last over time.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
Let’s be honest, it was DOA. Even Gruber admitted to it later. The whole thing was basically a scam.
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
> I will never understand why people think ACA was so great.
I would never have healthcare without it due to pre existing conditions from childhood. I literally was going to be locked out of healthcare barring becoming wealthy enough to afford everything out of pocket until it passed. And that’s really wealthy not just software engineer money. I know a lot of doctors are offering routine services for cash at a discount in increasing amounts but if you need anything with a hospital or a specialist it’s a nightmare to even find out the price before agreeing to the service.
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
> "Findings suggest Medicaid expansion under the Affordable Care Act saved about 27,400 lives between 2010-22, including among younger adults."
> "Their findings show that Medicaid expansions led to a 12% increase in enrollment and significantly reduced mortality—not just among older adults, but also younger ones, who accounted for nearly half of the life-years saved."
Huh? Did you read it? My point was that we could have just expanded Medicaid to achieve this.
If we are going to be unbound by reality then we could "just" put a medbed to cure all diseases, reverse ageing, and regrow limbs using quantum space-age tech in everyone's home.
Too many people think snark is a substitute for insight.
The major GOP complaint about the entire thing was that it was the federal government forcing people to buy a product from companies. The Supreme Court ruled that it had that power.
The ACA was the Republican plan until championed by Obama. The Republican goal was to say anything to denigrate their own plan. Romney later became the nominee for President and it was his plan that the ACA was largely based off of.
Republicans fought hard to discredit their own plan. They just wanted to move to the right of whatever it was that the black man championed.
It was the Medicaid expansion that has been cited as saving lives [0].
Medicaid expansion saved lives. That is true and not in dispute. Other lives were saved too. It wasn’t just poor people who obtained life saving care from ACA. In an alternate world where only Medicaid expansion occurred fewer lives would have been saved than were saved with ACA as it exists now.
> An expansion that has almost nothing to do with the rest of the ACA.
That's a very strange assertion, it's literally "the ACA medicaid expansion" and was a key part of the whole thing.
I'm saying most political argumentation is dishonest and not intellectually rigorous, and that's what the comment was doing. It wasn't arguing based on facts or data or actual specifics, but rather according to vague political ideologies.
That's one reason that I believe politics are discouraged on HN. It turns off our brains and we start using less interesting or useful ways of thinking.
"Saved lives" or "Could Save Lives" is a ridiculous, un-falsifiable, and unprovable claim.
First, it involves twisting correlation and causation into an Escher knot. Secondly, it's not even what cited source says.
Yes, "reduced mortality along a timeline for a certain demographic" is a good and desirable statistic, but there is no way that it translates into the self-aggrandizing and sensationalistic "ACA/Medicaid saved tons of lives" (whatever "tons" is supposed to mean, in terms of lives. Perhaps grossly obese people died less.)
We ban accounts that won't stop doing this. I don't want to ban you since you also make good contributions. If you would please review https://news.ycombinator.com/newsguidelines.html and taking the intended spirit of the site more to heart, we'd be grateful.
Alright, heard, I will be less snarky and aggressive.
However, in this case - https://news.ycombinator.com/item?id=49323758 - if HackerNews guidelines allow for someone to defend torture and call it “life affirming medical care” but don’t allow someone to wish for turnabout, then this site isn’t compatible with my worldview and you should just ban me. Because I do not intend to ignore such heinous things when I see them.
The real problem with universal healthcare is that it immediately completely eradicates religious charity.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database.
Everyone's getting free shit no questions asked.
I don't know that "inclination to judge" is a necessary component of religious charity. Religious charities beyond healthcare give out a lot of "free shit no questions asked," and usually without any attempt at proselytization. Catholic hospitals are not known for turning down patients due to moral judgements.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
Republicans finalized things to address medical costs and chiseling at hospital billing - regulations promulgated during Democrat regimes - so I would say there is bipartisan consensus for the actual arguments, if people listened to the actual arguments instead of seeing a no-vote as an opposite nonsensical ideology.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
These types of studies, and the goals they aim to support, always frustrate me as solving a surface-level problem rather than root cause.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
The problem with models is that depending on your assumptions you can show just about anything. In general I think the foundation of a good argument, and good science, is assuming the minimum and seeing if your idea still works. They assume:
- hospital reimbursement drops to medicare rates ($296 billion)
- pharma prices decline 51% ($378 billion)
- administrative overhead way down ($286 billion)
- fraudulent billing way down ($286 billion)
- people stop going to the ER and stop being hospitalized as frequently, so the expanded use of services only costs $198 billion
Those seem like extremely optimistic assumptions, and the paper gives 0 consideration to most knock-on effects. For instance I don't think it's reasonable to cut hospital funding by $296 billion, increase the access to these hospitals, and assume everything will work out just fine. They at least acknowledge not acknowledging this, but that one factor alone already is likely to dramatically reshape things. And there are many others.
(1) we don't know the claims of the study will be accurate if implemented and (2) we would need studies modelling cost savings of alternative approaches to actually compare anything.
Obamacare made wild claims about cost savings as well. That didn't work out for many reasons that could show up again with another universal healthcare push.
There's a multitude of evidence that points to the success of the ACA from a cost perspective (among other things).
Cost of healthcare for individuals is not a good metric to judge by. The ecosystem of hospitals, patients, doctors, insurers, health systems, and the federal government is complex and you're not going to get a clear picture of the overall impact of the ACA by looking as something as simple as cost savings.
One example, hospitals are required to treat patients whether or not they hold insurance. The hospital foots the bill for that care and it's a major reason why hospitals shut down (especially in underserved communities). Getting more people on insurance plans was a direct factor is keeping many struggling hospitals and health systems afloat.
If the ACA was so successful at reducing coats we wouldn't still be having discussions like this about the excessive costs of both care and insurance in the US.
We will never know how costs would have changed if we didn't implement the ACA, and cost is not the only metric of success. But it clearly hasn't led us to a place where people feel okay with what the industry costs.
The purpose of the ACA was to get more people to sign up for health insurance by creating plans everyone could access regardless of employment status or income. Solving the healthcare crisis in this country from top to bottom is going to take more than an act of Congress.
Also necessary to remember the ACA was only passed because of Democratic support in 2010. Republicans hacked away at the proposal before it became law, kneecapping any real institutional changes it had contained, and have effectively killed it since becoming the majority in the House and Senate in 2024. That bipartisan support piece is required in order for anything meaningful to happen.
Making healthcare more affordable was literally in the name. I agree they also aimed to expand coverage, but cost reduction as a top line item and my point was simply that it didn't land that goal.
At a minimum since we don't know what prices would be today without the ACA, prices have risen dramatically in recent years to a point that I think most agree its unaffordable.
1. Do any of the cost savings recommendations you address come close to $1T/yr impact? This is the scale we should be aiming for.
2. If you think this modeling is inaccurate or incomplete you can directly discuss that. That would be a much more interesting discussion than "it might be incorrect."
That's a great question, and one that should receive similar funding and attention to properly compare.
My hunch is that (a) this study over estimates on the cost reduction side and would not pan out, and (b) improving health should always be a better cost savings than reducing corporate overhead (especially given how piss poor our average health is today).
The point of nationalisation is to address those underlying concerns. But it’s fair to say that in practice, nationalisation doesn’t always solve those problems.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
I don't think our problem is a lack of regulation though. If anything its a lack of market competition, and that is caused by over regulation and legal protections that make holding companies responsible difficult or impossible.
I think the high upfront capital required to start out in the industry is a much much bigger hurdle than the regulation.
You see the same problem in IT with hardware startups vs purely software ones. The moment you need to own something more than 1s and 0s, the risk grows exponentially.
Reducing regulation doesn’t solve that problem.
And that’s without even considering all the shady tactics that the incumbents can do to drive new ventures out of business.
It's also caused by absurd nonsense like how doctors can't tell you how much anything they're proposing to do actually will cost (a necessary condition for entering into a contract!), but then the system makes up arbitrary bills after the fact - with fraudulent amounts that nobody actually pays! No other industry works like that, as it's not the foundation of a market in the first place. Imagine if going to the grocery store involved "paying" some token amount at the cashier for their time to put your items in bags, then for the food you received shakedown bills for years afterwards, that you had to spend time going through your old documentation to refute and bargain down. Absurd.
Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.
That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advance. The current HIPAA adopted standard transactions don't allow for sending a prospective claim. So all they can realistically do is perform the procedure, submit a claim to the patient's health plan, wait for it to (maybe) be paid, and then send a bill to the patient for the balance.
The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.
Nothing stops a doctor or an office from saying "treatment X costs $Y."
Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.
Right, and as I already pointed out below, cash pay patients have the right to demand a Good Faith Estimate (GFE) from providers under federal price transparency rules.
That shouldn't be limited to cash payers though. Insurance companies should not be part of the process of care providers pricing their service, nor should they be able to deny a charge after the fact.
Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.
One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves will charge for anything. The problem I'm describing originates completely with them - no escaping blame here.
(And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
Feel free to blame doctors if that makes you feel better but the reality is that in most cases they literally have no way to accurately calculate a patient's out-of-pocket cost in advance. Like there's just no technical way to do it.
If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act.
You keep misinterpreting "how much [a doctor] themselves will charge for something" as "patient's out-of-pocket cost". I'm certainly not asking for the doctor to get involved between the patient and their health plan [0], but rather what the doctor charges, regardless of who might pay. In other words, the straightforwardly-legible prices that exist in every other market - even markets where insurance companies often pay (eg auto repair).
I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless.
[0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
Are you perhaps unfamiliar with existing price transparency rules? Patients paying cash already have the right to demand a Good Faith Estimate in advance. Those using a commercial health plan can see the negotiated rates for every participating provider.
I'm aware of them, but I'm not familiar with them as they seem like band-aids that add even more patient self-administrative bloat, rather than fixing the core dynamic - making healthcare pricing work like every other industry. The word "demand" is a tell, showing that this is not the normal course of the relationship. Another tell is that it's two prongs - why can't everyone receive a "good faith estimate" from a provider? Note I'm still not asking the provider to grok the patient's health plan - rather to be upfront about the prices they themselves are choosing to charge.
Also the ambiguous place between the two cases - "you have a health plan but we didn't do the work to actually bill it" - is a common source of the fraudulent shakedown bills, and this does nothing to constrain those types of fraudulent bills!
In general, I don't need to request a "Good Faith Estimate" from a grocery store about my upcoming food purchase for when I go later in the week, nor for an oil change down at the mechanic. If I go to the mechanic with "something is making a noise", then they are upfront about any fixed diagnosis fee, and then give estimates routinely in terms of a shop rate and book hours. If there are still unknowns about what might need to be fixed/replaced, they are up front about that and readily communicate with the customer. All of this is straight up missing in the medical industry, even when you try to engage. Rather they shove "consent" forms at you that say nonsensical anti-contractual things like "we can bill you whatever we want and you're responsible" and when you start pushing back on them they look at you like you have three heads.
(and just to head off the inevitable drive by comments like "It's not practical to shop around while you're in an ambulance" - the vast majority of medical care is scheduled ahead of time rather than on an urgent basis)
Sure, I'd be all for such reform. Those are the kinda of changes we can and should make before even considering nationalizing an entire industry. If nothing else we'd want that setup anyway under a centralized system, and we could change pricing regulations now with much less controversy unless you ask the lobbyists who would fight it tooth and nail).
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
medicare is basically the biggest culprit for the "too much paperwork" stuff. A m4a plan that doesnt involve capitation would have even more paperwork than the current system does.
Exactly. I'd at least want to see similarly funded studies comparing solves for underlying causes beyond just insurance companies not being nationalized.
Similarly we could look into the likely cost of over medicating our people, and the atrocities we call food in grocery stores.
We never attempted to solve the issue of distorted price signals that occur when customers aren't the ones paying for something. We're still charging $600 for a bag of saline.
That's not necessarily true; fewer limitations on who is allowed to provide health service and manufacture medicine and health technologies would also drop prices. Competition in healthcare is very, very difficult because it's often illegal to compete.
You're actually talking about the same problem. Competition in healthcare is heavily restricted by stuff like certificates of need because there is little cost-sharing with utilizers so you get overutilization & induced demand. This is Roemer's law [0]. A large part of the reason for competition restrictions is because of a hacky attempt to control overutilization without direct cost-sharing.
In some cases they are provided healthcare services without a choice, so they're not really "consuming" those services. E.g. tests that don't change outcome but do cover a provider from a legal risk.
Something like 20% of healthcare services are "low value care" which aren't justified by evidence-based medicine criteria and may even harm the patient. Regardless of the financing system we could free up a lot of capacity and slash costs by eliminating that low value care. Of course in practice it's difficult to do that at scale.
Given that people constantly, literally AVOID care because they can’t pay for it until it’s such an absurd problem that it’s very, very expensive, I struggle to believe this, at all.
And money amount doesn’t matter in this evidence because, again, Americans regularly avoid care until it’s catastrophic because they literally can’t afford it and/or have to wait for insurance to meet a certain harm level threshold where it literally can no longer be argued (emergency care)
The wonders of American healthcare really mean that it's all more expensive, and at the same time, more is consumed, because so much of what is paid is done past deductible. If you look at so many standard of care situations vs, say, Spain, the American system will do a whole lot more. Even for preventive care: For instance America wants colonoscopies every 10 years from 45. Spain will give you a non invasive fecal test every 2 years, and only consider colonoscopies after the test is positive. Every time I send my american prescribed intervention list, given my symptoms, to my family members working in the Spanish public caresystem, they look at it with their hair on fire. Very different standards. You might think US insurance is restrictive regarding what needs to be done, but most public care system are significantly more restrictive than that. It'll be for better reasons, instead of defaulting to no on everything, but ultimately still far more cautious regarding their spending.
So we fail both ways at the same time: We avoid interacting with the medical system, but when we do, far more is done, at far higher price per intervention, so we end up with more interventions for the same outcome, even though we avoid doctors more!
The people who avoid care they need because they can't afford it are a very small portion of the population that gets an outsized share of attention on the issue.
Until public healthcare advocates understand this and make actual attempts to convince the majority of people who are satisfied with the current system that there are benefits, the status quo will remain.
I'm not convinced that your assumption that they are a very small portion of the population holds up, but I only have the same anecdotal evidence you likely have.
I find it hard to believe that people who would like to seek care but are unable to do so because of limits on their existing coverage would say that they are satisfied with their medical insurance.
No, the problem socialists have is that most people are smart enough to realize they won't be better off under a socialist regime, to the chagrin of the self-selected vanguard.
Exactly. Although even if you can avoid the words they don't understand or were told to be frightened of you'd still have the problem of getting them to vote, even for policies they think would be good for them.
I think a citation is needed for "Americans regularly avoid care ... because they can’t afford it."
I think there are other reasons, e.g. they don't like doctors, or it's too inconvenient, or waiting times are too long. I have good insurance and haven't seen a doctor in probably 20 years.
I know people who are visiting the doctor for every sore throat, ache and pain or sneeze and sniffle, and that's not me at all.
When I’m having a heart attack, or when I’m in anaphylactic shock - you know, some of the most expensive procedures that happen - I’ll make sure to confirm the ambulance is in network, the hospital, the specific first ER doctor, the specialist, the surgeon, the lab, the lab techs, the anesthesiologists and so on, while I’m either unconscious or actively dying.
This is the crux. Capitalism doesn't work here and a fair bit of people like to pretend it does.
Then there's the people who bemoan "paying for someone else's healthcare" while completely ignoring that's what they're doing in the current system anyway.
It's extremely challenging to go after high costs in the current system, because the doctors who charge them are popular and the insurance companies who pay them are hated. There was a 2024 story that stuck in my mind (https://www.npr.org/2024/12/05/nx-s1-5217617/blue-cross-blue...) when Anthem tried to negotiate down the rate of certain anesthesia procedures; the public was absolutely outraged, successfully demanding that Anthem must back down and accept whatever the doctors feel is the appropriate pricing model.
The disconnect between prices and end consumers is itself a huge problem. I should know what care costs before I get it, and I should know how much my instance company is paying on my behalf before I get care.
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
I think that’s a reasonable model to want, but it’s what we call “preauthorization”, and many patients along with most doctors absolutely hate it. In order to know with certainty what your care will cost and how much your insurance company will pay, the doctor has to contact them in between deciding what treatment you should have and giving you the treatment.
You can and I do solve that annoyance with an HMO, where the doctors and insurance can communicate more effectively because they’re part of the same organization. But that also means it’s difficult or impossible for me to get the kind of care that a normal insurance company would hesitate to approve.
Preauthorization is a bit different, and yes I can see care providers hating it.
Its possible for a provider to know ahead of time that providing a saline IV costs $60, for example. Its also possible to have health care policies that approve any treatment deemed necessary at any healthcare provider, or at any healthcare provider in network if that concept was still a thing.
We don't have to have a preauthorisation step where doctors are expected to ask insurance companies if they will approve a certain treatment for a certain patient before it can be done. That is a particularly terrible implementation if you ask me.
I have a strong dislike for the industry as a whole. There's too many ridiculous situations I've been subject to, along with hearing of some from my friends.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
No one benefits when there's a single player in an industry. When that single player also owns your taxes and military, its a risk we should at least avoid if at all possible.
Let’s try and deal with actual facts here. If you disagree then you should be able to post some actual data in terms of lifespans or costs that says otherwise.
There’s multiple healthcare systems around the world, single payer results in vastly less administrative and thus overall spending and equal or better outcomes overall. So by objective criteria the average person massively benefits from single payer healthcare.
Companies don't hesitate to lay people off when their jobs aren't needed. I don't see why these parasitic insurance companies need to stay in business.
I agree that this proposal would not solve all of the problems; absent more changes you would still see the creep up of healthcare costs at too high a rate. But slashing $1 trillion off of a $5.3 trillion costs is a pretty big bite of the apple. Even if you go with the more conservative $663 number, that is still a great first step. And both of those numbers are after adding the costs of covering currency uncovered people. So we are collectively getting more for significantly less money.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I understand that theres an argument for removing private insurance companies in favor of thr government can cut costs. It can also increase them.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
The "just" is doing some heavy lifting there. Clinicians aren't required to participate in Medicare; in fact they have to go through a complex process in order to join. And there's no way that such a mandate could ever pass Congress, or be effectively enforced. Let's focus on reforms that are actually achievable in the real world.
Social Security in its current form will be gone within two years. Instead you will be required to pay a contribution (just as you are now) but the money will be managed by a private company who will charge fees and provide no guarantees. Current retirees will get to keep the current arrangement, everyone else will be moved to the privately managed Social Security option.
Is this based on something real happening within 2 years, or just a continuation of the 30 year sentiment that social security will be gone before my generation will get access to it?
People have been saying this forever. It will never happen. Republicans and Democrats alike love Social Security. All that needs to be done to fix it is raise the cap.
We're talking about healthcare, so you're essentially claiming that the reason the GOP has failed to repeal the ACA despite numerous opportunities is because they actually like the policy, not because they're afraid of the political fallout. Can you elaborate more on when and why you think that happened?
We still have Medicare, Medicaid, and social security. Even though each program has been weakened, none of them have been abolished and they can all be restored.
Heck, we still have SNAP, even though it's almost universally hated by republicans.
It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty. For everyone else, political suicide is still very much a thing (see the various conservative republicans who've chosen to go against Trump over the years and have been cast out in favor of new loyalist challengers).
> It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty.
These are the same ones who currently would be able to repeal the ACA tomorrow if they felt like it. You're essentially asserting that the reason they aren't is that they like the policy, and I don't think it's crazy to expect more justification for a claim like that if you want people to find it compelling.
ACA is not Universal Health Coverage. So this would be different enough. And you don't need perpetual majority control, only sensible politicians for about a generation (like FDR/Truman/Eisenhower/JFK) to lock in a popular entitlement.
FDR and "sensible" is always funny to me. The sensible politician that imprisoned Japanese Americans, destroying the lives of 120,000 of our fellow citizens.
George Bush Sr. made a deal with Democrats to raise taxes and cut spending. Ever since then the Republican strategy has been to oppose pretty much anything a Democratic President proposes. The ACA was a Republican healthcare idea and they didn’t support it because a Democrat proposed it.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
> There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
For what it's worth, Obama did actually initially consider a public option[0]; it was Congress who made it clear that they wouldn't pass it that caused him to pivot to what we have now.
[0]: edited from "single-payer" to reflect correction to a similar comment I made elsewhere in this thread
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
You mean like overturning Roe v. Wade? Can't ever happen, right?
"If your solution requires addressing the slow-burn civil war, your solution is just a campaign slogan".
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
> ACA was predicated on studies like this, to no avail
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
You mean obstacles from politicians who took money from the healthcare industry. That’s how we ended up with PPACA and they used it to justify massive cost increases and consolidations. They passed that junk to save face and now healthcare is far worse. But we “closed” the donut hole, right? Quite literally made everyone worse off and no one wants to talk about it. I still can’t believe they allowed payors such as UNH to buy up everything without ANY proper investigations during that period.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
My favorite part of the ACA is that the nickname, Obamacare, was created by Republicans, thinking it would fail and the nickname would make that failure stick to Obama better. Problem was, the ACA helped a lot of people, particularly people in red areas. So, then Republicans started complaining that Obama and the Democrats were being arrogant for putting Obama's name on the ACA.
There's been tons of short interviews showing MAGA people having no idea ACA and Obamacare were the same things. They cheered when Obamacare got repelled even though they were beneficiaries of it. MAGA propaganda is powerful
I would never have had healthcare as an adult without the ACA due to an illness as a child that was expensive enough that I’m sure some insurance exec was only able to get a 26 foot yacht instead of a 30 footer.
It was a great success for people in my boat(no pun intended)
can someone tell me this. Right now level of care is rationed by type of insurance you can afford. eg: northwestern in chicago downtown is inaccesible to ppl below certain income level.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
You're right, it's not just that people opposing it are stupid or brainwashed: Some of them, to your point, are selfish and don't want others to have access to the nice things that they have.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
> Now the acess to best hosptials is gated by a queue?
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
Sadly, this is a better comparison than you probably intended, because access to school lunch is still not universal in the US.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
Most of society also doesn't require paying for indirectly via employer subsidy (driving up the cost to people who are between jobs or have money by other means).
If your objection is to a system that operates differently than the rest of society, it's not clear why the hypothetical healthcare system is more of a bugbear than the very real one that doesn't resemble pretty much any other way that things get purchased. I don't really understand how you think spending time arguing against something that has very little chance of happening based on principles that ostensibly conflict with the actual version that genuinely does exist is a sign that people are not being misled by those with incentives to distract them in that way or otherwise are struggling to reason about an issue logically.
From my perspective, what you're saying sounds like nonsense. I'm not sure why you're more concerned with my karma than I am, but since you're curious: no, I did not spend much time thinking about the one singular downvote my comment received. It's pretty common for people to downvote for any number of reasons (downvoting for disagreement in particular is controversial but not against the HN guidelines), so I didn't really read into it at all. Sometimes a comment I make that receives a downvote will end up with upvotes a few days later, and sometimes it won't; sometimes a comment I make that initially receives some upvotes will end up neutral or worse. At the end of the day, I comment because I have something to say, and while others' opinions on that is potentially useful feedback, and a single upvote or downvote is literally the smallest possible signal that can exist about whether what I said has merit.
I mean, the original plan for what became ACA was single payer. They didn't have the votes from the moderate democrats though, which is why the "private plans on public exchanges" became a thing instead.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
They had 59 votes from Democrats for the public option, not single payer. Public option is to let people choose either a non-profit government insurance plan or private insurers. They needed 60 votes to break a Republican filibuster. Joe Lieberman (Ind-CT) said he would filibuster the public option but would vote for the ACA without it.
Whoops, good correction, I did misremember public option versus single-payer, and I guess technically Liberman was not a Democrat at that point, but he had been for a while up until shortly before then and still had committee chair positions from the Democrat leadership, so it mostly feels like a distinction without a difference.
I still think this is an important historical detail that seems to go under the radar a lot; if anything, it gives me yet another reason to disdain the filibuster!
This is exactly the argument that gave us the Affordable Care Act. It was literally a republican plan from Massachusetts. It was supposed to be broadly acceptable and that's why it was implemented with a billion compromises.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
Universal Health Coverage has a lot of other benefits:
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
As a Canadian, I would caution against the kind of universal health plan we have. But yes I agree there should be some kind of public healthcare. Perhaps more as a government owned hospitals and clinics alongside the private ones rather than the fully public system we have here which comes with its own host of problems.
I think it's easy to shout free healthcare as a slogan but I think the important bit is how it's implemented.
I don't think anyone really envies the American system. We have all the capacity problems that you guys do up north, and we pay a lot more out of our own pockets for the pleasure. Our results are also worse.
I don't think anyone from any country thinks their healthcare system is perfect or even sufficient. It all kind of stinks although some countries it is easier to solve problems with above average money (but not if you are average). We need to fundamentally figure out how to do more with less, automation (AI) could help out a lot here and I don't care about purists who want hand crafted artisanal advice about how they need to lose weight or they will die of a heart attack. But otherwise, a lot of problems exist just due to bad incentives.
I'm curious how Taiwan operates. It's a public side insurance system with mostly (if not all private hospitals). Obviously very different population case though, much smaller island.
The US is far too broken for such a thing to ever come to be. Politicians are bought and paid for, and the impact on the insurance companies and their profits make this impossible.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
The US has gone through a lot of changes since it's inception, so there's no reason we can't change this. Preferably to a system where people have the freedom to pay out of pocket for whatever level of care they want when they can afford it, avoiding the "death panels" and extended wait times that exist just about everywhere that already has a universal health system.
When I was a kid, my parents would say “with that attitude, you’re right.”
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
Producing political apathy and learned helplessness is an explicit purpose of the "Flood the zone" propaganda strategy.
It's a serious requirement for despots. You don't need a large and supportive group. You don't need 80% of the population expressing support for your acts.
All you need is like 20% of the population absolutely Ride-Or-Die levels of support for you, willing to do violence and hate on your behalf, and everyone else just kind of apathetic, unsure, or oppressed enough to stay down.
> We have problems, too, but we are not powerless to fix them.
Indeed. Even as some of the more mainstream methods to address our current problems become less effective, we should be open to other ways change can come about. Among your list, many of those achievements had their roots in various approaches that didn't involve legislators.
Nobody, including congress, gives a rat's ass about insurance companies and their profits. The truth is that someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision. After the CEO of United Healthcare was gunned down in the streets for doing that thankless job do you think congress is saying to themselves "hey, maybe we should get into that business"?
That's their point. Congress isn't going to get $10 million from providing universal healthcare (at least for any system that is any good), so they have no incentive to pass it. The year the ACA passed, Democrats suffered one of the worst legislative defeats in history. Nobody wants to be the person to tell millions of people that they can no longer see their chiropractor for free or that their healthcare is not longer paying thousands of dollars a month for weight loss medications.
There’s a disconnect between what people say they want, and what people actually want.
People say they don’t like the ACA. But if you try to revoke its grants, it’s political suicide. Which is why republicans don’t even try.
Bring back denying insurance for pre-existing conditions? Lower the age for parent-child plans? Can you even grasp just how wildly unpopular either of those would be? Or what about marketplace plans? Congratulations, you’ve just destroyed every small business and entrepreneur in the country. I’m sure that will go over well.
The ACA is universally loved. Yes, everyone likes it. They won’t say that because they don’t know exactly what it gave them, and they’ve taken it for granted. Many of you would be uninsurable without the ACA.
And that’s why, despite people complaining, the republicans do not dare repeal even parts of the ACA. It’s too popular, whether people know it or not.
I suspect a single payer system would be equivalent. It would be contested hard, but once it’s passed, it’s passed. It would become so unbelievably popular for a majority of the population that suggesting a repeal would immediately end your political career.
Nonsense. In every nationalized healthcare system there is care rationing performed by government bureaucrats. Regardless of a doctor's opinion on medical necessity, some treatments involve long waiting lists or third-party reviews or are simply unavailable. That might be preferable to our current system in certain ways but let's not pretend that there are no trade-offs.
For example, let's say you're in England and your doctor decides you need Enhertu or proton beam therapy. That decision is meaningless because the NHS won't pay for them.
>With Universal Healthcare the government just provides the funding.
And what makes you think that they fund everything? I support universal healthcare as well (I'm literally Canadian), but I can accept that there are tradeoffs associated with it.
They don't fund everything. They don't fund anything in particular.
They provide the funding and the medical professionals decide how best to allocate that funding for the best results.
It's a bit different in Canada to my situation in Scotland since there is also the choice of private healthcare here if you want to pay more to skip queues etc.
Huh? NICE sets a cost-effectiveness threshold of about £20,000-30,000 per QALY gained from a drug[0]. There was even a controversy where a drug for pancreatic cancer was denied funding for this very reason[1].
Man I wish I could downvote a comment. This is what you’d see on Reddit.
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits? How many small businesses are crushed by the cost of providing healthcare to their employees? It would be great for business to remove any involvement they have in personal healthcare.
But I suppose they are the party of big business, not the party of business in general.
The Republican party is not a Conservative party, its a Reactionist party of capital, so generally anything that threatens the interests of capital will be absolutely crushed.
As a reply to Helloworldboy (sibling comment marked as dead), the US is not even in the top 10 of best countries to live in terms of quality of life. It's not even close to the top in any QoL metrics: life expectancy, child mortality, education, poverty/wealth gaps, air pollution, food quality...
When they make campaign promises, they go to small towns and talk about "Main St" businesses. Not sure why anyone believes them at this point (for the reasons you mention), but it is what they campaign on.
I think republicans could get behind some measure of portable health plans between employers. What they could not get behind is universal, in the sense of "everyone living in USA" health care footed by the US Government. The objection would be about centralization of health care funding and about, you know, who would get the benefits.
… in Massachusetts. New England Republicans are not the bulk of the party, and that’s not all bad - remember, the phrase was “banned in Boston”, not “banned in Bakersfield”.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
> In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits?
Decoupling health insurance from your job and going single payer are separate things.
You can have one without the other.
You can have a very healthy system with private insurers (like in Switzerland) and you can have completely dysfunctional single payer system (like in Poland and I guess many other countries).
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
BigCorp gives money to politicians and gets to depress worker wages because they can't leave — sounds perfectly sane to tie your insurance to your employer under capitalism.
The insurance companies had substantial input to the specific text of the ACA. I'm not sure how you can imply the ACA was not a BigCorp bill when BigCorp wrote it.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
If they published the plan, it was a normal rational one without carveouts for their friends, and they started pushing specific legislation now to implement it, they'd crush the Democrats, and Trump could declare himself God-Emperor.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
It should never be shopping in the first place. I live in Canada, my family has needed the hospital and the ER a few times and we never ever had to even reach for our wallet.
Your example is an edge case. Presumably sick people were once healthy. When people are spending their own money, they become a lot more discriminating.
Also, if you're looking for treatment after you're sick, that's not health insurance.
I'd tend to think the majority of healthcare is sought after something happens - car wrecks, cancer diagnosis, sports or exercise injury, stuff like ear infections or strep throat...
Healthy people without concerns aren't looking for treatment, they're visiting their PCP once a year.
>Legislate transparent pricing for all medications and procedures first.
This is an impossible ask. Truly impossible. The medical care providers have spent the last 50 years or more honing the art of making costs inscrutable. Not really to make it harder for you or I to know the costs, but for the insurance companies to know the cost. 50 years is a long time, that's not just one set of workers who have done this, it's 4-6 career spans now... the first to learn it taught it to their underlings and coworkers, who invented new sophisticated techniques and bureaucracies and taught that to the third career generation, who did the same and so on.
Even if we had universal healthcare, you're not getting rid of that. It's now a culture. A transmissible, everlasting culture.
For any political ask you might come up with, absurd and difficult and even intractable as it might be, this is light years beyond that. God himself couldn't make these prices transparent.
> Force hospitals to expose API's with transparent pricing.
Unless you're uninsured (which is a whole separate clusterfuck), the hospitals aren't the ones who decide how much you pay for any service - the insurance companies are. The sticker price that hospitals charge is almost meaningless and is intentionally high because it's used as the starting point for negotiations, which always bring the price down (never up). There isn't any expectation that any insurer is actually going to pay the billed amount as-is.
That's how virtually all industries work though. The computer you are typing on right now probably costs a different amount depending on which retailer you bought it from, even though it's the same manufacturer.
The fact that it's already common doesn't mean it shouldn't be illegal.
And I'm talking more specifically about a single entity selling to multiple customers. If two different retailers want to charge two different prices of course that's fine.
Hospitals shouldn't have to negotiate with insurers. It should be illegal for an insurer to not pay for a necessary procedure at the hospital's standard rate.
Yeah I'd like to see this before universal healthcare. I think we can do better than universal healthcare if we start with transparency on pricing to kill graft.
Just had a kid, navigation all the procedure codes and everything was insane. I just wanted to figure out what they were charging us for. I just gave up b/c we thankfully hit out out of pocket max for this year.
Also legislate transparent negotiated pricing for medications and procedures for each insurance plan, as well as rejection rates for medications and procedures.
>A single-payer universal health care system could cover every American, save more than 100,000 lives a year, and still cost $1 trillion less than the system it would replace, according to a new preprint study led by researchers at the Yale School of Public Health.
FWIW, the methodology that produced this particular result is known to have significant issues. The claimed effect disappears after correcting for them. It also isn't the first time that these authors have published similar studies with these issues. They are not a credible source.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
"known" by whom, and documented where? if you're going to just parachute in and say this paper by domain experts is dead wrong, at least link to what you believe shows this to be the case.
Per the study we are discussing -- as well as the results from every single other developed country I believe? -- more efficient when it comes to healthcare, yes.
Because both studies and real-world results from every other developed country show gov is more efficient at healthcare, is your argument that means gov is more efficient in every field?
The perverse incentive of the politician / general / bureaucrat to favor their personal interest over the public interest is identical to the perverse incentive of the CEO to favor his personal interest over the same.
I would argue the government case is actually much worse because at least the CEO has the feedback mechanism of revenue because the company <> customer relationship is entirely voluntary on both sides. The public vote is supposed to restrain the government in the same way, but in practice it seems to be much less effective in restraining politicians than the customer is at restraining companies.
I can if I want to switch jobs too. Probably not a good idea given the current economic conditions. I'd be all for forcing a decoupling of these things, but I don't see that anywhere on the table, and it would probably run afoul of politics anyways.
Total profits for US health insurance companies in 2025 were $50 billion. The other $950 billion has got to come from cutting:
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
The average Georgian plumber has higher purchasing power than the average German doctor. In order for the United States to balance its medical books, doctors will have to be paid dramatically less than they are at present. Perhaps there’s a deal to be made where doctors take the hit, but all of their debt is paid off by the state. Going forward medical school is free, but like in Germany you have to qualify, I mean really qualify to even get your foot in the college door. That’s an expectation change for the United States population on all fronts. We don’t do well with expectation changes.
You can afford to go to law school if you're willing to prioritize it and make some sacrifices. There are plenty of law schools that have part time night or online options. Take one class at a time and you'll eventually get through.
And most of that income is salaries to existing healthcare administrators. Quickly ending the employment of the people working those jobs would be a significant shock.
Not really. Private health insurance would still exist alongside for the more wealthy (including nearly everyone on HN) that doesn’t want to wait a year for their public system MRI. Same thing that plays out in other countries. The U.S. already has a form of this in so-called concierge / premium providers too. Lots of profit to be made.
This isn’t true of the Medicare for All Act, for what it’s worth. That would ban private insurance altogether. Personally I think that’s a bug, not a feature, but if you’re very concerned with fairness then you probably think the opposite.
Having the machine capacity to get non-urgent MRIs in hours is part of why US healthcare is so expensive. Anyway, the average (again for non-urgent MRIs) where I live in canada is 9 weeks, which is i am sure skewed due to the rural population. In the city it’s like half that.
If private health insurance was allowed, UHC would be stillborn. It only works if providers don't have better options than medicare reimbursement rates.
> It only works if providers don't have better options than medicare reimbursement rates.
1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
2. Less importantly, in this world where everyone has medicare, but a smaller fraction have private coverage, your argument is that the existing healthcare providers would choose to give up most of their (medicare) patients? If so, why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
> 1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
Mainly, expectations. I understand that UHC in European countries doesn’t cover all the things Americans assume it does.
Japan apparently keeps costs down by not using cutting-edge drugs. That’s not going to happen in the US.
The US Congress just isn’t good at keeping costs down.
> 2. ... why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
They absolutely do. Many providers don’t accept Medicare. Very few providers accept Medicaid. The payments just aren’t high enough.
The US is dead last in terms of health outcomes among every developed country (despite spending far more), but you believe expectations will cause every other developed country's system to fail here? I guess your argument is that the propaganda machine pushing the idea that America's healthcare is not the worst in terms of outcomes (while also being about the most expensive), would prevent Americans from accepting no longer having the worst results and the highest costs?
> Many providers don’t accept Medicare. Very few providers accept Medicaid.
1. About the same percent accept Medicare as private insurance (85-90%, while ~70% accept Medicaid - is that "very few"?).
2. "Medicare for all" is one of the primary proposals being discussed.
3. Previous smaller expansions of government healthcare resulted in expanded provider capacity to handle them, not less, but your argument is that we'd see the opposite results from further expansion?
4. And in this new world where everyone had Medicare or similar, your argument is that providers would choose to ignore most patients, where they don't under the existing system where government-sponsored healthcare makes up a significantly smaller portion of the customer base?
5. And your argument is that if the government finds that healthcare providers contract to the point that outcomes remain the worst among every developed country, as they are today, that the government would be unwilling to make any changes (such as reimbursement rates) to address this?
> The US is dead last in terms of health outcomes among every developed country (despite spending far more), but you believe expectations will cause every other developed country's system to fail here? I guess your argument is that the propaganda machine pushing the idea that America's healthcare is not the worst in terms of outcomes (while also being about the most expensive), would prevent Americans from accepting no longer having the worst results and the highest costs?
The argument is that the US system has a much lower floor, which leads to the bad health outcomes, but also generates a lot of people who expect and demand more than most universal healthcare systems would give them. An Uber driver with the cheapest marketplace plan he could find would benefit greatly from any universal healthcare system; a guy with really bad ulcerative colitis (https://www.propublica.org/article/unitedhealth-healthcare-i...) would likely not be able to get a prescription for a cocktail of drugs at non-FDA-approved doses costing $2M/year.
I’m saying the US won’t implement anything like what other countries implement. I honestly think Philip Greenspun’s proposal ( https://philip.greenspun.com/politics/health-care-reform ) makes sense but has no chance of being implemented. Americans asking for some kind of single payer system are expecting something better than basic health care.
I remember when President Obama suggested “maybe you’re better off not getting the surgery but taking the painkiller” ( https://youtu.be/rin4h4cRs6Y ). That seemed to surprise many of the people who wanted a single payer option. He stopped suggesting that kind of cost-cutting that very quickly.
I also remember when a few people received anthrax in the mail. Every news story said that people who had any contact with the letter had received Cipro to avoid developing an infection. After a couple of weeks, the government actually announced that other (cheaper) antibiotics were effective against anthrax, but it was obvious that no company was going to hand their employees something other than Cipro.
Incidentally, my autistic adult son has Medicaid. I don’t think I’ve yet found a doctor who will accept it. Luckily he’s also on my health insurance.
In all seriousness, this would be a massive stimulus to the economy. Americans are consumers at heart. All the money saved on insurance and/or other healthcare related costs would then be spent elsewhere.
Cars, clothes, TVs, Labubu dolls. People will use the savings to buy things. In massive quantities.
There is also some indirect bonus: if people's healthcare is not tied to their employer then it's easier to look for a new one. Also if the system is done well, then many companies would lose the incentives they currently have for not giving full-time employment.
Presumably not; the same national income would just be redistributed from shareholders to insurees (or shareholders of companies that pay for employee health insurance).
Are you implying you would decide to sacrifice citizens health for a few GDP points, a somewhat useful but oversimplified metric that doesn’t reflect anything tangible?
Most of the problems of the US system aren't really a matter of who pays, but the fact that so much is paid for services, at every level. Any really significant savings, cutting bureaucracy and pressuring providers to make costs resemble those of other developed countries, are taking money out of someone's pocket. Many hundreds of thousands of them, if not millions. This makes any significant reform very difficult, as those people vote, and will know exactly who made them worse off, even if the country in general was made much better off.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
It’s also geographically distributed. Substantially all congressional districts count a healthcare system as a top-5 employer. Those 70k/yr butts-in-seats admin jobs are occupied by voters, making them difficult to eliminate nationally. You’d have to go down to the state level at least to get anything done.
I think it’s because Americans been taught that were democracy, not a federal system, but that’s exactly where we expect to do these kinds of reforms. The federal government could reasonably set certain regulatory requirements. The states would need to make sure that any provider within it conforms to the federal levels, you know like auto manufacturing and exhaust emissions. Seems doable. Unfortunately we’re gonna have to wait for the boomers to die because they’re the ones that have gotten theirs and they’ve screw everyone else. Also, unfortunately, the millennials are gonna have to take it on the chin like we have for so much else and realize there is going to be some lost jobs.
What about quality of care tradeoffs? In Canada, for example, you are forced to use the government system, and if it doesn't deem you important enough, there is no private option.
Interesting. In every European country I know of, the private option is still available. Just vastly cheaper and more beneficial due to having to compete with a public option which covers basic necessities, surgery etc.
Yes, this is what I find a little odd about the US proposals. I've lived in UK and Spain and in both they have great free public healthcare for everyone, and if you (or your employer) want to layer private insurance on top you can. Wouldn't that be a much more appealing proposal to Americans?
Perhaps, but given the current shortage of healthcare providers we would probably see many doctors drop out of the public healthcare system and only accept private insurance or cash payments.
Is this quality improvements including or ignoring the 30-ish percent rejection rate of the most popular healthcare system, including such gems as insulin and pre-authorizations refusing surgery for necrotic tissue when “maybe they could PT it, have you tried?”
PT? Luxury! My daughter had PT referred by her pediatrician, then the insurance didn't pay all of it and when I asked the insurance company for the EOBs they said they were not allowed to give them to me because it would violate my daughter's privacy.
Our insurance paid for the bill from my wife's surgeon but spent 8 months refusing to pay for literally anything else, including the anesthesia. They said it was "medically unnecessary".
There are private options for lots of things in Canada, depending on the province.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
This is frequently true in the USA as well. My provider's dermatology department is pretty backed up and couldn't make me an appointment for an excision until November. Fortunately it's not urgent.
Agreed, it was 2-3 months wait to get to see an ENT for me last year. My daughter's regular eye check identified a problem and it's 3 months to get her into an eye specialist to review it.
Somewhat related: a couple years ago my spouse had cancer, and the doctor could do surgery either 5 days after our insurance was changing companies, or 2 months after that, those were the next two openings. The insurance said that if we proceeded with the surgery, without the new insurance company giving us approval, but they couldn't start approving it until the insurance started, and the pre-approval from the other company didn't give us anything. We finally decided to go ahead with it and take on the risk of ~$70K if it was denied. Which we decided to do rather than my spouse spending a few months worrying. Turned out that was a really good call, because when they did the surgery it turned out that instead of the expected slow growth, it was actually growing extremely fast. That was probably the difference between it being fatal and it being treatable.
ZocDoc isn't reflective of availability as a whole. It has a lot of depth in certain areas, like dentistry, dermatology, and primary care, and less in other specialties. Many of the providers are not physicians, they're NPs and PAs. Perfectly qualified for certain kinds of issues but not others.
ZocDoc is also, obviously, working only with the providers who are willing to pay for new patients, such as newer practices trying to build a patient base. An established practice that is booked out for the next two months obviously isn't going to use such a service.
Finally, you're not considering insurance and continuity of care.
So yeah, in an urban area, you can probably find someone to see you sooner than later if they're in network or you can afford to pay, and you're okay with seeing someone you might never see again or with whom there might not be continuity of care.
Are all of those specialists "in-network"? Have you tried contacting them to see if they truly have availability? It's common for providers (or the insurance carrier), at least in my area, to claim they take new patients when in fact they do not.
(For those not in the know, out of network means costs to the patient are much higher).
I agree with the main point. The thing is, in the US, wait times are a function of how much you're willing to spend. You can always pay for priority. But most people won't pay more, and the reality is that most healthcare systems have far less provider supply than demand, particularly in dense urban areas where most people live.
> If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
That's not at all unusual in the US. My dad saw a neurologist for chronic severe headaches. It was very common for us to go to an appointment, have the doctor request a follow up appointment in 3 months, then be told during checkout that the earliest available time was in 5-6 months.
Hah, even with "platinum" healthcare in the US, urology referral, 4 months. "You should start PT immediately" after a car accident, "we can see you in 5 months".
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
Yeah, I think we have a lack in our area. Years ago when I had a kidney stone, the L3 Trauma Center hospital a few minutes from me had to load me up on dilaudid and ship me from their ER across town via ambulance.
The US is not much different.
We don't have a wealth of specialists available to see people right away.
I've flat out been rejected from a specialist because they had no availability at all.
I actually tried again and got to be seen, but an appointment is months out, always.
I don't know about Canada, but here in Spain you have both. You have public health guaranteed, but many people also have different levels of private coverages, usually to get quicker appointments.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
I'm in Canada. The only time I ever needed a doctor in my life it was denied. I ended up having an issue that took ~5 years to resolve, which could have been prevented easily by any competent doctor in a 30 minute session.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
Does American private insurance pay for everything? And if you say "but they can pay out of pocket", well Canadians can come to America and pay out of pocket too.
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
The differences in life expectancy are due entirely attributable to vehicular accidents, homicide, and life style factors. It has nothing to do with medical care.
My dad, in the US on Medicare (one of the government funded systems), was denied a test. Because we have the option and had the money, he went and got the test himself on his own dime. That kicked off a series of events that led to a quadruple bypass, avoided an impending heart attack, and likely added many years to his life and his ability to remain and functioning member of society.
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
What about them? The Canadian healthcare system has better outcomes than the American healthcare system in several areas. Most simply, Canadians live longer.
I'm 29 and when I was a kid, getting a family doctor used to be an easy task and if you needed to see your doctor you could get in that day. Now all the doctors are so overworked, they're fleeing to America where they can get paid a reasonable wage for a reasonable amount of work. If you can even get a family doctor, if you want to book an appointment, they'll ask you which day you'd like 4 months from now.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
Life expectancy is a function of demographics, which averages ignore.
Income is also an assertion not supported by data. For simple procedures such as a knee or hip replacement, many people earning under $80K CAD opt for US treatment.
Likely because Canada has extremely bad waitlists which are continuing to deteriorate. That coupled with a lack of specialist medical options and lesser quality.
In Canada, a woman with breast cancer could be waiting 2 months to even start treatment. In the US, you'll be starting next week.
It's just because America is big and has a lot of hospitals and has changed dramatically many times over the past 100 years.
There's lots of places in America with spare hospital capacity. In those places, locals still cannot get affordable treatment, because our health insurance system is bad.
Meanwhile, plenty of places in the US have the absurdity of our broken healthcare system, and get to wait 4 months to see a doctor after having a stroke, like my mother had.
Or like my ex, who had to wait TWO YEARS for an MRI and neurology appointment, and that took so long that by the time her appointment was coming up, her situation had changed and needed other investigation and that appointment was not really a good fit anymore.
The situation is so mediocre in most of the US, that you have to travel hundreds of miles to see specialists anyway.
Nearly every single person in Maine who needs to see a specialist is waiting months. If you are in northern maine, you will have to wait months and travel to southern maine, or wait a year for a traveling specialist who has to fit a hundred patients into a timetable meant for 20. If you need to see a special specialist, you will be triaged on the same list as the entirety of New England for the one doctor in Boston who can actually do anything for that condition.
The same guild system that keeps US doctor compensation high is also keeping supply low! Someone is going to be waiting to see a doctor! If they weren't, US doctors wouldn't be paid as much!
I also feared this, until I read that some US citizens avoid going to the doctor until it is unbearable. Take this examples: here in Spain you go to the doctor because you think that mole is slightly bigger than past year. They point you to the dermatologist in january 2027, a terrible 6 months waiting. In the US a lot of people thinks "hey, doesn't look that bad, and it could cost me $5,000". Five years pass, and now the mole is five times bigger, it bleeds and... well, it is a full blown melanoma: you get to the dermatologist 1 day after consultation, yet is too late.
In New Zealand we have private insurance and universal health care. Insurance kind of fills the gaps and usually has faster turn around time, like 1-day vs 1-month for an MRI.
But like insulin is free for everyone, so nobody is going broke while dying here rationing it.
This is what is never mentioned. Quality of care, access to cutting edge treatments, timely access to care are never discussed when moving to universal healthcare. There are examples of private and public systems out there, which would be a much better model.
My understanding is that a clinic or hospital can’t legally charge you for a procedure that’s universally available through the provincial healthcare system.
So you’re free to pay for anything else if you want.
If spending drops by $1t, it will come out of someone's paycheck. Yes, some are greedy folks who will be just fine making 20% less a year. But many will be nurses or hospitals or some combination of providers.
it would not because the margins in the insurance industry aren't high. The OP is entirely correct, insurers are a source of payment, not a driver of cost. Insurers don't benefit from hospitals charging them high prices, they try to negotiate cost down, that is their service. They don't enjoy paying hospitals more money.
What is driving the actual cost is the high expenses hospitals have, and the biggest source of that is labour cost, as in any other industry. American healthcare workers, doctors and nurses, earn about 2-3x as much as their peers in the developed world.
One of the biggest benefits of a national healthcare system for consumers is that the government becomes a monopsony buyer of healthcare workers. The British system is half as expensive because the government gets to set the prices for its healthcare workforce and that gets passed on to the patients.
they don't, for the simple reason that if they did all you'd need to do is go to the hospital and pay out of pocket, most US states don't require you to have health insurance. (or switch your insurance provider, as you pointed out there are many).
There's no logic in what you're trying to argue. Healthcare providers charge for their service, insurance companies negotiate that cost down, next to risk management that collective bargain power is the reason you buy insurance in the first place. Again if what you're saying is true all you'd need to do is just buy your healthcare from the hospital directly, if you end up in the ER take a look at the bill and tell me how that went
The United States government does not set prices for doctors bills, what are you talking about? Healthcare providers in the US operate privately and set prices based on market rates. Again, if you want to, you can go and purchase whatever healthcare you like already without a middleman, the point is, it isn't going to be cheaper, which is why people, voluntarily, purchase insurance.
Don't believe that - not that the US doesn't pay well over the odds - that's clear - but it's the major cause to overall higher healthcare costs.
Typically health care is massively human capital intensive with like 50% on wages, and only 10% on drugs.
I suspect the blame lies with a broken market and inflated prices costs across the board ( ie the higher drug prices are a symptom of a wider systemic problem ).
You can believe whatever you want, but the facts are pretty clear.
It's not the entire reason, but when America pays 2-3x more for the same drug, it can blow out.
Reading the source I attached helps. "In 2022, U.S. prices across all drugs (brands and generics) were nearly 2.78 times as high as prices in the comparison countries. U.S. prices for brand drugs were at least 3.22 times as high as prices in the comparison countries, even after adjustments for estimated U.S. rebates."
I accept that the US pays over the odds for drugs. I don't accept that's the driving force behind overall health care costs - as 2.78x cost for something that's only 10% of overall costs doesn't get you to doubling the overall spend. ( If overall cost is 100 - then a 2.78 increase in 10% of that is = (10 * 2.78) + 90 = 117.8
That's a long way from double the cost - ie 200.
My contention is that the higher drug prices are a symptom, not a cause - and that's important to understand if you want a cure. Simply targeting drug pricing alone is an exercise in whack-a-mole.
The problem with insurance systems in markets that aren't operating properly is that it's actually in the insurance companies interests to increases costs.
Why? Because in the absence of proper competition in the market, insurance companies profits scale with the size of the thing they are insuring against as margins are % based.
So I would argue there is indirect collusions between all the parties involved ( insurance companies, doctors, hospitals, middlemen, pharma etc ) to escalate costs to increase the money flow they are all feeding on.
The idea of free markets driving ruthless competition is fine on paper - however in the real world there are all sorts of reasons why they don't happen in practice - so they have to be actively managed or in some cases acknowledge it's just not the best way - but that's a much longer post.
US federal budget is 23% of GDP, while UK is 44% of GDP. You can't compare fractions of the fractions directly. (Total spend is something like 11% vs 18% GDP.)
We hate it and are more and more powerless to change it every day. The parties are entrenched and swing districts are becoming increasingly rare. Those competitive districts that remain are flooded with unlimited campaign funds from big business and plutocrats, thanks to Citizens United.
The mortality numbers in this paper appear to be extrapolated from an observational study of 9,000 cases from 1988-1994. That paper distinguished between "privately insured" and "not privately insured". This paper distinguishes "adequately insured", "underinsured", and "uninsured", and applies the original paper's hazard numbers to everybody but the "adequately insured", with a coefficient modifier for the "underinsured" that they came up with themselves.
Of course it does, but only one country has to keep commissioning and ignoring studies to work out a group of 300million people can get better prices for everything if the incentive for the government is to decrease the price rather than increase it for their buddies
I think it comes down to the healthcare trilemma: cost, access, and quality (or "cutting-edge-ness"); the US optimizes for quality and access, while countries with universal healthcare optimize for access and cost. You can only pick two.
Regulatory capture of our legislature and regulatory bodies, intense bribery, proof of need legislation, and people consistently providing an obviously corrupt system with more money and power thinking that somehow, magically, the people who’ve obviously been corrupt and dishonest will be made angels when given more money and power.
1) 2 friends had to wait over a year for gallbladder surgery.
2) A friend with autistic child had to wait 2 years for any type of therapy. He couldn't afford the $80k/yr for private care. Ontario has 70,000 autistic children on the waiting list for treatment.
3) Another friend had to wait several years to find a PCP in Ottawa, the capital city of Canada. He has a golf ball sized lump on his head and he can't see anyone without a referral from his PCP but he has none and no one was taking new patients. He put himself on a list to get the first PCP available anywhere in the city. After that he has to wait a year for a consult and who knows when surgery is.
4) Another friend had to wait 9 months to get an MRI for a pain in his neck. After that it was another 4 months to see a neurologist.
You don't pay in money but you pay in time and suffering.
Healthcare worker shortages are a problem in the US and other developed countries with universal systems. The type of system doesn't really influence the waiting time.
It's crazy that universal health is the political third rail in most modern countries but for the opposite reasons
In most of the world it's the policy that cannot be touched, just in Europe, Canada and Australia its _existance_ is invoilable, in the US the _introduction_ seems to be the unwinnable war
Since when has a government projection of costs ever been in any way realistic? The estimates for the costs of Medicare when it was established were low by a factor of 10.
Last time I joined a discussion about US health care on HN (years ago), the picture looked bleak: secret chargemasters in every hospital, no realistic way for patients to compare options because the options are too complicated, and lots of people still falling through the cracks.
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
There are many studies from reputable sources (one being the CBO) that say it would result in almost no savings or potentially even higher costs, just like there are many studies like this one that say there will be massive savings with no reduction in quality of care.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
There aren't enough Physicians, they don't make much and they all seem to be working 12 hour days but being paid a salary that would equate to an 8 hour day.
Doctors see downsides of a universal coverage are mostly about loss of autonomy and increased demand because when care becomes free demand rises along with pressure to expand access without extra staff.
There are not enough physicians because we have limited the number of physicians. This was done, in part, by limiting the number of residency positions.
Most other countries don't even have a residency system. After graduation you simply apply for and work as a junior dr. for some number of years. No federal funding of a 'residency' position necessary.
Yeah, having lived under universal care, the dark side of it was atrociously long waits to see a specialist and having a GP who is obviously overworked and barely spends any time seeing you.
That may be your experience, and I’m sorry to hear it, but that is not the universal experience.
I’m in the hospital right now. My two year old had her tonsils and adenoids out this morning.
Regular Dr visit lead to an X-ray on the same day, specialist appointment 3 weeks later, surgery 2 months later (would have been one month, but we pushed it back because timing and life).
Just talking about how my wife is coming off 18 months of maternity leave. Before that she quit and just didn’t work for 3 years because burn out. I’ve been self employed for 10 years earning about $20k a year.
This whole thing cost us exactly nothing. Would be the same if we’d never had jobs.
Mum got stage 4 cancer in another country where she lived. 2.5 years of radiation, chemo, X-rays, mri, and dozens and dozens of specialist appointments (which she got paid for transit and free accommodation in the capital city) not to mention the mountains of serious drugs.
Total cost $0.
Anyone that argues against this is either not very intelligent (easily manipulated by the propaganda) or does not want to help others (“freeloaders”), or is getting rich from the status quo.
In America, anyone who earns $20k a year with with a 2 year old is going to get free medical care, too. I have several kids and my medical care is free up until we make about $55,000 per year. If we had no jobs, same thing.
A close relative of mine (who is single) also had cancer and had 100% of it paid for.
Transportation costs are also paid for, although we never needed overnight accommodation so far.
My prior experience was in Australia was a youngster under a particularly terrible universal care system in the 1989s, and then in the 2000s when I lived in Canada.
I get a little weary of the refrain about how American healthcare is terrible, esp. for poorer people - it’s actually very good.
1)People who choose not to buy insurance because we don't force them to.
2) Adults in the remaining states that chose not to extend medicare who don't earn enough to qualify for ACA subsidies.
3) Adults who qualify for subsidies but still can't afford relativly expensive ACA plans.
4) Others? Not sure if that number includes noncitizens who don't qualify for assistance?
That sounds extremely complicated and confusing to navigate.
We’re checking out of hospital right now after an overnight stay for my 2 year olds surgery.
Never a single piece of paper, and of course no bill. They’re sending us home with the pain meds we need for the next week, plus a stack of yogurt and jello for the little one.
I would like to know if anyone has a method or resource to cover rough calculations on things like:
1) how much cost comes from "friction" like middleman, administrative bloat, shitty digitalization/note sharing, all the time the nurses and doctors have to spend on paperwork... Etc.
2) how much drug development is subsidized by the US patient via higher domestic vs. foreign pricing. Or even how much of the cost total is drugs?
3) how much roughly every added year of life past some marker of "high quality of life" is spent just keeping people alive. And if there's any trends there, cost going up or down total and per person.
4) some basic accounting of where the spend is actually going. A lot of people in this thread are talking about hospital margins. There's much more to health care than that. Labs, hospice, mental health, labs/diagnostics, drugs, r&d, nursing facilities and many things I probably don't even know about.
Basically an equivalent of david mackays "without the hot air" but for health care.
Also if anyone has some good reading on ideas around kind of SEZs for drug/treatment development where people opt in to riskier care. Not quite the same thing but I know for example that lots of medical device development and proving is done in spain to gather evidence for the FDA since the FDA process for devices is legitimately insane.
Oh and if there has been any proposals or even adoption of better health record management, digitization. Especially access to your own health record. Im not a crypto guy but it seems like maybe it could be an application for it?
I’m a physician in the US. In my experience main cost drivers are administration (documentation is part of it but the way billing works is you basically do the job, document what you did, then submit to the payer. This process can take 6+ months and they often just don’t pay for parts of it).
And then ICU/end of life. Way too many Americans don’t ever talk about what will happen when they die and what they do or don’t want at the end of life. Then they become incapacitated, family pursues all advanced therapies because they don’t know what to do and they spend a long time in the ICU getting things done for an unclear goal
Thanks! I half-jokingly want to come up with a mental health/memory + physical health test for myself where if I ever fail it my wish is to not be a burden, don't extend my life.
People talk about policies like they're something like can be picked up off the shelf at supermarket. If you could take the policies and Sweden copy-paste them to the US, then sure, we could save $1T and a hundred thousand lives. This would be a very difficult thing to replicate if you're a country without any existing healthcare system. It is impossible in a country with an extremely mature healthcare system, which accounts for nearly 20% of GDP.
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
The US already has a national health insurance network that pays the vast majority of all providers, and as far as I know it is widely popular and covers everyone legally present in the US for a portion of their life, Medicare. Old people experience just about every ailment young people do, we can just get rid of the age restriction on Medicare, it's already fully integrated with our medical system. No need to copy-paste from Sweden.
Medicare also isn't something that you can copy paste from covering only old people to everyone. For one, margins from Medicare patients are much lower and often negative for hospitals, and that money has to come from somewhere. Medicare doesn't cover a lot of drugs that people are already used to their private insurance covering like GLP1s for weight loss. Of course, a transition from point a to point B is possible, but there will inevitably be a lot of kinks and bugs to work out, which MFA proponents seem to be unaware of.
Lots of studies have shown that the US spends a much larger portion of our GDP on healthcare than other countries, there is plenty of money to solve this problem already allocated to healthcare. I am aware that Medicare does aggressively negotiate prices, and our current system is a complex mess of different parts of the system subsidizing other parts to keep hospitals somewhat solvent, but this is largely just to enable all of the useless insurance middlemen to take big chunks of the money for no good reason (and its not all yacht money, its also just bullshit jobs that accomplish nothing productive but are sufficiently complex to require expertise, training and pay decent wages in many cases).
And I do know that you mentioned a real material reason why this isn't pushed harder by either political party despite the nearly inevitable massive savings if we pull it off. Causing an upheaval in the job market by removing a bunch of unnecessary admin work has real short-term impacts that will be hard for any US political party to weather well. That being said, I do think there are very real paths to achieving this and rhetoric about needing to copy-paste big parts from other countries distracts from how achievable it is. 90% of the work is already there with Medicare, and expanding the list of covered drugs and having a price negotiation with hospitals to make Medicare a good customer rather than a burden in some cases is definitely possible with some political will. A public option if it had been included in the ACA would have likely moved us a lot closer to universal coverage, especially if the mandate was still enforced, and likely would have spurred some of these necessary discussions.
> rhetoric about needing to copy-paste big parts from other countries distracts from how achievable it is
When have you ever heard "rhetoric" that actually brings up the details of how universal healthcare would actually implemented in practice? If you have an idea at work and a coworker brings up a caveat that you missed, do you dismiss it as rhetoric? If you are to be worried about rhetoric, it should be about how the general public talks about policy like it's sports whereas corporations talk about policy like it's work.
It would fine if it were just internet comments. However, this article is talking about a paper from one of the most prestigious university in the world and yet it's devoid of meaningful analysis. It literally does the "copy-pasting" that I'm talking about.
> Hospital and clinical fees are paid at Medicare reimbursement rates, which are below the rates paid by commercial insurers and above those paid by Medicaid.
Even if the headline claim is true (other people have already critiqued it), this would dramatically increase the federal deficit without massive tax increases - and as far as I know, none of the advocates of a M4A-style program have ever explained how they would pay for it.
Cut their pay by 50% and get rid of malpractice lawsuits. Have some other system that doesn't incentivize lawsuits where doctors are still held accountable but I think that's a deal most doctors would take in a heartbeat.
You think they’re getting so much money from out current system that cutting out insurance companies would result in a 50% reduction in their pay? Have you ever looked up the size of the health insurance sector here?
You're being dishonest if you claim otherwise. UK brain surgeons get paid less than a Walmart general manager in the United States, let alone a like for like comparison.
Hard to believe, currently Medicare/Medicaid make up around 23% of the budget. If you opened that to all, there would have to be a huge tax increase to pay for it. I suppose if you are very poor then it would be good, but the middle class would be the ones having to foot the bill for this.
Cuba achieves similar life expectancy and infant mortality rates to the U.S. despite spending a fraction of the cost, focusing heavily on free community prevention.
At this point I'm 90% convinced that any kind of a healthcare system will work as long as the politicans and everyone involved is not corrupt.
Alas...
The real question is then: since corruption seems to be everywhere, which system is the most resistant to it in terms of the price + quality for the end user.
And the real real question is: what can be done so that every country has a political class that has the same strict rules of law for corruption etc... as Singapore does?
That's a very weird framework and dichotomy you have there. Try untangling yourself out of it by considering some empirical facts, for example, hospitals acquired by private equity often have worse outcomes.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
This is certainly true to an extent, but it ignores some big problems with fee for service. The biggest one is that incentives between patients and providers are not aligned, which means more than 10% of healthcare provided in the US is wasteful stuff the provider knows is unnecessary but prescribes anyway because it makes them money. There are real opportunities to save money without making outcomes worse, in fact, if we stop doing useless stuff that leaves more time to treat people with real issues.
What's the point of "state of the art healthcare" if it's only for rich people? If Jeff Bezos and I get the exact same health issue - say, some form of cancer, we're going to have radically different treatments and mostly likely outcomes. His will be "state of the art", mine will (hopefully) be good, but definitely not be like his.
Malcolm Gladwell is a massive charlatan and hack. Seeing tech bros use him to discuss healthcare policy (Malcom Gladwell is neither a health professional, public health expert, nor has he worked in the healthcare industry in any real capacity, nor has he ever discussed the plight of workers in the US once during his entire career) feels on point for out of touch our industry is.
That $1T that it might save is currently hitting lots of quarterly or annual reports as profits. With that much on the table I think the chances of seeing Universal Health Care here in the US are not great. The ones banking that money now will fight hard to keep it flowing into their pockets.
Real lives don't factor into their decisions, even if there are more than enough to fill a large city in this country - every year.
The UK is the counter example to this analysis. The NHS was a marvel in the early years, now however it is bogged down with so many layers of bureaucracy it is massively inefficient.
1) U.S. healthcare spending subsidizes the rest of the world, much like U.S. defense spending. New drugs wouldn't be developed at the same rate if it wasn't profitable to do so, and it's profitable largely because it's profitable in the U.S.. Some proportion of the high U.S. spending relative to other countries is this. It's pretty stark. In revenue terms, for new drugs 2018-2023: 67.1% of total sales in the USA alone, 15.8% in Europe, 3.9% in Japan, and 13.2% for the entire rest of the world ( https://www.efpia.eu/media/2rxdkn43/the-pharmaceutical-indus... )
2) I believe the U.S. is willing to go to greater lengths to save people. So they will spend obscene amounts of resources keeping a cancer patient alive for an additional six months, or saving a borderline case of a premature baby, etc.
It looks like this does not even include the current disincentive for insurers to treat chronic issues effectively early on. Since people switch insurers so often the odds you will be their “customer” in 5 or 10 years is low, so investing if your long term health won’t generate a return for them.
There is already a healthcare program run by the US government and it's called Veteran Affairs. Veterans can't even access the care they need resulting in almost twice the risk of suicide.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
It will never not be funny that whenever universal health coverage comes up, Americans will act as if it's some impossible task that wouldn't solve any problems when the rest of world seems to have sorted it out just fine.
I think the evidence is quite clear that universal health care reduces aggregate costs, but the public cost in aggregate is enormous.
1. This means large new taxes for everyone. For those on lower incomes, they might end up better off. For those on middle-upper+ incomes, they will unequivocally end up paying more.
2. The U.S. already has unbelievably high deficits and debt. This would make that worse without significant spending cuts elsewhere, and without very large new taxes. And before someone says "just tax the rich!", even if every billionaire in the U.S. had all their wealthy confiscated today, it would barely cover U.S. federal spending for *one year.* Then the party's over and the government collapses. "Just tax the rich" is an absurdly superficial position. European taxation is broad and deep. Everyone pays high tax - even those who do not earn much.
3. U.S. society is built on rugged individualism. Acceptance of immigrants under the premise that they will work hard and contribute. For this reason, U.S. success at integrating immigrants is better than anywhere else in the world, by a wide margin. Our issues re immigration in Europe are numerous and unbelievably contentious. Should the U.S. become a "welfare state," like European countries, it would no longer have a natural filter for immigrants. It would realise the type of immigration that we get in Europe, where for many groups, a majority refuse to work - for life. For this reason, it would require a MUCH tougher filter on immigrants - much more so than what the current administration is doing.
I do not see the U.S. materially reducing spending in other areas, including the military. I do not see general public support for large taxation increases across the board. I do not see public consensus on strict new immigration requirements and enforcement. For these reasons and more, I do not think public health care is a realistic prospect for the foreseeable future.
> universal health care reduces aggregate costs, but the public cost in aggregate is enormous. This means large new taxes for everyone.
If the US could spend healthcare dollars as efficiently as the UK, the US could pay for a single payer healthcare system covering every resident using only existing Medicare + Medicaid spending.
Is the US willing to reduce the price of healthcare? I observe a large appetite in congress to increase the visibility into US healthcare spend. I observe rather more limited effort spent to use this data to reduce the aggregate costs (e.g. negotiating drug prices [1]).
The math:
The US spends $2 Trillion dollars on Medicare + Medicaid a year [2][3]. $2 Trillion dollars / a population of 342.7 million [4] = ~$5800 per resident per year.
NHS (UK's universal healthcare system) costs ~£3,500 or ~$4800 per person per year [5].
I think you did not understand my comment, and that is perhaps my fault. To be explicit:
1. Universal health care reduces the total cost of healthcare across the nation. If the bill is $x now, the total cost would be $x-0.2 (or whatever).
2. This is EXTREMELY expensive FOR THE GOVERNMENT. They would need to either raise taxes considerably (broadly and deeply, as in Europe), or deficit spend.
For some people, the increased taxes would be offset by not having to buy health insurance. For some people, they would be spending more.
My point is that we already pay $2 Trillion dollars for existing single payer healthcare (Medicare/Medicaid). I think it's fair to call that extremely expensive.
You say that universal single payer healthcare would have a huge price tag, my point is that we are already paying a huge price tag ($2 Trillion) but just not getting universal single payer healthcare as a result of this spending.
My point is that we could have universal single payer healthcare without raising taxes if it cost less than or equal to ~$5800 per person per year.
UK spends ~$4800 per person per year on their single payer healthcare.
Note: This just considers existing taxes spent on existing single payer healthcare. This doesn't consider other healthcare spending. The majority of the US get's their insurance through employment-based plans. Some pretty reasonable percentage buy their plans directly through the marketplace. And some pretty reasonable percentage don't have health insurance.
This would be much easier to sell if everyone stopped referring to it in the context of “healthcare” and instead used “universal health insurance” or “universal health insurance rates”.
The number of politicians that conflate healthcare and health insurance (notwithstanding the actual convergence of the two through payers’ purchasing provider entities) is mind boggling.
Striking the word “healthcare” from the conversation would make this much more digestible for folks afraid of the “socialism boogeyman”…
The thing studies like this never take into account is the degree to which all of these administrative jobs are corporate welfare. The inefficiency means a lot of people get a regular paycheck for work that is ultimately nonproductive. If you kill off those jobs by eliminating waste there will be millions of people looking for a new job.
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
Administration is ~25% of provider expense; billing and insurance is ~8.5% of provider expense. Administration is:
* Billing and claims management
* Compliance
* Customer service
* Operations
* IT
You can drive billing all the way down to zero and you're still going to be spending a lot of money on administration just like any large enterprise does. Those jobs aren't really "corporate welfare" and they exist in every system, although the single-payer systems get a bit of a break on them because they can and do trade responsiveness off for customer service (at likely little cost to outcomes, to be fair!)
That ~25% is compounded at every step of the way. 25% of your doctor's office. 25% of the insurance company. Plus don't forget the brokers, which are almost all overhead effectively. 25% of pharmacy. 25% of drug companies.
The people providing actual healthcare end up being a minority in the system.
It boggles the mind when you hear people defend the US healthcare system in terms of efficiency (OK, granted, maybe people have long stopped doing that).
It has to be one of the most bureaucratic and paperwork overloaded systems of all time. It's hard to imagine somebody who've had an actual health crisis would think otherwise, unless they can afford people who can shield them from the BS.
For the most part, any time one person in the economy saves money, another person loses money. So, what about all the insurance company, private equity, and hospital system profits that would be eroded by a system that better serves individual humans?
If this were at all true, now read it like the big wig or law maker holding the on/off lever who’s eyes see “Universal Health Coversge Could reduce $1T in available/taxable income”.
Did you notice the gorilla walk by? They sure didn’t.
What UHC proponents never honestly admit is that these headline figures require incredibly optimistic assumptions and also much more rationing of care than our current model. We spend a lot on healthcare because we consume a lot of services. To save money, you have to buy fewer services. Yes, you can squeeze providers a little bit ("Medicare-level payments to providers" -- which they will absolutely hate, by the way), and you get another little bit by disposing of insurance provider profit margins ("reduced administrative overhead"). But the vast majority is coming from rationing, which people hate. And it would also cost massively increased taxes on the middle class, which voters also hate.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
they're tryna convince the populace who don't like to read with useless studies.
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
How will the capitalists survive then, they would go extinct as a species. Healthcare and defense are the two prominent sectors where the options available are kept artificially scarce / high in demand (wars), thereby reaping money unfairly from both taxpayers and individuals.
This is why almost every wealthy country and most middle income countries and many poor countries have universal health Canada,UK, Australia, almost every European country, Cuba, Costa Rica, Kyrgyzstan, Sri Lanka, and Rwanda.
There are a few minor weird oligarch run kleptocratic exceptions like America, but in the global context they are irrelevant.
This doesnt need yet another study. Instead of narrating the problem we should figure out whats actually stopping it. And people saying the ACA was universal health coverage or even an attempt at it should stop intentionally derailing this discussion.
American living in Berlin: insane to me that in the US if I would rather stick it out in an abusive or otherwise terrible job just to keep my benefits.
Taxes here are high. They pay for a lot of things. Is it the best of the best? No. There’s private insurance for that. But does it work? Yup. And it’s just another thing we don’t think or care about while we take all of August off. ;-)
let's imagine an impossible country where somehow Democrats pull this off in 2029 and the 2030s start with actual healthcare for all and not just "insurance"
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
How on earth have administrative costs been soaring when there have been so many healthtech startups propped up in the past 10 years to bring down the cost of administration?
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
I've become so cynical that I think even if universal health coverage would be passed, since it almost certainly would be run by the executive branch, it would become just another political football to be fucked with every 4 to 8 years.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
I'm honestly curious how we square this with the only experimental evidence we have on cost-sharing in the US, like the Oregon Medicaid Study and the RAND study which showed no impact on mortality or really any physical health outcomes at all.
This study appears to just take observational mortality averages between insured and uninsured and then assume that UHC would close the gap. Patently absurd imo, but I guess I'm not a healthcare economist.
They're excessively optimistic (as in, unrealistic) about both. (Healthcare mostly doesn't bankrupt people -- the vast majority are insured, and the rest pay ~nothing.)
That's basically my concern, too. If we had a "Medicare for all" system, would it end up like Social Security, a system that started out with great intentions, but has since ballooned into an expensive, bureaucratic nightmare?
The Jews are obviously to blame for the lack of universal health care.
The USA spends the equivalent of about $10 per citizen per year on Israel. Medicaid spends about $10,000 per recipient per year. But antisemite math has its own rules.
Literally everything in the federal budget costs $10 or 10 cents per us citizen. Do you know calculus, or arithmetic? By this reasoning we cannot cancel anything.
Bro nothing is free, if the goverment pays for all of us, then it is our own money being used for that, we have the most liberal tax code in the world, we spend the most in healthcare.
Look no further than the UK, with 24 month waiting lists, the shunning of experimental treatments (many high profile kill decision cases) and skyrocketing costs.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
The US, we ration too. We just do it in the most cruel way possible where the working poor doesn't get access to health care, because they can't afford it, and just lives with preventable and easily treated conditions until they die sooner and more miserably.
> The first issue with this is that the gap between the uninsured and insured is not necessarily due to the lack of insurance. It could be due to factors associated with not having insurance, like living on the streets, being schizophrenic, being poor, and so on.
Made up perspective to justify his angle.
Not having healthcare access for a lot of people is 100% a policy choice. Waved off here by a list that really says why we should have universal healthcare; some people are mental and not aware they could have access without the stupid policy decision.
Just strings together sentences to ultimately make a reductive point about arithmetic and their own literacy.
Despite Yale's issues they're still a better source than random blogger with high school math literacy.
The point he is making is valid: these groups are not randomly selected and are not representative of one another. Hence, it is not that simple to extrapolate from one to the other.
Would free healthcare reduce deaths in uranium miners that are smokers? Probably some, but would it bring that to the same levels as non-smoking, non miners? Unlikely so. Hence it would be silly to pretend all the cancer deaths are due to lack of health care.
The smoking uranium miner example has a surprisingly realistic story, comes from real data; the dangers of radon in the basement were deduced from comparing cancer rates in smoking uranium miners with high radon in their basements, then they removed what they thought was the smoking and uranium contribution, then fitted to the general population.
He's actually a well-known and widely promoted political activist on X. His niche is using technocratic language and a whiff of 'analysis' to advance MAGA policies.
Quite weird to see such a study from Yale, Yale is the heart of the capitalistic western empire, and it exists to serve the oligarchy and the capitalists. So then what gives ? perhaps the person working on this report is still an innocent person and has not yet seen the reality of his situation :)
The last time we got similar results in the data (but not the text) was a Koch-backed study that a bunch of economists reviewed and went “so you’re saying we’d save 2 Trillion over 10 years relative the alternative?”
"They" never intended for it to work and never tried.
Do away with the finance ledger.
Accurately measure where the people are.
Ensure enough resources flow there.
Special interests with a social moat to protect can pound sand or be hung from ports as a warning.
I would like to be free from hallucinated social belief Jeff Bezos is meaningful to humanity when mfer just gonna die and be forgotten like everyone else.
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
By "free up", I mean "allow to job hop until they find a comfortable healthy fit" like hermit crabs.
With their health expenditure potential liabilities reduced by universal health coverage, people would be more able to take good risks in developing small businesses for example.
impose universal health coverage & the jockeying will commence to see who is in charge of it. medical & diet fundamentalists will rejoice at the opportunity to seize control & force everyone to take certain drugs, eat or not eat certain foods or types of foods, exercise a particular way, surrender their organs at a particular age, or whatever else their hearts desire for everyone else. there have been so many rabbit trails taken, so much malfeasance, so much misinterpreting of data, etc., which has been uncovered just in the last decade or two to give anyone the ability to harm or control entire populations in this way. the increase in suffering will be great, & the long-term effects devastating.
Standard single payer insurance is not identical to 'seize total control of ever living body in America'. I shouldn't have to point this out.
The attempts by the current republican admin to seize control of certain 'illegal' bodies has caused so so much harm, I'd agree there. But even operating at 10x the nominal level of the past and ICE still haven't been able to exert temporary control over a single American city that resisted them, much less everyone in America.
You should figure out specifically what you are scared of and deal with that, rather than catastrophizing about things that cannot physically happen on any near timeframe.
It sounds like you have issues with people telling you what to do. Would you like a pamphlet on the virtues of Anarchy as a way of building community to survive in a terrifying world?
Because none of the things you said have ANYTHING to do with "universal healthcare" and everything to do with "bad actors worming their way into positions of authority to enrich themselves". Surly you can't believe that "let every induvial person figure it out themselves in an unbalanced capitalist system" is a better answer, right? This isn't just about "if too many people are in the system then MY healthcare quality goes down", right?
In what possible conceivable way is single-payer healthcare in any way related to any of that tripe? Seriously, what an atrocious post. You may begin by observing that countries in e.g. Europe with such systems are not totalitarian hellholes where "the gobmint" tells you how to eat with "devastating long-term effects".....
Universal healthcare works just fine in Europe without major issues like that. It's the American political system that is broken. Your de facto two-party political system lets idiots take total control way too easily, as we can see with current US administration.
My country has universal public healthcare, and nobody forces you, or even your children to get vaccinated, monitors what you eat, or any other form of control that you're worried of. Organ donations are voluntary too, you can opt-out easily. And if you think the system sucks, nothing prevents you from taking extra insurance and using whatever private healthcare provider you want.
WTF are you talking about dude - we average white collar/blue collar people are so desperate for a unified healthcare system in this country not tied to our (constantly unstable) jobs
We are so desperate that someone murdered a Healthcare CEO - ie resorting to violence
We are so desperate that many is (myself included travel to cheaper countries for dental and other healthcare)
Its a simple calculus but one that is obtuse to conservatives and richer people
I don't have a dog in this fight (I live in Japan), but I'm a bit disappointed to see the responses here refusing to engage with the assertion.
reply1: "The alternative is bad, and Trump is evil"
reply2: "Uhhh, source for that? /reddit"
reply2a: "I bet he subscribes to the wrong politics"
reply3: "Americans are idiots"
reply4: "I bet you have a personality disorder"
reply5: "You're dumb but I'm not going to expound"
reply6: "WTF dude" (proceeds to uphold a murderer as an example)
Can no one explain why the ideas the OP fears will not come to fruition? Can anyone explain the safeguards of the UHC system? Or do discussions about policy now all fall under the teamsport known as modern politics?
Is this what hackernews has become? It wasn't like this a decade ago.
I wonder how many people would be on board for a program to make Medicare available for free for households making over $100,000 annually with 1-3 children.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
Many people feel that winners should be rewarded and losers should be punished.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
Why do you limit it to people with children? Why do you assume that the children are beautiful and healthy?
> Medicare available for free for households making over $100,000 annually
Sure, why not try it? It's still 50% of America getting coverage.
After a few years maybe they'll realize that not having to think about health care insurance is a good thing actually (tm) and start supporting it for lower brackets of the population too.
First class citizens? Wow, that is both disgusting and sad. What do you do that you think is so important and irreplacable that sets you above the average person?
This is why it doesn't happen: politicians get bought.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Universal healthcare doesn’t happen in the US because a certain subset of the American population would rather have worse health outcomes than guarantee abortions, HIV prevention, and gender-affirming care.
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
There's also a racist element (I know that's a politically incorrect word here, but such things happen). People don't want to fund services to the lazy ______s - fill in one or more of many groups toward whom hate is promoted.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
Another way of looking at is that some people are concerned about what happens to limited "free" healthcare resources when you simultaneously oppose any controls on immigration.
You can easily drop those from a universal healthcare system - look at the NHS and gender affirming care across the pond. So it can't only be that part - I think it's wanting the undeserving to not have healthcare.
It’s not that easy. You have to make it through the primaries to stand for election. Both parties are increasingly dominated by their outside wings. If you said “I’ll try to get universal healthcare done and I’ll build the coalition needed for it, even if it means accepting painful compromises like not covering gender affirming care” you won’t make it out of the democratic primaries. That’s why there’s so many common sense positions that have majority support yet never a majority in political bodies.
What I mean is that if the conservatives only objection to universal healthcare was these things, they could just leave them out. There's no requirement that a single payer system cover all procedures.
Ergo the reason they didn't support the ACA and won't do this is something other than it covering hormones and abortion.
There are many reasons Jeffries might change positions; why do you say the reason was that he was bought? Is there evidence?
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
One of two major political parties, and the one that currently holds all 3 branches of federal government, has labelled it un-American and communist. And yet you point the finger at...a Democrat.
> the one that currently holds all 3 branches of federal government
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
> Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass?
I don't. However, if I were a betting man, I'd bet on the Democratic leadership to come around well before the Republicans. Not least because a significant, non-zero fraction of their politicians are already in favor of it (compared to the other side, which has close to zero).
Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen. So ultimately Republicans are the bottleneck.
> I'd bet on the Democratic leadership to come around well before the Republicans.
Jeffries was already around. He supported single payer but now rejects it, so he's moving backward.
> Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen.
Democrats had 60 during Obama's first term. They'll always find a rotating villain to oppose it, Joe Lieberman, Joe mansion, etc. Anyway, the filibuster can be eliminated. In 2013 Democrats eliminated the filibuster for most nominations, and in 2017 Republicans eliminated the filibuster for Supreme Court nominations.
> So what do you propose? Is there a 3rd party that has a reasonable chance of doing it?
No, I propose calling out Democratic leaders for corruption, removing corrupt leaders from their leadership positions, and running primary challenges against them.
As you said, Republican leaders are calling single payer "Communist". When the Democratic response is, "I no longer support single payer", they're essentially allowing Republicans to win the argument. That's political malpractice.
I would note that the Republican House Majority Leader Eric Cantor lost a primary challenge in 2012, yet as you noted, this hasn't stopped Republicans from taking control of the House and the entire government. "Vote blue no matter who" is not necessarily a winning strategy.
Why even bother asking me what I propose then? What do you propose?
I can certainly understand pessimism, but if you're going to be a pessimist, asserting that there's nothing we can do, then at least be consistent in your pessimism. Don't pretend that you somehow have a better answer than I do. The only possible "plan" I've seen from you is "wait around for Republicans to support single payer", which IMO is vastly less feasible than challenging corrupt Democratic leaders, since the majority of Democratic voters already do support single payer, while the majority of Republican voters do not. And if the debate is one-sided, "Communist" vs. "I don't support single payer", then voters will never be persuaded to support it. Leaders need to lead, persuade, not just take a current poll. If you don't persuade, the other side certainly will.
> The only possible "plan" I've seen from you is "wait around for Republicans to support single payer"
That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged, nominally-independent voter hears that and assumes it means "don't vote D".
> That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged voter hears that and assumes it means "don't vote D".
But how can Democrats possibly blame Republicans for not supporting single payer when the top Democratic leaders don't either? That's the dilemma. What's the "Do vote D" reason? Biden didn't support it. Schumer doesn't support it. Now Jeffries doesn't support it. And Harris flip-flopped too, supporting single payer in 2020 when she ran for President but as the 2024 nominee became a Biden parrot (which obviously did not turn out well). In 2016, Hillary Clinton sent her own daughter out on the campaign trail to fearmonger about Bernie's single payer plan. That's why I point the finger at Democratic leaders. You're correct that Democrats are the only hope for passing single payer, but the leadership of the party is actively hostile and working to prevent it from ever happening.
I'm not sure that the "disengaged" voter would even hear this debate, but in any case, voters seemed attracted to the "drain the swamp" concept, despite the irony that it was proposed by the swamp creature.
Come to a country with universal healthcare (England) and realise that if you work then you're paying 5x the market price for the worst healthcare imaginable. MRI scan - we don't know, one month wait, maybe two. Operation - are you going to die tomorrow with out it? No, ok then that could be years.
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
I think this one might not be true anymore. Canada has 432 machines as of ~2023 (340 in 2015) and MA is on the order of ~300 (can't find exact figures). It's still a lot lower per capita (10.8 per million vs 42 per million).
It's kinda weird, yeah! Not sure if Canada thinks the rest of the world overuses MRI machines in a cost x diagnostically inefficient way, or what, but I'm sure months-long waiting lists aren't optimal either.
I know that you tend to be balls deep in American Exceptionalism, but the truth is that reasonable countries with reasonable health care average 15-30 MRI machines per million inhabitants.
America is a wild outlier, and unless you have data to back that those machines are put to good use, I'd trust the rest of the world who decided the sweet spot is 15-30 mer million, not 60.
This statistic appears to have flown directly over your head. It is not an illustration of how awesome the United States is. The overprovision of MRIs in the US drives costs in a variety of ways; one of the most obvious is that routine imaging for things like back pain leads directly to things like spinal fusion surgeries, which don't work.
The gap between Canada and the United States is immense. Canada could add quite a large number of machines and not come even within the line of sight of where the US is.
There are a lot of people making a lot of money on the inefficiencies of the US system. They won’t give up their revenue streams without a fight, and they are filthy rich on the backs of sick people. You better believe they will play dirty.
I saw Jim Clark (of SGI and Netscape fame) talk one time about his new healthcare startup (Healtheon). He said something insightful that captures a lot of why it's hard to get things done in general: one person's inefficiency is someone else's bottom line.
The flip side of Bezos' "your margin is my opportunity". But that's for competitive markets, not for heavily regulated multi-party setups with minimal competition. That's the real wonder of American healthcare, as it manages to neither be a good market, nor to have regulator mercilessly going after the largest profit centers. Near the worst of both worlds.
And someone else's bottom line is also the wages of friends and neighbors.
Last I heard healthcare is like the only employment sector that's seeing real growth right now.
Actual healthcare delivery is a growing field because boomers are getting old and dying and advances in health care mean that people that would otherwise die (eg people with cancers) are now receiving treatments that keep them alive.
Note that this is a Good Thing.
The issue with US (and privatized) healthcare delivery is that there is an incentive (by insurers) to deny treatment, as well as an incentive for healthcare suppliers (hospitals, doctors) to over-deliver treatment, as well as incentives to use more expensive solutions.
Demand in healthcare is inelastic, no one is ever "too healthy".
Supply is always insufficient, so there needs to be a mechanism to resolve that.
In the US, that mechanism is money, or the cost of insurance etc to provide a restriction on demand.
In universal healthcare, that mechanism is a combination of subsidizing medications based on results and waiting lists for limited supplies, prioritized by need (eg surgeries).
Is there any reason to believe less healthcare professionals would be employed under a universal system? Insurance claims adjusters and call centre scripted finance deciders, sure. But actual health delivery agents?
No, if anything there will be more because some of the funds freed up can be spent on healthcare delivery.
But you will lose endless billing departments at general/specialist practices, hospitals etc, because actual consumers would not engage. Hospital administrations will be driven by the government setting reimbursement rates for services that are transparent, so the argy-bargy between someone paying cash, someone getting insurance etc will disappear (mostly).
I'm in Australia, and the billing departments, even at private hospitals are minimal. Ditto at general practices. Reimbursements for GP/specialists that are not "bulk billed" (ie paid at the government rate) are automated into a nominated bank account and are usually instant.
Medicare for All in the US would move the 2/3rds that are not covered by Medicare, VA, etc into the same systems, with the reduction in overhead from 10-20% to the 2-5% of the current government run health systems.
Allowing Medicare to negotiate both drug prices (as a large purchaser) and health services will also dramatically reduce costs, because the government has the purchasing power to drive hard bargains.
I was responding to a thread I thought implied economic downside in employment, as a fellow Australian I'm a strong believer in national health.
The UK has a "universal system" as does Germany and the inevitable reality is that if administration does not limit/deny overuse of the system then it requires setting prices artifically low to limit costs. --> Causes Doctors to earn less wages and be overworked (many med cases). Ultimately, less doctors. =(
Alternatively, the government starts relaxing legal requirements on medical schools with the intent to flood the market with doctors. This not only severely depresses their wages, it leads to unemployment and indirectly to charlatanism and quackery as people try to make ends meet. Better hope the future AI doctors are good.
Alternatively alternatively the government could subsidize medical school for doctors and nurses reducing financial barriers and allowing more medical professionals without lowering standards.
Subsidizing existing schools merely makes it easier for existing medical students. It does nothing to increase the number of doctors entering the jobs market per year. You need to make more schools to increase that number.
You can't just conjure up a medical school out of nowhere though. That's extremely hard and expensive. You can do it if you relax your standards. Maybe by making the "hospital" part of the school optional or something. Students won't see patients but what does it matter.
Except this process is independent of whether there is overuse. It's always a pressure to lower costs, whether they are appropriate or not.
Medicare, Medicaid and Tricare are all basically universal systems for segments of the population. None work well. And all are subsidized from what people with private insurance pay. And the UHC proponents rely on a stacked deck--UHC is "better" in a system that makes 20% of the score "fairness". That is, UHC. And one of the other yardsticks is life expectancy. Sounds fine--but dig deeper. A big factor in lowering life expectancy is infant mortality. Again, sounds fine--except you see a big difference in infant mortality across the developed world that is not reasonably explained by differences in their medical systems. But you see an inverse relationship between infant mortality and stillbirths. Most of what you're really seeing is whether the doctors consider it a live birth that promptly died, or consider it a stillbirth. (And, yes, we are still an outlier--but by only 1/3 of the amount claimed.)
Show me it's better without your thumb on the scale!
If someone shoots some more CEOs, they'll have a change of heart.
(A lot of people are going to be very mad at me about this comment, without having the awareness to understand that this is the inevitable conclusion to, "You wanna play rough, ah?!"ing people's access to life-saving treatment. Please grok that we can preclude any more assassinations by cutting profits and letting people get the care they need.)
I'm skeptical. It will be cheaper to hire a couple security guards and buy a couple armoured cars then turn away profits.
The reaction was short lived while the insurance companies figured out how to bolster security and return to the usual.
Look at what's happening in California with the proposed wealth tax.
>Page’s co-founder, Sergey Brin, has poured at least $45 million into the Building a Better California Super PAC specifically dedicated to blocking the tax
So I think the wealth tax is different.
The reason more CEOs getting shot might make a difference is that many CEOs care about status and being able to mention it in the right places. Historically many people love it so much that they call themselves CEOs and Presidents of companies that are small businesses.
If these same people can no longer be open about their role and status, which they value, there will be some kind of change. I'm not sure what it is, but security guards don't restore their freedom to feel thoughtless about their role and lifestyle.
Whereas with taxes... Maybe some people brag about dodging them or their suspect filings that get them big refunds. But they're mostly not public and not tied to identity the same way. And even the wealth tax isn't remotely the same as the public being vocal at large.
For it to be comparable we'd have to have modern highwaymen and Robin Hoods somehow stripping the wealth, not the tax man.
Because the weight of any changes or perceived need to change come from the social burden that public violence would create in the shooting case.
And that doesn't seem to exist near at all with the wealth tax.
>It will be cheaper to hire a couple security guards and buy a couple armoured cars
This is still a possitive outcome brought from the presence of a threat to their lives. Not as positive as the healthcare thing, but it's still jobs and a "tax" in that they are forced to purchase the vehicles which do have to be built and driven by someone not in their tax bracket.
If it were only the CEOs that were at fault you might have a point. Hundreds of thousands if not millions of Americans benefit from this system and the leaders are accountable to them - the shareholders, employees, and on down the chain.
Congress is our only hope, along with a president who signs reform.
The people are in charge of congress, and they consistently show they do not support socialized healthcare systems. It will never be a politically viable path for the u.s, regardless of the economics. Even if it somehow passed, opposition would quickly sabotage and dismantle it.
Obama had a generational mandate and couldn't even pass a public option which, is far more moderate than a single payer approach. Even the abomination of the ACA that actually got signed into law was subsequently gutted to the bone in the following years.
There is room for more tweaking, but the system we're living with now is pretty close to what most voters prefer.
If people voted for universal healthcare we could get it done. The issue is that there’s a sizable, significant voting population that votes against it
I have wondered if an option would be to have a state make it law that every 4 or 5 years they open the bidding for a health care insurance provider for the entire state. A state committee then takes the bid with best premiums to services ratio and they do the job for the contract term.
There would still be the option of people and businesses to buy 3rd party "extras" like private hospital rooms, vision care etc. on top the state plan, but some level of basic health care would be provided to all people paying into the state plan.
Would that work?
You’re proposing a rational option on an issue where irrational dogma has taken hold
the "irrational dogma" you speak of is simply the status quo in all other civilized countries.
No, overwhelmingly more people support a single payer healthcare system. The issue is that the people in Washington won’t make it a “votable” decision.
> The issue is that the people in Washington won’t make it a “votable” decision.
Sorry, that's ridiculous. Universal Health Care policies are an almost 100% partisan issue. I can literally count on one hand the number of federal lawmakers who cross party lines here.
The real problem is people like you refusing to vote for the people with the policy you want, as often as not as part of a bothsidesist stance designed to get more upvote in peer forums like HN.
The two party system may be flawed and unjust, sure. But people who want single payer are still democrats.
I already have universal healthcare here in Canada. I just feel sorry for people living in the US who could have it too if it wasn’t for stupid political shenanigans and ideological stubbornness. Health should be a right, not a commodity sold by private corporations to those who can afford it.
> The real problem is people like you refusing to vote for the people with the policy you want, as often as not as part of a bothsidesist stance designed to get more upvote in peer forums like HN
That's a lot of words they didn't say. It is a true statement that Congress did not give the USA single-payer healthcare nor even a public option.
Nothing about that says anything about who voted for whom, where anyone even lives for that matter, or anything about political parties.
To say this is the fault of "people like you" is out of line.
> That's a lot of words they didn't say. It is a true statement that Congress did not give the USA single-payer healthcare
But that is what they didn't say! They said it wasn't "votable", in the sense I took that means that this isn't an issue you can get by voting. And it is, clearly. And was, in 2010, when they were within one senate vote for a "public option" in the ACA. It 100% boggles my mind that you'd look at that once again incredibly partisan voting result and decide "Oh well, I might as well vote republican" (instead of "damn Joe Lieberman").
> It 100% boggles my mind that you'd look at that once again incredibly partisan voting result and decide "Oh well, I might as well vote republican"
Who said any of this? "I" said nothing of the sort
I don't think you're going to convince anyone of anything this way. If anything you'll probably end up turning people off who otherwise would have agreed with you
> Who said any of this? "I" said nothing of the sort
You quite clearly came in to defend someone who did, though. This is the second time you've tried this end-around strawman. Please engage with the discussion as it is.
> You quite clearly came in to defend someone who did, though
> "I already have universal healthcare here in Canada"
I don't think I'm the one misreading the discussion as it is.
If you take a deep breath and re-read, maybe you'll understand the point I've been trying to make is you're jumping down people's throats that aren't disagreeing with you, which at best does your own arguments a disservice. To put words in someone's mouth and say this is the fault of 'people like you' is out of line.
Have a good one
Please don't tone police on HN. If you agree with me but think I'm an asshole, the polite thing to do is just to keep quiet and not troll a discussion by convincing me you disagree.
But I'm very happy you agree that health care policy in the USA is among the most directly partisan issues and know who to vote for given those priorities.
If you think I'm merely "tone policing" then you still miss the point. I don't agree with your translation of "Washington didn't make it a voteable decision" to "both sides are the same" (with the added irony of accusing others of strawmanning).
Edit: and even now you still put words in my mouth with your edit (so that's every message in this thread that does so). Best of luck to you
Oh, come on. That edit was a clarification added like 40 seconds after the post. Really, it seems like you're the one getting bent out of shape. Again, I thought (and still think) you agree with me on the partisan nature of the issue, right? That's not putting words in your mouth, that's your opinion.
You just don't think I shouldn't have engaged with advocacy around the issue or taken offense that you and upthread commenters feel that this isn't something that can be... I guess "achieved by voting"[1]. I think that's a weird thing to troll a discussion this deep about, but OK.
[1] Does that match your understanding of the point? Genuine question! I think it's bonkers and wrong, but you seem attached to it and I'd like the opportunity to convince you.
I do believe it's mostly partisan. I don't believe it's exclusively partisan nor the most partisan
In the 2020 debate, Joe Biden said he would veto Medicare for all*. Just this week, Hakeem Jeffries said he did not support Medicare for all and wouldn't vote for it. You already mentioned Joe Lieberman
None of what I just said implies "it's not partisan" nor does it imply "both sides are the same" -- multiple things can be true at the same time
It sure does, however, reinforce the original, plain statement: "The issue is that the people in Washington won’t make it a 'votable' decision."
*By April 8, 2020, Biden was the "presumptive Democratic nominee" -- at that time, 22 states still hadn't yet held their primary elections. As such, for those 22 states it was quite literally not a votable decision
That being said: the whole thing is a complicated clusterfuck. Someone's health care spending is someone else's income. If one just snaps their fingers and enacts whatever ideal healthcare plan, what happens to those now-redundant workers? How does provider capacity ramp up to match the increased demand? I can understand why politicians might be hesitant to jump into such a woodchipper
As the joke goes, "how did God create the universe in 7 days? No installed base"
> Joe Biden said he would veto Medicare for all
Oh for... Joe Biden was literally the tiebreaker vote in the senate when the public option was still part of Obamacare and was stumping for it like crazy. MfA is one particular proposal from one particular faction of the party. We aren't talking about MfA specifically, and that's quite clear all the way upthread.
This kind of dissembling and trickery is what's driving me crazy in this thread. You just don't seem to be arguing in good faith. No, Joseph Biden Jr. is very clearly not opposed to government-provided health care, nor is any democrat in office right now that I'm aware of.
"Mostly" partisan. Good grief.
I wandered into a stupid thread that said "single-payer healthcare." The article/study that spawned this thread is about single-payer healthcare
Public option is not single-payer/universal healthcare. Medicare for All is generally used as a synonym for single-payer healthcare in the US. The article stated it models the results of implementing a plan like Medicare for All
"Public option" still results in a vast bureaucracy of "paying for healthcare machinery", and so is scarcely comparable. Note: that does not mean a public option would be a bad thing. But it is not the same thing
I've already wasted way too much time on this, against my better judgement. I tried to leave twice, but third time will be the charm. Be well
Oooph. So this is all down to dithering on whether the public option qualifies as "single payer"? Like, is the "single" applied to everyone or just to the beneficiary? I'll point out that Medicare (the global archetype for this kind of coverage!) isn't "single payer" by this definition either, as senior citizens exist with private coverage or self-coverage.
Indeed you've wasted too much time on this. And I still have no idea what it is you really are trying to argue about. You agree with me on everything I've tried to pin you down on, and want to dither over tone and jargon when challenged.
My question is why a sizeable portion of the American (and greater Western) public seemingly votes against their interests?
A few things.
-The US has had a lot of success by letting businesses run pretty free. This has produced some of the largest and most powerful companies on the planet.
-The conservative party traditionally has been suspicious of a powerful, centralized government
-In the US, there is a common thread of "government workers are impossible to fire" as well as a common thread of "government moves at a snail's pace".
In light of just that, there are many people who would prefer that healthcare is run by a private industry, as private insurers are enormous companies in the US. Everyone knows Blue Cross Blue Shield, Aetna, or Kaiser Permanente. Many people give a benefit of the doubt that companies are doing things efficiently. Additionally, health insurance companies in the US have a requirement to spend a certain % of their revenue each year on medical care, and will sometimes send out small refunds when they simply cannot suppress costs in certain other regions of the company enough to keep their spending at the right rates.
Beyond this, states may provide additional benefits, and many do (some with the help of federal funding, even). You may find someone in one state where they are suffering greatly, while someone in an identical economic situation in another state is not suffering at all. It's easy to convince the first man to vote for a better healthcare situation. It's hard to convince the latter.
I could go on for ages, but this is getting long. There are like a billion reasons.
> there are many people who would prefer that healthcare is run by a private industry,
The grammar is a little ambiguous around this, but you seem to be claiming that this is a majority position. It isn't. Single payer polls over 50% basically every time it's tested (the exception being some spun partisan reframings you occasionally see pushed), and has for decades.
I did not intend to imply it’s a majority, just that it’s not some ignorably-small minority
The people who vote are old. The median age of primary voters is 65, regular voters 54. This is why you get a gerontocracy - old people vote for their interests, and young people don't vote. It's also probably why the median age of politicians has risen to 58 and 66 in the house and senate, respectively. With an 80-year-old president.
The solution is to have both a) mandatory voting and b) a voting holiday. This is done in many other democracies around the world, and it works. Personally I would prefer term limits and age limits for congress, the president, and federal judges. Diane Feinstein, Ruth Bater Ginsberg died in office. Mitch McConnell is working on it. We have age limits for lots of professions that require high performance - political leadership should not be an exception. But of course to make any of these changes young people have to vote, but they're mostly busy being poor and doomscrolling to block out the pain.
Stupidity https://youtu.be/HbQ-t8GXYTA
- Dogma - us vs them mentality - we’re not that smart
If I voted for this, could I save $1 trillion? Or would it save other people who are not me $1 trillion?
You’re right. Two related observations:
1) In the immediate aftermath of Thompson being shot, policies were deliberately briefly softened. Anecdotally, people were helped to live longer by this. It didn’t last long.
2) The response to Thompson’s assassination was the closest I’ve seen to a class consciousness almost forming in the US, as people from across the political divide who had suffered at the hands of the healthcare insurance companies found common ground.
How do you typically react when right wingers make similar comments about what they see as overreaching government?
I acknowledge their bloviating as I would a tough-talking teenager: with a wariness respectful of their capacity for violence, paired with an understanding that, 9 times out of 10, they're not going to do jack shit.
Probably important to point out here that leftists are looking to see a threat to a corporation's leadership change the behavior of a corporation, whereas right-wingers are looking to see a threat to a government's leadership change everyone's behavior ("overreaching government" in a democracy being the will of voters). They're not the same thing.
They've lost all credibility under Trump with the massive amounts of overreach. It becomes apparent they only care when the other party is seen as overreaching.
"Healthcare costs have been rising faster than inflation, and a staggering share of that spending is consumed by administrative middlemen, soaring drug prices, and emergency care for conditions that should have been treated earlier and for less"
-----
It's a n-tuple-whammy. Co-pays and deductibles discourage early diagnoses by preventing most people from visiting doctors for issues that aren't serious. The painful process of claiming the small amounts that would cover preventive care discourage people from getting it even if they've seen a doctor and been told to. Preventable conditions balloon into things that are very expensive and unpleasant. This process takes years though, and there are many, many insurance companies, plus people change jobs and coverage frequently. Odds are, the company denying preventive care won't be on the hook for the heavy costs down the road. If they are, they have ways to wriggle out of it. Also, with more people waiting until conditions get bad before seeking treatment, the whole system consumes more resources to keep people less healthy, on average, than if the system pushed preventive care effectively.
When governments assume responsibility for medical coverage, incentives start to be much less perverse. You pay taxes while you work. You work while you're healthy. So, the government wants you healthy. The government wants to do that as cheaply as possible, so they're incentivized, not just to provide preventive care, but to make sure you take advantage of it. I live in Canada. I have a genetic condition that could cause me problems if I don't get preventive care. One of my relations had those problems, so they tested her and found the problem gene. The government then tasked a genetic counsellor to seek out everyone related to her. I had the gene, so they now book me for the care I need to manage it. I don't have to pay for this. I don't have to fight insurance companies to prove I need preventive care. I just do what they ask me to do and I get to live longer. This is the kind of stuff that happens when the incentives are right.
Insurance companies need to be cut out of the loop entirely. They know they're what's wrong, so they employ expensive lobbyists. Americans need to realize this and start making it an election issue.
_______
EDIT: TIL that preventative and preventive are used interchangeably in the context of medicine, so I changed my very inconsistent use of them to just one.
You’re blaming it on lack preventative care, but the truth is that there is very little preventative care that is shown to be effective at anything more than burning money. The few things that are effective (e.g. vaccines) are largely inexpensive, and don’t require “insurance” as we know it.
Most of the things that are predictable and lead to long-term bad outcomes are behavioral (i.e. diet and exercise; smoking cessation; quitting drugs), and therefore both largely unaffected by medical care, and heavily confounded with socioeconomic status. Your doctor cannot make you eat better and exercise and quit smoking.
In the developed world, if you don’t die at birth or succumb to diseases of lifestyle (diabetes, heart disease, addiction) or accidents, you basically then die of cancer. The lifestyle diseases cannot be prevented by a doctor, and we have essentially no ability to prevent cancer. It’s all just acute treatment.
North Americans in particular hate to hear this, because they have an almost religious faith in doctors based on decades of bad TV. Honestly, though, doctors are pretty impotent when it comes to prevention of illness, and it is ironically this desire for treatment that is helping to balloon costs.
> diet and exercise
GLP-1 drugs do seem to help people change their diet (or at least intake), even in this environment of unhealthy, hyperpalatable foods that we have created.
Lifestyle can help, it's not a cure-all.
I'm one of the 20% with the lipoprotein A gene. Mimics high cholesterol. Diet and exercise still help but that just slows the clogging.
No ability to prevent cancer? Ever heard of the HPV vaccine? I had polyps removed from my colon 10 years ago. There's a decent chance those would have developed into colon cancer by now. Prevention is a major part of reducing deaths from cancer. See also the effects of increasing taxes on tobacco products or restrictions on the use of asbestos.
Those are the exceptions, not the rule. But also, you're wrong: most polyps would not become cancerous -- only 5%-10% ever do. As a preventative intervention on otherwise healthy people, colonoscopy is one of the most effective things we do, and it's not that effective [1].
You've also included vaccines (which I explicitly mentioned) and "taxes" (which are not medical interventions), so you've completely missed the point.
[1] The NordICC trial found an impact of 0.03% on risk of death from colorectal cancer, which was insignificant. It did find an 18% risk reduction for getting colorectal cancer, but this didn't translate into a survival benefit.
https://www.nejm.org/doi/full/10.1056/NEJMoa2208375
Aside from war, there is likely no other place where one class "winning" means so certainly that countless others are dying.
Not just the wealthy people on top. All the administrators and suppliers, and all the machinery of pharmaceuticals and insurance brokerage, even HR benefits specialists in corporations are all tied to the current system. That’s a massive block of voters to be overcome.
this is a great example. What a horrible human...
https://www.miamiherald.com/news/politics-government/article...
This is a top-level example but you do not have to look at the top, really. The whole private insurance system is a scam at every level. I mean: I immigrated to US couple years ago, and I can tell you that any hospital visit, or a diagnostics, such as CT scan or ultrasound are 15-20x more expensive here than in my home country (which is in the EU).
Funny thing is: if you tell the hospital that you do not have an insurance they will charge you a price that actually sounds reasonable, say $700 for a CT scan (which is still like 2x more than in my home country, but then the US is a high cost of living place), but if you do have insurance they will try to extort as much money as possible from your insurer: initial bill will be like $10k, and then they will settle for, say, $6k.
>The whole private insurance system is a scam at every level.
All for profit insurance must by definition bring in more than it pays out. From cars to homes to health to pets.
If instead of paying all your premiums, you'd be far more likely to be able to afford the services that the insurers are supposedly paying for. Like, yeah, there's a chance you need a new engine, and a small chance that all of your monthly car insurance totals up to less than the cost of the engine, but the entire point of the company is that they know that it is far more likely that you will end up paying more for their service than you'd have actually payed for turns out the only thing that ever went wrong was a small crack in your windshield.
On car insurance, you have a competitive market with actuaries trying to identify actual risks, and that, with their prices, modify bad behavior and purchases of cars that are expensive to repair. So all in all, you can end up with very narrow margins, and end up ahead only on the float between receiving premiums and paying out. Health insurance, especially how it works in the US, with no public system williyto cover all the expensive stuff for catastrophic situations and chronic conditions, would compete by trying to fail to insure risky people. But since most insurance is handled by employers, all the levers for that fail too, so it's an especially bad insurance system. Home insurance, car insurance, normal life insurance... all more competitive and more beneficial economically, as their efforts lower costs overall.
>fail to insure risky people
Why can't they just charge higher rates to more risky people. If you are a risky driver you pay more, and if you have a risky body you should also pay more.
> All for profit insurance must by definition bring in more than it pays out. From cars to homes to health to pets.
Well yes, but you are paying for reduced variance, which itself has a value.
>...Funny thing is: if you tell the hospital that you do not have an insurance they will charge you a price that actually sounds reasonable, say $700 for a CT scan
That has not been my experience. Insurance negotiates lower rates and without insurance, the full fare price suggested price has always been higher.
Providers are contractually forbidden by insurers to show you the much lower "out of pocket+ price schule if you have insurance. It's why the first question posed to new patients is always " do you have insurance?"
I'm clueless about healthcare economics, but this sounds fishy to me. Why would insurers go along with that? In fact I would expect insurers to be in a much better position to bargain with a hospital than a private party. Actually it's if the hospital were billing the govt (not as motivated as a private party) where I would expect that overcharging to creep up and up.
Insurers can only spend 15% of premiums on admin spend (e.g. salaries, etc). That means if the CEO (and everyone else) wants more money, they need to pay more money to the hospitals, so their 15% cut grows.
Also, for beyond that, unspend premiums have to be refunded, which also cuts into the potential admin spend bucket, so it's best to always ensure your paying as much as possible in claims.
Plus, patients hate denied claims, because typically your forced to sign paperwork saying your responsible for anything insurance refuses to pay.
And with most health insurance spending being locked to employer benefits, the big market is the group market, which means your stuck with either getting your job's option(s), finding a new job, or not getting insurance basically.
In other words, you don't have a price choice as an individual in a group.
>typically your forced to sign paperwork saying your responsible for anything insurance refuses to pay
Now that is some sick shit. Making every doctor's visit a gamble you might lose, discouraging people from seeing a doctor.
It's even worse when they claim to be "in-network" and they make you sign that. To me, the entire point of being in network is I shouldn't have to worry about the provider filing claims correctly on my behalf, and if there is an issue, it should be on the "network" side, not my side.
Hm, seems to be a bit of a contradiction between what you’re saying in terms of “insurers want to pay more” and the infamous tendency of insurers to deny claims as much as possible?
Well, they also need to ensure they aren't spending past their premiums coming in...
Alot of insurers the past few years have actually gone bankrupt from ballooning costs and claims.
So, they want costs to go up, so the next year they can up the premiums, so they can then up their admin spend, but the costs still need to below the premium. And they can't just up the premium without an associated rise in cost, because groups are owed their premium money back if it isn't paid out.
This is true and I have seen it in many cases.
This is largely misunderstood. At the time the government went after many hospitals for what it perceived as "fraud" in a politically driven campaign. The hospital group he led was the largest at the time and targeted as such. While there are/were bad actors in the system is extremely complicated so try not to generalize. https://pmc.ncbi.nlm.nih.gov/articles/PMC1115078/
They absolutely will, but I've been on the provider side of healthcare for over a decade and I can assure you there are lots of organizations who are EAGER to move to single payer and will absolutely help the fight. If you told a healthcare CEO that in 6 months they could let go of 90% of their RCM staff and 100% of their benefits verification staff, they'd be THRILLED.
And the PE firms getting in to healthcare delivery space will take up that fight too, so they can keep more of what they make.
They are already playing as dirty as possible.
I assure you that is not true.
Luigi had that idea already.
Are those still "inefficiencies" or is it just the usual market-greed?
Agreed
And, there’s also a lot of people who actually believe we have a superior system because M’urica and Europe is communist or something
We're also at the point that if there existed validated evidence that 'Universal Healthcare' made everyone rich and happy and beautiful and able to freely stroke kittens at will then we would still vote against it as a socialist conspiracy benefiting weak, lily livered failures.
Right.... but it is also an industry that provides an insane amount of (often well paying) jobs to a large amount of people to do "make work", admin tasks.
Reliable details are hard to come by, but some estimations are that more people in the industry are doing admin tasks than instead of providing care, admin tasks that will be reduced drastically once the industry is streamlined.
Once we get affordable care there will be less people who can... afford.
So is that a defense of the broken system?
Feels like their job is mostly to enrich the corporations profiteering from these inefficiencies, they're doing admin fighting the sick and dying who also gained the job of admin of fighting them (a job thrown at them to - in a lot of cases - literally save their lives, financially and physically).
> Once we get affordable care there will be less people who can... afford.
This just plainly isn't true. The US is unique in the way it doesn't have affordable public healthcare, but the rest of the western world doesn't have an affordability problem because of less bean counters scamming patients.
This is what's called the "broken window fallacy"
I'd like to believe this, but the study makes a bunch of really hasty assumptions.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
Healthcare reform is hard.
[1] Reasonable breakdown on the economics of advanced primary care models: https://olearykm.medium.com/the-cost-equation-for-new-primar...
>> Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
> Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
Would this go away, though? Instead of fighting with insurers they would be fighting with the government insurer?
I am very pro universal healthcare, I just don’t want to pretend there aren’t still going to be fights over what should be paid for.
No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
The way a lot of other countries deal with this is that the government calculates out a benefit vs cost assessment for every new treatment and only covers ones that come out ahead. But, that ends up with things like new targeted chemotherapies being unavailable for years after their initial release, vs in the US where they are available to much of the population once the right prior auth is filed. There is also more top down management of costs, such as long term life support for people in vegetative states.
All of this was branded as "death boards" in the American healthcare debate.
People hate it when faceless bureaucrats decide that some health care expense is too expensive for the large faceless bureaucracy to cover, when they have a medical issue that they would like the large faceless bureaucracy to spend money on. Perhaps in that world, some insane guy with a back injury who's unhappy about the quality of his care assassinates the Secretary of Health and Human Services, rather than the CEO of a medical insurance corporation (and hey, a lot of people hate RFK Jr. anyway, so maybe that assassin still becomes a folk hero for doing it).
This is already how Medicare works and it covers 70 million Americans. I’m not aware of any of these hypothetical violent outcomes being a huge problem for the program.
The HHS secretary during that time wasn't RFK, it was Xavier Becerra.
> Instead of fighting with insurers they would be fighting with the government insurer?
1. I'd rather fight the non profit-motivated entity 2. We can probably compare to VA and Medicare and even other countries to see what the fight will be like. I'm willing to bet it will be a big improvement.
> No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
Government insurance has a service motive. Private insurance has a profit motive.
Government has a cost motive. Lower taxes. There is no such thing as non-profit, cost drives all organizations.
And government can just lower the definition of acceptable service rather than provide any accountability for not providing it.
> And government can just lower the definition of acceptable service rather than provide any accountability for not providing it.
but why would they? OTOH for-profit companies do this all the time.
To lower spending. People always complain about taxes.
you know who else lowers spending (at the expense of service)? For profit corps. You’re ignoring that part.
What hospitals makes has nothing to do with physician pay - those are separate categories. Hospitals aren’t going to magically start giving some of their profit to doctors to help cover their lower fees.
OP makes a good point. The studies assumes two diametrically opposed things will happen - doctors will take a 50% pay cut but access to primary care physicians will increase.
Why would we solve the primary care physician shortage by cutting their pay?
Allow/force medical schools to grow, increasing the provider pool, thereby reducing their pay?
Those are two real effects, but together they wouldn't compensate for the rate cuts.
About 8% of the population is uninsured. The uninsured population skews younger, with less healthcare utilization (Medicare already covers everyone 65 and older).
Another comment in this thread estimated billing overhead at 8.5%. Medicare for All would eliminate some, but not all of this, since Medicare is still a claims-based system. You would remove a lot of overhead around prior auths, which I agree is a good thing, but could be achieved with more focused legislation.
> .. 8% of the population is uninsured. .. this is Bogus, one of the first argument hospitals make for inflated pricing is that they have to cover the cost of uninsured. if the uninsured doesnt exist then the whole line of BS argument falls.
> 2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
This layer won't go without a fight. Maybe it _is_ the layer we're fighting against. The owners will still make profit, the providers still have jobs.. but the middle layers are useless bloat. They don't have skills to provide care, they don't operate at the capitalist layer. They are useless today, and even more useless tomorrow.
And that is likely useless layer is millions? of jobs.
How would this change solve: "Hospitals eating the cost of the uninsured..."?
Wouldn't it just transfer the cost from the hospitals to the universal coverage agency? This would make the financial picture even worse for the proposed system.
>>> Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance.
The hospital can be paid less without reducing their margin if they can remove a cost from their balance sheet. It does not make the system cheaper overall, but it means the hospital does not have to bear those costs directly. They may not have to bear them at all, because hospitals are not the only things in the system.
Think about corps merging to save cost on back office. Here is the same idea. With AI, it would even cut additional order of magnitude of cost.
No, because that cost is included in the $300 billion increase in spending that is part of the calculation they do.
Healthcare reform isn’t actually hard. Every advanced country has done it bar the United States.
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Yeah, and they all generally get there by paying practitioners much less than the US does (by integer multiples). Single-payer, which this working paper equates with "universal coverage", is in fact not the norm among universal systems; besides using Medicare to ration the supply of practitioners, the original sin of our system is employer-based coverage, not payer structure.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
Why do doctors need to be paid integer multiples more in the US than every other country on earth? This is not rhetorical, I mean it sincerely.
And I’m aware that medical debt is a big issue, but it seems like a chicken-or-the-egg type problem. Of course you can charge $500k for a medical degree when the doctor can make it back and then some in 5-10 years.
Nurses are also highly-paid in the USA (relative to other developed countries), and they make up a large part of the wage expenditure in the system. This may not make a difference to your point, but it is important to note that doctors are not the whole problem.
For those that have never looked it up, the median RN salary in the US is about $100k a year. Germany and the UK are more like $60k.
It’s funny, because it’s a career that feels both overpaid and underpaid to me. I went to a college where almost half of the students were going for nursing - and you certainly don’t need to be especially intelligent.
At least to an outsider, some nursing fields seem damned easy. The nurse that sees me before my GP? Pretty easy job.
Other specialties? Like the nurses that needed to clean up my wife after she massively bled during/after a c-section and they had to give her medications that also caused all sorts of other fluids to intermingle with the blood? Or the nurses that had to stand there for 10 minutes squeezing our infant daughter’s heel in the NICU to try to get enough blood out while she screamed as hard as a little baby can?
$100k doesn’t seem like enough. Odd occupation. For $60k I’d rather work at Costco, that’s for certain.
because in the us everything is integer multiple times more expensive
No, that's not why. Doctors also make drastically more than the median wage. Doctors make so much in the US because we have artificial scarcity of doctors.
i mean sure, but all skilled labor is trending towards 200-300K wages in the us.
if a "senior" software engineer can make half a mil, and an electrician can make 200k, of course doctor pay are high.
who is going to take 10-15 years of school and debt otherwise?
No it isn't! The median wage for an electrician in the United States is about $65,000. It's nowhere near $200,000. The median general skilled wage is lower than that.
"Gen Z electricians making $240-280k in data centers" was a viral ploy by Mike Rowe on a podcast to promote his trades-training hustle.
> "The electricians that I interviewed and met two months ago in a data center in Plano, Texas, all under 30 years old, all making $240,000 to $280,000 a year, all with as much overtime as they want, none with any debt, all three of whom were poached three times in the prior 18 months," Rowe said ...
Google AI summaries then pick up wealth/finance grifter social media clickbait about it and parrots it as a fact.
There are contract data-center electrical jobs paying $55-65/hr (some with signing bonuses, per-diems, and benefits on top), but they only come close to $200,000 takehome by working 12/7 with generous overtime. And these are 5+ years of experience, OSHA 30, journeyman license, bring-your-own-tools. They're also exceptional; most are still $25-40/hr.
They don't! It's a huge problem! It's probably the problem in US health care, which, despite my own belief that single-payer is bad policy, is in fact a total shitshow.
I think there's also the gamified confusion of over how much goes to the physician versus how much goes to administrating orgs and liability coverage.
We have numbers for this, we don't need to derive them axiomatically. Practitioner compensation is the largest component of health provider spending. Liability coverage is the second largest component of admin spending, which is 25% of provider spending.
“We have numbers” is always refreshing, especially in a shell game. Cost of all licensed medical practitioners? Or overweighting incomes of outlier CEO physicians? 25% is a steep tax on health in any case.
At the point where you're just dismissing the CMS NHE, you're well into the terrain of unfalsifiability.
Fair enough, but it is a political topic, and there are different and more confusing slices of the healthcare system exposed to patients than org spending breakdowns. Not sure how many of this thread's comments could hold water if falsification were universally applied.
Just so that people reading this thread know that there is the medical expense version of the Bureau of Labor Statistics, and it lives inside Medicare (CMS), and it publishes data. Most things people are trying to derive axiomatically on this thread, you can just look up.
It's really easy now with Claude and GPT5; just ask them a question and tell them to answer it for you, with cites, from the NHE. (The data I argue from precedes widespread LLM research; I built a site for this a couple years ago and didn't bother to update my data, because I assume it didn't get much better.)
Claude, gpt, and ai in general still hallucinate. What data do you argue from and please cite your source.
Funny how one of the arguments against Medicare in the 60s was that providers wouldn’t accept it.
Turns out when you have the choice of accepting lower payment per patient for Medicare or having a lot fewer patients, you choose the lower payment per patient.
I would expect the same situation here. Doctors would grumble, but no one would force them to accept patients on whatever “Medicare for all” would be called. Nothing other than market forces.
A number of things would probably have to change, including the cost of medical school. But the system right now is expensive and essentially unsustainable. So change is inevitable.
Nope. More and more providers are dropping out of Medicare, or imposing limits on the number of Medicare patients that they're willing to see. It's tough to sustain a financially viable medical practice on Medicare rates, especially for primary care in HCOL areas. Medicaid is even worse. There are a lot of patients who nominally have coverage but in practice are functionally uninsured because they can't find a local doctor to take them on.
>In every case costs have gone down and outcomes have improved.
this isn't really true though, if you look at survival rates of many diseases.
Can you give any examples?
I think for the math to work you have to consider the bigger bulk of work that could be eliminated by universal healthcare: the payer industry. Insurers, PBMs, and all the smaller sectors that support them. The utility provided to society is fairly low — basically, just selective claims denial.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Truly. Aetna, United Healthcare, Anthem, etc are examples of industry that does not need to exist, and exist only to serve the status quo.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
They do perform one useful service: forcing a hospital that tries to issue a $100,000 bill that should be $10,000 to reissue it, and not leave the patient saddled with a giant debt.
(Medicaid & Medicare claims processors do the same thing. Medicaid claims processing is mostly handled by private, third-party insurers now, and seems to be able to do so more efficiently and cheaply than when it was being run directly by states; the savings is mostly in the area of catching fraud.)
Companies do this because it's massive song and dance by everyone. Hospitals issue big bills to insurance companies knowing they will want a discount so there is plenty of wiggle room. Also, it's free marketing for insurance companies because people see 100k, see all discounts for their insurance and are happy it's only 10% of true cost. It's like car buying except with your healthcare.
Medicare is much cheaper because they have fixed rates and hospitals know what to bill.
A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
They are not taking any losses; they just charge the regular price with a very tiny profit margin. US healthcare costs are heavily inflated. Insurance is a scam that lets the rich get richer. All insurance should be non-profit.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
It doesn't matter what they charge if the patient doesn't pay it; which is what often happens with uninsured people showing up at the ER.
> Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary
Under the ACA, excess money in the pool must be rebated to policy holders. In practice, this worked for a few years, but eventually insurance companies ended up increasing cost in order to increase the absolute amount they were allowed to keep. Maybe this is still good (more claims approved), but it is counter productive to the goal of reducing healthcare costs.
It often happens with insured people showing up at the ER as well. Many patients don't pay their bills, either because they can't afford it or are just deadbeats. As overall healthcare costs have increased, insurers and employers have shifted more costs to plan members through higher deductibles / co-pays / co-insurance. So hospitals end up with a lot more bad debt, and this in turn causes further price inflation.
Carriers and providers don't make this easy, either.
I had a recent doctor's visit, with very good healthcare coverage, that was an in-network facility but an out-of-network provider. Coverage would have kicked in if I had a referral from my PCP, but my PCP recently retired and I was advocating for my own health for a small dermatological issue. They said it was cosmetic, my old PCP said it was not. I got a stack of 10 bills over many months all stating different things -- everything from $0 EOB to over $2k in uncovered expenses. No one would take ownership of sorting out what I was on the hook for. No one I talked to was empowered to actually solve it. It wasn't an affordability problem over $2k (but would be for my elderly grandparents on fixed income). Even asking "If I give you $2k does that resolve the debt?" was answered with "we won't know until we apply the payment" type non-answers.
Burn the whole stack down -or- earn enough you can operate on cash for the tier of care you want. Nothing inbetween seems to be working.
> All insurance should be non-profit.
Aren't their profits regulated regardless? If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
There are many factors, e.g. amongst other things American doctors are better paid than just about anywhere else in the world.
> Aren't their profits regulated regardless?
Yes and no. It's sort of a weird thing where insurance is somewhat regulated nationally but also regulated in a piecemeal fashion state by state.
There's a non-government standards body called the NAIC which provided national guidance for insurers. Most (all?) states basically say that "if you follow NAIC standards, you are good".
> If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
It's a huge mess. It's not even really a profit vs non-profit thing but rather "what's the motivation". One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
This is a big part of why I think universal public insurance is a must. Basically the only organization that's motivated to keep costs as low as possible is the government.
> American doctors are better paid than just about anywhere else in the world.
This is a problem, but the bigger issue and why doctors are paid so well is because becoming a doctor is one of the more costly and hard to do things in america. There are limited spots, schools, and residency requirements that severely restricts the number of possible doctors we add per year. That drives up the their salaries.
I have a nephew going to medical school in Idaho of all places, and he's looking at $500k in debt by the end of the whole ordeal.
> Basically the only organization that's motivated to keep costs as low as possible is the government.
Unfortunately, this isn't true for the government either.
Source: personal experience of me and literally dozens of people that I know. I've briefly worked with my country's government, and in that time I personally experienced and got dozens of stories along the lines of "the government spent tens of thousands of dollars of aggregate government employees' time because a single employee booked a hotel that was less than one dollar above the approved rate while traveling".
There's a good reason for this, of course: bureaucracies' policies are mostly "scar tissue" from high-profile cases where a bad actor did something they shouldn't have but wasn't specifically against policy, and then a policy was written for that case and stands for the rest of time. And, bureaucracies are risk-averse, especially democratic governments, whose leaders are elected based on optics almost as much as policy.
But it doesn't change the facts. Not only are large bureaucracies inefficient, but government bureaucracies specifically are incentivized to optimize for optics and structure rather than improving that inefficiency, and anyone who has actually worked for a large government can tell you that.
> One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
Investors care about margins, not absolute dollar figures. If your non-medical costs are capped, the incentive would be to reduce your other costs to preserve or maximize profits.
So the 80/20 rule is unlikely to have caused anything. More likely it's too low, and the profit ratio that can extracted and passed to investors is still higher than most investing alternatives, which is why it keeps attracting more investment. Without the 80/20 rule we would have seen the same thing or worse, though perhaps slower premium increases but less treatment delivered.
Really this all points to structural problems in the market. Naively we might presume there's not enough competition, and there could be many reasons for that--over regulation, lack of transparency. But it's more complicated than just that because medical treatment, particularly the most costly treatments, presumably have very high price elasticity [citation needed]. Over the long term, investors are just gonna keep trying to draw as much from the well as they can. The problem with public single-payer is that the basic demand curve dynamic doesn't magically change, so rather than complain about high prices people complain about shortages, OR the government just keeps borrowing to maintain satisfactory treatment access until they can't borrow anymore.
Maybe the only solution to rising healthcare costs is to slow down the pace of medical advancements. People love to point out how cheap care is elsewhere, but the most advanced and costly treatments usually become available in the US first, taking years or even decades to spread. (Note, higher prices on pre-existing tech subsidize the cost of bleeding edge treatments, so comparing MRI prices isn't very helpful.) Moreover, people elsewhere don't really know about them so it doesn't detract from their perception of the quality of care they receive. If you're dying and the doctor says there's nothing he can offer you, then that's that and no ill feelings toward the medical establishment. If he says there is something but it's gonna be crazy expensive or there's a shortage/waiting list, now your pissed.
The bigger factor in the American system is taxes. If everyone in the healthcare industry stack, from suppliers to nurses, is exempt from federal and state taxes, healthcare costs could come down by 70%+.
No. Under EMTALA, hospitals are required to treat anyone who shows up to the ER regardless of ability to pay; this is an unfunded mandate.
I'm not necessarily opposed to making all health plans non-profit, but that's kind of a red herring. Many of the largest insurers, like most Blue Cross Blue Shield Association members and EmblemHealth, are already non-profit. They generally don't charge plan members any less than their for-profit peers.
> They are not taking any losses;
Not really accurate if you look at the closure of rural and smaller city healthcare facilities. They don't have the base to charge "regular price" to make up for the aging, less healthy, rural populations.
We all pay for it, but some pay heavier costs than others.
"Insurance is a scam that lets the rich get richer. All insurance should be non-profit." Such empty platitudes never made for a good argument.
No, this absolutely does not explain the US's wildly off-base per-capita expenditure because uninsured people still go in the denominator of the per-capita figure! I'm sure the per-insured-capita figure is worse but that's not what we are comparing!
Americans are constantly trying to exclude uninsured people from their statistics (and, worse, from the care itself) but the comparable countries don't do this so it is utterly ridiculous to propose that the correct statistical comparison is one in which the US excludes the undesirables while other countries don't.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
The fun part is when you break those numbers down between government and non-government expenditure. You’ll find that US governmental spending on health care per capita is higher than every other country’s entire (gov and non-gov) spending per capita.
https://www.oecd.org/en/publications/health-at-a-glance-2025...
Could this be because US gov healthcare spending takes place mostly via Medicare, which is specifically for people 65+?
Per capita stats are computed based on population, not per treatment or per person eligible for treatment. The US spends more per head on giving only a fraction of them subsidised healthcare than other nations manage on universal health, [more years of] education, [more generous] welfare payments etc. Some of that is down to medical professional salary discrepancies, but some of it is down to a terrible system...
>"Per capita stats are computed based on population, not per treatment or per person eligible for treatment. "
Your point is correct, but since the majority of healthcare spending occurs in the last 18 months of life, and the vast majority are on either Medicare or Medicaid during that time of their life (either due to age or ailment-related incapacity), it doesn't make a huge difference.
The spending per capita, unless I’m mistaken, is just “per person in the country” not “per person insured by the government”.
That means that even though government insurance in the US only covers a relatively small percent of the population, we pay more than other countries that cover the whole population.
Close to the same percent that doesn’t have employer coverage, they’re saying, those too old or ill to work fulltime.
I say convert SSA to UBI, set a floor, and let the price of things find a new level with more people in the marketplace:
That number seems hard to believe? Specifically that non government spending would be this low. Presumably "compulsory" includes way more than direct government spending.
https://data.worldbank.org/indicator/SH.XPD.GHED.PP.CD?locat...
According to the world bank it's closer to 40:60 (government spending still being the majority). So that puts it behind Switzerland but still more than combined spending in just about any other country.
In that link, government/compulsory for the United States seems to indicate times when an insurance company covered it. Voluntary/Out of Pocket is when insurance company wasn't required to cover and did or person paid out of pocket.
Even if it's US Government only per capita with people the government insures, it makes sense it would be so high because only people on government insurance are the poor/disabled AND old. Two groups that have extremely high utilization.
That interpretation would require me to believe that a Canadian pays, on average, only 12% less out of pocket than an American. $2483/yr vs $2186/yr.
That claim is at odds with the working paper's methodology, which gets a good chunk of the $1T in savings it discussed by assuming very sharp cuts to practitioner compensation.
It also means that emergency rooms can be used just for emergencies and ongoing and preventative care can happen in clinics. Cheaper to operate and preventing preventable emergencies lowers the load.
Here's what happens in my locale. If you show up in an ER, they quickly decide whether you need emergency care, or regular urgent care, delivered in the same facility. And medicine is anything if not statistical, so they know the amount of each kind of service that they need to plan for.
In my locale urgent care is only open from like 9am-4pm on weekdays, reduced hours on Saturdays, and closed on Sundays.
I could make observations about who tends to be there at either but that might rustle some jimmies.
My jimmies are hard to rustle. I'm fortunate that I have flexible hours, and can leave work if I need to visit a clinic. If either of my adult kids gets sick, they start making calls to find someone who can take their shift. So I suspect it boils down to individual or family circumstances.
Usually tied to employer coverage contracts, and with strictly limited menu of offerings for patient health needs.
Uncompensated care attributable from uninsured patients is ~2–3% of operating revenue/costs. So it's there but not massive.
A lot of the rest of the reasons are carrying the deadweight of administering regulation, and dancing with the existing and prospective malpractice suits that randomly benefit the system sometimes, but always cost everybody, and warp the practice of medicine and patient healthcare experiences.
So what's the solution? Some states have already limited malpractice liability but that hasn't done much to hold down costs. When patients are harmed by preventable medical errors they should be compensated.
The solution is NOT to decide on one problem at a time to all agree on solving by incremental compromise, or trust free market competition driving what is in reality a non-free market.
Most patients never file a lawsuit, even if things don't go well, and most injuries that aren't deaths or newsworthy are not worth the trouble to an "overburdened" court system itself imposing a lot of burdens.
And the quality life years lost waiting to share a verdict with attorneys ought to count for everyone affected, not just those who spearhead a trial by catastrophe.
I think the solution is to make the practice of medicine more scientific, and less dominated by competitive incentives, but as long as research and development, reform, or even consumer choice, is strictly a cost, that will be considered "too expensive", if not "too risky".
That's a non answer. The medical profession is already embracing evidence-based medicine as well as specific tools such as checklists and EHRs to reduce preventable errors. But there will always be some providers who are simply sloppy or incompetent or even malicious. Nothing else you proposed is actionable, just vague complaints and hand waving.
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When patients are harmed by quacks, it is a true problem and those quacks should be incarcerated and never allowed near medicine again. If there are too many quacks, then this is a systemic problem that needs to be addressed completely separately from malpractice and professional insurance.
When patients are harmed by medical errors caused by non-quacks, that's just tough luck. Not everyone can be saved. Creating a gigantic medical malpractice insurance industry so that a few hundred surviving families per year can have lottery jackpot settlements isn't a solution in any way, and has done very little to incentivize fewer errors.
That's a silly comment. There's a huge difference between establishing civil liability versus a criminal conviction, and rightly so. The quacks aren't going to be incarcerated.
I think instead of my comment being silly, it's just difficult for you to understand because your Overton window only allows people who agree with you but differ on how much compensation should be allowed and the particulars of how that compensation is decided and doled out.
I'm used to this though.
No, you just don't understand the basics of how the US legal system works. It's always disappointing to see that level of aggressive ignorance on HN.
It is run by self-motivated humans and it often doesn't work.
> Hospitals have an operating margin of 2-5%
Very curious where this comes from and how accurate it is. For example the $37 a provider charges for an Aspirin seems like more than 2-5% margin.
You can search for more reports, because they do vary based on methodology. But the median hospital in the US makes between -1% (yes, negative, they lose money, because a huge percentage are non profits) and 4% depending on the source.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
Eg Kaufman: https://www.vizient.com/insights/reports/national-hospital-f...
It is a system where all prices and costs are so far detached from reality for multiple reasons, that looking at any current profit margins is not going to be very realistic either.
Really need to step back and start from first principles.
When I go to urgent care I get 15 minutes with a doctor who on average makes about $300K and maybe another 15 minutes with a nurse assistant who might be making $100K (or less). So that is less than $50 in doctor+nurse salary. Of course there are then all the overhead of rent, utilities, etc, etc but those are not so different from any other business in the same strip mall. So let's say total cost for my visit is maybe $100. But I'm charged $500-$600 for the visit. Someone is pocketing a lot of money and it is not the doctor nor the nurse.
We could do the same exercise for surgery, the costs for surgeons and anestethicians is much higher, but you'll be hard pressed to find any realistic scenario where the cost of a two hour surgery is more than $100K.
How much does insurance, legal representation, a department to argue with insurers, etc cost the hospital?
> a department to argue with insurers, etc cost the hospital?
My surgeon friends routinely complain about the inordinate amount of time they personally need to spend fighting with insurance, in the form of filling endless forms that insurance insists must be filled and signed by the doctor. This is in addition to whatever time/cost the hospital staff wastes fighting with insurance paperwork.
The surgeon time is not cheap, but the insurance companies expect these doctors to do all this paper pushing for free on top of their day job.
About 8.5% of revenue. This is not a poorly-studied number.
The old saw about the engineer who says that the $100,000 bill was $1 for the bolt, and $99,999 for knowing which bolt it was... that's just funny AND true!
But if it's a team of nurses, doctors, and other healthcare specialists rushing around doing checklist work to make sure you get that aspirin, that's just evil.
The principle is only applicable to our industry and closely adjacent industries.
Not buying any of this when the world is now full of dark patterns¹ and the ultimate result is that people in charge keep getting richer, faster.
¹ https://en.wikipedia.org/wiki/Hollywood_accounting
This is immediately what came to mind to me. You can be extremely profitable but paying out tens of billions in dividends, or a million other things.
Dividends aren't a Loss.
many hospitals are run by non-profits or the government (e.g. universities)
How do the salaries of administrators at such hospitals compare to for profit hospitals? How do they compare to non-medical institutions of similar size? Without a lot more information, your statement doesn't mean anything.
My point was that if it is all Hollywood accounting to scam consumers, then the nonprofits and government hospitals are doing the same thing.
Administrator pay scale is completely irrelevant to the point
fyi: Your link returns a 404 for me.
Oops! We can't find the page you're looking for
It's the salaries. That's where all the money is going. So that 37$ asperin, the profits... most of it is going to pay salaries. Not just of the doctors but administrators and all that.
Audited financial statements of all kinds of hospitals, both non-profit and for-profit. Here’s data from Moodey’s a credit rating agency: https://www.chartis.com/insights/hospital-margins-trend-high... (“This month, Moody’s credit rating agency released its annual not-for-profit and public healthcare median financial report for 2024, showing that overall hospital performance continues to improve. The median operating margin increased from 0.5% in 2023 to 1.5% in 2024.”).
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
Insurance pays the higher of their negotiated rate or the billed charge. Medical facilities set their billed rates so high that they’re guaranteed to be higher than all negotiated rates, ensuring that they get paid.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
It almost seems like obscurity is the goal with the current system. Basically, job security (for admin, insurance) via obfuscation.
All healthcare systems have administrative overhead, including completely nationalized systems. The US discourse on health care overestimates the administrative overhead by a large amount. We could remove all insurance company profits and adjust our administrative overhead to be in line with countries with nationalized systems and it wouldn't change health care costs by an appreciable amount.
The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system. No politician wants to propose reducing the salaries of doctors, surgeons, or even researchers making new medications. The only acceptable villains are the administrators and insurance companies, but even in this inefficient system that's a much smaller slice of the pie chart than most people imagine.
One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
> The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system.
Well, the salaries of medical personnel only account for about 20% of total healthcare spending. So even cutting those by half wouldn't change much.
> One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
If that was a major reason, then those who don't pay would balance out those who pay and the grand total of all healthcare spending in the US would be pretty average despite individual premiums and out of pocket costs being sky high. But in reality, the total healthcare spending is just as sky high (several times more per capita then median OECD country).
That number might be true across all health spending, which includes hospital plant, home health care, all public health work (including animal control), and medical equipment. But if you zoom in on clinical and specialist practice, the parts of the health care equation where payer-structure actually enters the picture, compensation for practitioner shoots up; it's the dominant cost of running a health provider.
It’s more like a politically palatable Rube Goldberg machine for transferring costs to those (well-insured through their jobs, the Federal government, rich supporting institutions and donors) able to pay.
Nice comment, and true enough, but $37 aspirin and similar is a criminal fraud, and so are the laws not treating it for the coercive robbery it is.
The laws that define criminal fraud are themselves fraudulent?
Stop asking so many questions and buy the aspirin.
> The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
The comparison you make between a bottle of wine vs a glass is not the right one. It's two different stores selling the same product. What's different about hospitals?
The nursing staff to give the patient aspirin costs a lot more than someone stocking boxes on shelves.
This is like that thing about about $15,000 toilets at DoD. What's actually happening is a cost allocation function where an agreed-on list price for a whole project is getting distributed pro-rata over as many different line-items as possible.
That seems like a way to disincentivize cost optimizations in the project (for the client).
Oh, sure, it's bad! It's just a particular kind of bad.
Sure, it's more expensive, but is it thousands of times more expensive? That $5 bottle probably has 50-100 pills in it. A single dose for $37 is 740X more expensive. And its not just that the apsrin is expensive to cover salaries, EVERYTHING is similarly inflated.
Hospital billing practices are often terrible or even fraudulent, but stories about the $37 aspirin are generally misleading. Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
To be clear, they are billing for all the coded line items at the listed prices, it is just that the agreements with the insurance company will disallow many of the line items in favor of other ones. They bill everything, because they may accept some insurance that has not negotiated a day rate, and in that case, the day rate code would be disallowed and some of the other line items will be paid at relevant negotiated rates instead (with others still likely disallowed). It needs to be the same bill in both cases, so they need to include everything, and the list prices need to be greater than or equal to what any insurance would pay, or they might lose out on the difference.
This is one of the areas where more standardization would certainly help. If there were more standardization of which codes disallow which other ones (which can currently vary wildly by plan even with the same insurer, must less across insurers), then a lot of line items could actually get removed as truly redundant, vastly simplifying the bill.
>Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
Yep. Hospital "bills" are a fiction. On one occasion I was presented with an "Explanation of Benefits" for a hospital stay where I was "charged" for being in two hospital rooms at the same time. As if that weren't enough I was also "charged" with having a "Pap smear"[0], even though I don't have a cervix.
I complained bitterly and after making a big stink was informed by the hospital my insurer that the items weren't actually "billed". Rather, the insurance company paid $1500/day regardless of the treatment provided.
It's disgusting!
Just in case anyone didn't get the reference (I forgot to include the link -- mea culpa).
A Pap smear[0] is a diagnostic test to detect (pre)cancerous cells on one's cervix[1].
[0] https://en.wikipedia.org/wiki/Pap_test
[1] https://en.wikipedia.org/wiki/Cervix
I have the best health plan available (as a lifelong heart patient) from my provider, which owns the hospital. I've been charged 250$ for a covid vaccine, which was administered when I was recovering from a surgery to stop Sepsis. My hospital bill was itemized and I called to verify it.
I would be able to dispute a double room billing, but I was sedated and dying so I took whatever they offered, assuming good faith.
On the occasions that I’ve watched a hospital go through the actual process of selling a small amount of inexpensive medication for a large amount of money, there is a ridiculous amount of ceremony involved. I can easily imagine that it costs that hospital 2 cents for the pill, $5 in amortized capital plus operating expense for the facility that stores that pill, plus $25 in labor and IT expenses to get that pill to the patient.
My wifes a doctor and i can assure you they are gouging you. What it is is that the insurance companys are really in the purchase processing business. So what they do is institute fees on every possible charge and the hospitals in our area mark everything up as a result. Thats part of the problem.
I, too, can invent numbers from nothing.
Yes, but can you personally allocate four people, two computers, a wristband, a HIPAA-compliant database, a HIPAA-compliant data entry system, and at least two barcode scanners to get an aspirin out of the bottle?
I’m making a serious point here: medical overspending is not just gobs of money ending up in a single pocket. The US medical system really is incredibly complex, and the money is moving all over the place and being spent on many things. Most of those cost centers may all zero or even negative value to the patient, but that doesn’t mean they don’t exist.
Ever hear of loss leaders? Some parts of a typical hospital make money while others lose it hand over fist. The overall margin isn’t across the board, it’s after everything hopefully balances out.
ER’s for example are money pits, but society really needs them.
https://www.definitivehc.com/resources/healthcare-insights/h...
Exactly this. They need to offset the areas where they lose money. And we have federal laws (justifiably so, IMHO) that ERs must provide stabilizing services regardless of insurance and ability to pay.
And while that law is obviously humane and reasonable, my only gripe is that the rest of our system is so backwards that it increasingly forces people to leverage that. There was a story about a woman who needed dialysis but had no insurance. So basically, she had to wait every couple weeks until she started breaking down, go to the ER, get emergency dialysis, get sent home. Rinse, repeat.
I don't blame her but really just the system that made this her best possible option.
https://kdvr.com/news/local/every-week-this-woman-nearly-die...
There was a story about a woman who needed dialysis but had no insurance.
And who was in the country illegally so she couldn't use Medicare or Medicaid. Still a terrible situation, but not representative of the typical American.
But wouldn't nationalized healthcare help with this? The amount of uninsured individuals would drop drastically.
Nationalized healthcare might help with certain things but it can't create capacity out of thin air. Just because the government theoretically covers everyone doesn't mean that services are actually available when needed. In general the countries with the highest levels of nationalization also have the most problems with shortages. When everything comes straight out of the government budget there's always a political tendency to cut costs by reducing provider payrolls, imposing waiting lists for expensive treatments, or refusing to cover certain treatments at all.
> In general the countries with the highest levels of nationalization also have the most problems with shortages.
Do you have any citations for this? I've heard this rhetoric before, but every time I look into it, searching around for studies on google scholar or the web, I can only find studies and reports indicating that health outcomes trend better in countries with more universal coverage. There are think pieces with anecdata of course, but no actual peer reviewed publications I can find.
One way to begin is look for studies on wait times or procedures of a given type per capita.
Like this one: https://jamanetwork.com/journals/jamasurgery/article-abstrac...
> Among patients undergoing cancer surgery, waiting times to initiation of first-course therapy have steadily increased since 2012, particularly at high-volume academic centers and among patients referred for definitive care. With continued consolidation and expansion of health systems, system-level strategies are urgently needed to monitor and mitigate delays in the delivery of surgical care for cancer.
> Delays were more pronounced at academic compared with community hospitals and among patients referred for care. Predictors of longer waiting time included Medicaid insurance (5 of 6 cancers), lowest-quartile income (6 of 6 cancers), Black race (5 of 6 cancers), increased travel distance (4 of 6 cancers), care in the West region (6 of 6 cancers), and treatment at academic institutions (6 of 6 cancers). Receipt of robotic operations was linked with longer waiting times for nonbreast malignancies (5 of 5 cancers).
How does that compare to other countries? Also seems like government insurance was the worst risk factor.
Why would I want to trade my top tier private insurance for that?
Those studies have all, to my knowledge of them, shown no system mode that is better or worse than any other. The USA for many categories of care has often in those studies had worse wait times compared to nations with fully nationalized healthcare.
Heck when I went to college in Ohio's capital, the recommendation on how to get psychiatry or therapy as a new patient was to call the suicide helpline and claim that you were suicidal. That would get you a new patient appointment within 72 hours versus over 3 months on average for patients looking to get into care through normal channels.
Interesting you weren't able to find any examples. Here are some quick ones for CT scans in US Canada and UK.
The US maintains the highest hardware capacity of the three nations with roughly 43 scanners per million people and performs around 245 to 290 scans per 1,000 residents per year. non-emergency wait times are 1 to 7 days. The UK has 10 scanners per million people and ~100 scans per 1,000 residents, using centralized triage to keep non-emergency wait times between 1 and 6 weeks for NHS targets. Canada does 160 scans per 1,000 residents and 14 to 15 scanners per million, with wait times of 5 to 9 weeks.
When you consider that the US population is not fully covered by insurance, the number of scans is even higher
Okay, but that again seems to just be a few selected data points, rather than an actual trend, backed by peer reviewed study? Japan, Australia, and Iceland all have CT units per capita that exceed the US (~ 112, 70, and 50 /MM respectively), and all of three have universal care, two are full on single payer.
That's true, but obscuring the true costs through hidden cross-subsidies isn't helping anyone in the long run. We would probably be better off with state and local governments setting requirements for ER capacity in each region, and then running an annual reverse auction system where hospitals can bid on maintaining that capacity in exchange for cash payments.
It comes from the fact that lots of the charges they bill (both of the patient share billed to insured patients and of all costs billed to uninsured patients) end up written down or off because they are uncollectable.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
Medicare has been playing a shell game with reimbursements for decades. They cut the base rate for an office visit or hospital stay to below the cost of the actual service, but allow for separate charges for various things that make up the difference so that doctors don't just stop accepting Medicare in mass. That's why you get billed $37 dollars for aspirin, $15 for drug administration, $50 for IV placement, $10/bag for saline drips, $75 for vitals checks, etc. That way the hospital can make up the money lost from the actual visit charge, this also requires more administration overhead, to both keep track of all the additional charges, and to make changes as the rules change.
This is because a whole swath of people are getting the aspirin for free (uninsured) so they need to gouge the payers for the aspirin.
Also, then, of course, we need to cover the United Healthcare guy's salary, which decreases margins.
Hand-waving numerous details, but - That $37 isn't the price in the hospital's gift shop. It's n=1 pricing, hand delivered to your bedside by a nurse with a whole hierarchy of higher-level medical & admin staff behind her, and documented out the wazoo. Aspirin could be free & unlimited at the hospital pharmacy's receiving dock, and it wouldn't affect the @bedside price.
... and in other countries, medical administrative costs are far lower because they don't need to build entire divisions around correctly coding the same condition and procedure 11 different times before insurance approves it, because the insurance is universal and self-consistent by comparison to our private fractured mess.
It ain't just the insurance crap that drives up medical overhead costs in the US. Our health care system is treated as a money farm by plenty of other industries and interests.
All of which are willing to fight tooth and nail to preserve "their" fat slices of the obscenely bloated pie.
And on top of that you've got synergies like the horrific cost of housing in the US - which drives up the cost of every employee, no matter how essential they might be to providing actual medical care.
You understand that hospitals have more costs than just aspirin, right? Depreciation, amortization, utilities, rent, taxes, maintenance, salaries, etc...
Its all coming out of revenue.
Hospitals, now that private equity is involved, do this weird cost shifting accounting BS with shell companies etc, as such their books aren’t straight forward and the 2-5% thing is likely greatly underestimated given the amount of understaffing PE has driven in that space and how much gouging there is from PBM etc.
Even if universal health coverage lost money it would be better than the current system that is based on a "causing cancer is better for the GDP than curing it" mentality.
The US has top-tier cancer survival-after-diagnosis outcomes. We spend too much to get there, and other countries in our cohort would "argue" that we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar, but if you're going into these debates with "the US private health care system causes cancer deaths", that's a pretty rebuttable argument.
That overlooks the 27 million uninsured Americans. Uninsured cancer patients are more likely to be diagnosed at a late stage, less likely to receive treatment, and have substantially higher mortality than insured patients.[1] They also have worse survival, even after accounting for cancer stage.[2] So excellent U.S. outcomes among those who access care don't rule out preventable deaths caused by barriers to accessing it.
[1] https://pubmed.ncbi.nlm.nih.gov/25092774/ [2] https://doi.org/10.3322/caac.21732
No, uninsured Americans are captured in those numbers.
entirely beside the point.
It is fine to look only at patients with insurance/ access to refute the claim that US doctors dont cure cancer so they can make more money.
This is a cherry picked statistic. We still have lower life expectancy, high infant mortality rates, and one of the highest rate of preventable and treatable deaths among developed countries
The unfortunate truth is that if you break life expectancy out by ethnicity, it tells a different story. Generally Asians, Latinos, and Whites are above while Blacks and Native Americans are below and pull down the average: https://pmc.ncbi.nlm.nih.gov/articles/PMC9256789/#S12 If you break the groups out and individually compare against countries of similiar ethnicity, the US is often ahead.
For infant mortality specifically, in the US we count every baby with a sign of life, regardless of the age. In many developed countries, they simply don't count too premature (under 22 weeks or 500 grams, iirc) and therefore don't consider them in the metrics. It makes for an apples to oranges comparison.
You're right on "preventable and treatable deaths" with heart disease and diabetes being the biggest contributors. The question for that comes down to "is that a result of systemic issues or individual choices?" because we can do lots about one of those.
> they simply don't count too premature (under 22 weeks or 500 grams, iirc) and therefore don't consider them in the metrics
Nope, that's not the reason.
> The U.S. infant mortality rate was still higher than for most Europeancountries when births at less than 22 weeks of gestation were excluded.
https://www.cdc.gov/nchs/data/databriefs/db23.pdf
Statistical hustling is common, but the most usual form is that the US excludes uninsured individuals to make itself look like it belongs in the developed country cluster.
No, the uninsured are included in both infant mortality and, even more obviously, death statistics.
Um... really?
When I Googled life expectancy by ethnic group in the United States, it gave me the following numbers:
Asian: 85.2 years
Hispanic: 81.3 years
White: 78.4 years
Black: 74.0 years
American Indian and Alaska Native (AIAN): 70.1 years
Along with a source. (https://www.kff.org/racial-equity-and-health-policy/racial-d...) (Note: Based on the source, these numbers are for 2023.)
Overall, life expectancy in the United States in the last few years is around 79ish per the sources listed here in this Wiki article: (https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...)
This means that the average life expectancy of white Americans is actually slightly below the average life expectancy of all Americans.
Incidentally, while a lot of developed countries do not track life expectancy by ethnicity, the UK seems to have a few some studies. (https://www.ons.gov.uk/peoplepopulationandcommunity/birthsde...) Though the data is very old (2011-2014), and the data is broken out by sex with no summaries, whites actually fare the worst. Black African females came out at the top, with a life expectancy of 88.9. I asked Google's search what the comparable black American female life expectancy was in 2011, and it gave me 78.2, along with a link. (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a8.htm)
Our overall ranking generally is below all "developed countries" that I can see, which range from Germany (~80) to the ~84 of "developed" countries like Japan, Switzerland, and Sweden (along with a few countries still classified as "developing" like Kuwait). It's not completely terrible, but considering how much the United States spends on health care, that's quite a poor value.
There are multiple identified factors for explaining life expectancy, but access to healthcare is identified as a very significant factor. In a system, like America, that is very expensive (likely due to highly inefficient, over-bureaucratic, overly complex, and over-quasi-monopolized systems) and without universal coverage, it follows that those who are poorer may not have the same access to healthcare and may succumb to entirely curable illnesses. So I don't think it's a coincidence that the racial breakdown above almost matches the median ethnic household income (the median white American household earns more than the median Hispanic household, but elsewise it aligns).
On infant mortality, at least one link I found -- https://www.healthsystemtracker.org/chart-collection/infant-... -- which adjusted data due to the reported difference, and still found significantly higher infant mortality in the United States. Though the data is a little old (2016).
Cite the source for "access to healthcare" as a "very significant factor" in US life expectancy? We have pretty good numbers on the mortality cause differences between the US and other countries and they don't align with this claim (unless you're doing some bank-shot argument about how access to health care makes our car crashes more lethal or something).
You'd want to be looking for a scholarly source that puts numbers on this. It's been done! As I noted elsewhere on the thread, the study we're commenting on is based on 1990s numbers about differing mortality of the uninsured. But here you're looking breakdowns of all mortality causes and tying them to insurance, a trickier proposition. Will be interested in whatever you come up with.
https://www.ncbi.nlm.nih.gov/books/NBK62376/
This article repeatedly makes the point I made; I assume you cited it to back me up?
Our life expectancy and infant mortality rates are downstream of driving a lot of miles and unhealthy behaviors (mostly diet and exercise) of American mothers (i.e., obesity). Those are things it would be good to improve, but it isn't the fault of the ER or L&D departments or their billing models that people get in car accidents or mothers are obese.
Life expectancy differences between the US and other countries are dominated by just a few factors:
* Car accidents, because we drive much more and are much more spread out than other countries.
* Drug overdoses, though other countries are starting to catch up to us there.
* Homicide, because of our gun policy and the universality of firearms (which also bears on our suicide stats).
* CVD.
That last item sounds like an indictment of the US health care system, but it isn't. If you break CVD out by state, northeastern states like Massachusetts have outcomes resembling the Nordics, and Mississippi has outcomes like a developing country. But the structure of the health care system is the same in both places.
> Car accidents, because we drive much more and are much more spread out than other countries.
Somewhat off-topic, but I think this explanation of the car accidents misses the mark. It might be part of the cause, but car accident deaths were dropping in the US and Europe until around 2010 when they kept dropping in Europe, but flatlined and then rose back up in the US.
I don't think we were driving less and less and are now driving more and more. We changed policies. (I think it's mostly bigger cars, plus less focus on traffic infra/systems/rules that prevent fatalities.)
Sure, I'd buy any hypotheses like this. We just have way more traffic fatalities; I don't have a strong take on the underlying cause.
I'm sure there are qualifiers and rationalizations when comparing cancer survival statistics as well. As someone already pointed out, uninsured Americans aren't necessarily included. They cited sources, you rebutted without sources.
I believe a single payer system is a matter of when not if. It works just fine in other countries. In our country, the healthcare industry has evolved into extracting as many dollars as it can from the economy. This is because when someone is sick and needs treatment, healthcare providers hold all of the cards.
Uninsured Americans are in fact universally included in death statistics and in cancer survival outcomes; we have top-tier cancer outcomes.
Europe has several universal coverage systems without single payer. The original sin of the US system isn't private insurance, it's employment-based coverage; that's the thing nobody else has.
Again, you cite zero sources. Survival rates for lung cancer in the USA, the most common cancer in the world, are much lower than Japan and South Korea. South Korea is single payer and Japan has strict government regulation of healthcare costs.
The second most common cancer is Breast Cancer. The USA is "top-tier" but so is pretty much every other Western Country. Australia, also famously single-payer is a mere 0.4% behind the USA.
This is the only source of modern survival statistics by country:
https://pmc.ncbi.nlm.nih.gov/articles/PMC5879496/
Compiled into an easier to read format:
https://worldpopulationreview.com/country-rankings/cancer-su...
Take note of two things: First, some states weren't even included in the study and second, there is no mention of insurance. The statistics are only tracking people who were diagnosed with cancer. It's reasonable to assume that some people who had cancer symptoms did not seek treatment because they didn't have insurance and died without being diagnosed.
Start with CONCORD-3.
I'm not saying that the US is better than every other country. I explicitly said somewhere else on this thread that there's a common critique of our outcomes that we just do detection better, and that our life expectancy outcomes aren't materially better.
What I am saying is that it's difficult to make a case that US life expectancy is materially altered by our health insurance system. You won't be able to use cancer to make that case, because the US has in fact quite good cancer outcomes. That's it: that's the whole argument.
Again, though: this repeated claim that "the uninsured aren't included in survival statistics" --- I don't know where that's coming from. It's not true.
I literally posted a link to the CONCORD-3 paper and made arguments using it and you rebutted it with "start with CONCORD-3".
I'll restate my argument so it's clear: CONCORD-3 does not mention insurance status anywhere in the paper. It does state that the statistics require diagnosis. It's reasonable to assume that if you can't afford healthcare, you're less likely to seek treatment or diagnosis.
You understand that CONCORD-3 is about tracking people who enter the healthcare system. Isn't it reasonable to assume that if healthcare is free or very affordable, there would be higher participation? And on the flipside, if it's outrageously expensive, there would be lower participation?
Sorry, I'm talking about US overall outcomes, which is what I thought you were arguing with all this breast cancer stuff. I am not taking seriously your axiomatic argument that the uninsured are systematically not captured by the US cancer statistics, and was not bothering to rebut that, nor will I.
There are no "overall" outcomes listed in CONCORD-3 or any other paper. Everything is measured by cancer type.
You're argument that uninsured are included is just as axiomatic. Zero evidence or sources. I guess we'll agree to disagree.
I don’t see a source being cited other then the assumed llm.
Life expectancy tells you very little about healthcare without controlling for confoudners
I think the parent comment was a reference to the famous “Economists must learn to subtract” commercial that AdBusters ran.
Some good news is that ISH diagnostics manufacturing can go through 510(k) instead of PMA on Sep 16 onward, which should make those diagnostics 10x cheaper and twice as fast to get through.
>The US has top-tier cancer survival-after-diagnosis outcomes.
"Airplanes that get shot in the wing always survive" logic. People _do not get diagnosed and die_ because the US healthcare system is inaccessible to close to 50% of your population. A diagnosis easily reaches a few hundred dollars for the best cases (and several thousand if you need multiple tests/blood tests/operations like colonoscopies). And when you do get diagnosed, then you've just entered a world of having to pay hundreds of thousands of dollars.
>we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar
lmao no you simply don't diagnose people and they just "die of natural conditions" early because they couldn't afford the treatment even if they were diagnosed.
> US healthcare system is inaccessible to close to 50% of your population
So you have no idea what you're talking about. What is the point of making comments like this that are both verifiably false with about 2 seconds of online research and just sound incorrect based on anecdotal data to anyone living in the US.
There is a ton of ideology baked into naive-level analysis of this stuff.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
>Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
Did I mention the 100° summers or the fact that people usually live 20+ miles from where they work?
I agree with you generally on the incentives, but it took us 70 years to paint ourselves into this corner, and we’re not going to get out of it because of a third-order incentive.
Thats not every where nor is it everyone. Im not saying it will specifically be bikes but the government will be incentivized to have a healthier population. It could be higher tax on cigs, or sugars, it could be more annual leave it could be any number of wellbeing policies.
But it is many places. You can't just magically hand-wave away the fact that the demographics between these places are wildly different, and that changes the burdens on the systems in place.
From a political philosophy standpoint, this is exactly why many people oppose a single-payer healthcare system. When the government is paying for everything it creates a financial incentive for an intrusive nanny state. We can argue about the positives and negatives, and maybe we would be healthier overall, but many Americans simply don't want the government telling them what to do.
https://press.uchicago.edu/ucp/books/book/chicago/R/bo413854...
We are getting the "intrusive nanny state" regardless of financial incentives of a given healthcare system. That ship has sailed. It's a goal, not a side effect.
Europeans do pay much less (though: for roughly the same outcomes --- probably the same outcomes if you control for wild SES variance across the US).
Right… my exact point is that it’s not a like-for-like comparison.
Take Europeans, put them in Kansas. Fund their healthcare as though they were in Europe, and watch their health outcomes take a nosedive because the environment here is non-trivially worse for you health.
Unless I’m wildly misunderstanding these studies, it makes sense that we would need to spend more for the same outcomes because we are starting from a more unhealthy position, so the same results require more resources.
We need to at least be controlling for the 10%+ differences in obesity rates, and the enormous differences in UV index. That’s before even considering weekly exercise minimums that most European get when just walking to a bar.
Then compare, say, Massachusetts to high functioning north Europe systems. You will shrink the lifestyle and climate factors down to a pretty minuscule difference, but you will still find that the spending is dramatically higher.
You're not wrong at all that the US has some systematic issues that place additional strain on the healthcare system, but it's a "yes and" situation here. Even accounting for those, we spend far, far too much because our system is extractive.
You could maybe compare the Boston metro. It should resemble a European city with satellite villages connected by trains.
I would be curious as to the costs/benefits there.
I don't think there's a whole lot to understand in this study; it's pretty wildly extrapolated and its savings numbers come from spherical-cow projections of what single-payer would actually do (somehow, it would drastically cut pay to doctors without chasing them all out of the field).
I think the important bit in all these discussions is that "universal health care" and "single payer" aren't synonyms. Single payer is one way to do universal, and most universal systems don't do it. But this article conflates the two.
One wonders what the lowered stress vis a vis healthcare concerns that a reformed system would take care of would do for our ability, as an electorate, to make better decisions in other arenas.
Yes, these cost savings would be a deflationary event. Most layoffs will come from insurance companies and administration necessary to satisfy them in hospitals.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
https://worldpopulationreview.com/country-rankings/doctors-p...
> Hospitals have an operating margin of 2-5%
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
Not the parent, but here's one source: https://www.vizient.com/insights/reports/national-hospital-f...
There are many others as well.
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
To be fair, my experience has been exclusively with hospitals running a specific EMR with a relatively new-ish (at the time) and difficult to configure billing system. Still, we were expecting to see shortfalls nearly an order of magnitude smaller than what we found.
That the hospitals didn't seem to notice the problem, and upon being told of it, often pushed back against moving to fix the problem, is what gave the impression that they must be running on much larger margins than advertised.
> Hospitals have an operating margin of 2-5%
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
"Healthcare reform is hard."
People tackle hard things for nothing, never mind billions in savings.
Yes, but there's a difference between finding out whether P=NP and some of the brightest geniuses in the country actively opposing you.
Hospitals have an operating margin of 2-5%
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
>"fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care.
This is a hoot. There is an entire cohort of people who use the emergency room as their non-urgent clinic. This is not a small demographic, it must be at minimum tens of millions of people, if not going above the nine digit mark. They do this because their parents did it, and it's the only thing they know, and their parents did it because it's the only thing they knew, and they did it because their parents did the same. It is a culture that no amount of education and public service announcements will ever change.
Heaping one perverse incentive after another on top of this mess won't change it either, but will almost certainly make things worse for everyone.
>For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
My grandpa when he was still alive would have one new fraud story with every visit to the doctor, and he wasn't in great shape towards the end, so this was too many to count, every year for the last few. Diabetic, they ordered him compression socks at one point... a dozen show up instead of the two pair that was ordered. He'd come home and wait for a bill in the mail, and a few days later would see itemization for tests and procedures he never underwent. Over and over and over. He was sharp, argumentative, and as far as I could tell, less confused than most his own age. His experience, I think, wasn't atypical.
I don't think a price transparency reform would be hard. Other than in terms of political will. We did go part of the way there a few years ago, though it's not common knowledge yet.
Why is the United States the only country on Earth where free healthcare doesn't work?
Good old American Exceptionalism.
The US' healthcare model is not unique, and almost no countries have zero-cost-to-consumer healthcare systems (and none of them are free -- they're just paid by taxpayers instead of consumers). "Free" healthcare is the exception rather than some kind of international norm you incorrectly make it out to be.
The first step to reforming US healthcare is actually understanding it, and understanding some international designs. Lying about it doesn't help.
Not a single soul on earth thinks single payer healthcare is free. 8 billion people, not one of them thinks it.
They mean “free to the consumer at time of service”, which it is. Nobody is lying, everyone agrees, it’s just you who doesn’t understand.
The vast majority of those 8 billion people do not have single payer healthcare. A lot of Americans get confused on this, because we're the only country in the Anglosphere that doesn't do single payer, but it's far from universal globally.
I didn’t say they did. I said they understand that free healthcare is not literally free, but comes from taxes. Do not underestimate them, they understand very basic things.
> Not a single soul on earth thinks single payer healthcare is free. 8 billion people, not one of them thinks it.
You are incredibly optimistic about a large swath of the population's understanding, unfortunately.
> Nobody is lying
There are plenty of people in this discussion making statements of fact that are false. Call it whatever you want.
No, they’re not false, you’re just misunderstanding. When people say “free” healthcare they do not literally mean all healthcare is zero dollars. They don’t mean nurses earn a wage of 0 dollars an hour.
No, they mean free at time of service, which they are.
Don’t believe me? Great, then ask them, without doing word gymnastics to try to trick them.
Should medical equipment cost 0 dollars to produce? Should doctors not earn any salary or wage? They will say no, 100% of the time.
> No, they mean free at time of service, which they are.
I don't think that's true France, Norway, New Zealand, or Switzerland. (And that's just developed nations. The GP's claim was every country other than the US.)
People wouldn't be externalities if healthcare costs money. Next thing you know you would have to pay attention to the environment or god forbid the food. It would eat away the budget for overthrowing countries and bombing children. Watch them elect a democrat to do the bombing next round and a new republican after that. It sounds like a joke but it isn't funny.
If universal healthcare just made access simpler with less paperwork it would be a major improvement.
The flipside to fraudulent billing is that people that need care are denied. The fraudulent billing was perpetrated by the insurer.
No, fraudulent billing is the natural predator of insurance companies. You have this backwards.
I thought that is what I’m saying.
Or maybe I'm reading it backwards! Has been known to happen. :)
> Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Billing and insurance ("BIR") is reported at around 8.5% of revenue --- admin isn't just BIR, as you note. But replacing private insurance with Medicare doesn't drive BIR to zero; Medicare is also a claims-based system. Estimates are that you'd cut BIR by somewhere around 30-40% (of 8.5%).
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
Physician/nurse salary is not the major driver of the cost of healthcare. It's around 12-15% spending, depending on the methodology. Even if you force doctors to work for free, it won't meaningfully affect the cost.
It's really the overhead costs that are so Byzantine that they can't be quantified properly. Hospitals have teams of coders, insurance companies have teams of counter-coders, physicians have to waste their time on calls with insurance companies, etc.
"Medicare for all" would alleviate a _lot_ of this. It already works for the elder population, and pretty much every senior has health conditions. So extending it for everybody would result in savings. This is a no-brainer from a purely fiscal point of view.
Another way to fix the mess is to lean on the free market side: prohibit employer-sponsored insurance. Completely. All the health insurance plans must be sold on the open market to everyone.
https://nationalhealthspending.org/
BIR is 8.5% of provider spending, once you add the multiple cells up that constitute providers.
I don't think your argument is going to survive contact with the numbers here.
I just don't believe that it's correct. The Kraken hides here: Hospital Expenditures - 31.2%
I have a bit of personal experience here. I had a partner working as an endocrinologist, one of the higher-compensated medical professions. They were spending at least 1 _hour_ every day on calls with the insurance companies for prior authorization instead of seeing patients.
Some things are also weirdly broken down:
> Net Cost of Health Insurance Expenditures - 6.2% > Administration and Net Cost of Health Insurance - 7.4%
Why are they split?
I also suspect that they included some admin personnel cost in the physician/nurse salary. For my partner, their office employed a person just to deal with insurance. There is no easy way to break down these costs for small practices.
It's the CME NHE. It's literally the same data this study is based on. It's what every study of health care spending in the US is based on.
And they're not split: one row is an aggregate of subsequent rows, as you can see by simply adding them up.
This is just a colorized table view of a spreadsheet Medicare publishes every year.
There’s essentially zero doubt that universal healthcare would save over $1T per year.
How do we know? The experiment has been done multiple times, all over the world. In the worst case (Sweden), healthcare is a bit short of $5K per capita per year, or around $1.7T. We’ve actually got a nice margin to achieve $1T, even if we remain the worst.
I agree health care reform is hard, though. We have a clear roadmap on how it can work a lot better. But what’s the political path forward?
As someone who’s actually fiscally conservative, single-payer universal healthcare is an absolute no-brainer, but, ironically, the people who call themselves fiscal conservatives will fight it to the death (well, not that ironic — at this point we all understand that, in politics, what groups purport to believe and what they actually believe have little to do with each other).
What do you recommend?
As the article said - it has not been peer reviewed
You can quibble with the specific projected savings, or the projected lives saved. But it kinda doesn't matter? If we can have net savings of half what this paper said, or a quarter, and still have more lives saved, that would still be a strong argument to do it.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
> Hospitals have an operating margin of 2-5%
There's no way a Chairman/CEO would ever reduce the operating margin by just giving themselves and their buddies a raise is there?
Are you saying that most hospitals have 50% profit margins, of which 90% are paid to the chairman leaving only a thin margin? That seems difficult to believe.
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
I'm saying if you think that administrative expenses (among others) can't be inflated for a profitable company, I would like to run your company and demonstrate what executive compensation can include:
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
Yeah, if the hospital is part of an HMO, it wouldn't even be legal. The ACA sets a floor on medical loss ratio.
[dead]
Yes, I consider big numbers like this to be red flags.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
This is broken window fallacy. The $1T not wasted on healthcare inefficiencies would be spent/invested on other things, creating jobs there. Yes, there would be churn because a good number of people involved in the bureaucracy of private health insurance would lose their job and possibly their career. But these things get smoothed out. Social supports (should) exist to dampen the effects of such churn and keep the economy agile.
At least the laid-off workers would have healthcare.
Only the American mind can comprehend leading to the deaths of tens of thousands of your own people for the sake of 3% of your economy. As long as the line goes up.
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
The US spends more than 16% of GDP on health. The UK around 11%.
Shrinking US health expenditure by 3% of GDP while roughly maintaining health outcomes is eminently, obviously doable.
Sure, it's possible in principle. But the US also has a much higher GDP per capita than the UK. The UK is a (relatively) poor country and is increasingly being left behind.
Thats why they used percentage of GDP instead of raw
Posts like this truly boggle the mind...
The US is in a class of its own when it comes to health spending. The second highest OECD country (per GDP) is Germany which is 5 points lower than the US (and BTW these figures include public and private spending).
You are clutching at straws to discount clear evidence that shows just how ideologically driven the US System status quo is...
"'No Way to Prevent This,' Says Only Nation Where This Regularly Happens"
https://www.oecd.org/en/publications/health-at-a-glance-2025...
> these are about rebuilding an entire economy, a painful process.
"Sorry kids, can't turn off the Orphan Grinder 9000, there's a whole supply chain behind it that would have to restructure."
The money doesn't vanish. It stays in the hands of people. People who would spend it on other things, feeding it into the wider economy instead of the pockets of a small number of corporations. There's zero reason to think this would result in anyone rioting except maybe insurance company CEOs.
Well it wouldn't "vanish". The $1T savings (if produced) that were once spent on healthcare would instead be spent on anything else.
Yes, it will, but think about the supply side. If people spend $1T less on health, health professionals will earn $1T less, it means, as GP said, layoffs, cutting salaries, etc... Not just doctors and nurses but also drug researchers, medical equipment manufacturers, etc...
These people will now have to do the "something else" that will be spent on, let's say gardening. But you don't turn a nurse into a gardener just like that, that's the kind of "wide ranging repercussions" I mentioned, and the painful transition period where nurses become gardeners. "Nurse to gardener" is just a random example, it can be "drug researcher to petrochemist", and some transitions we may be happy to see, like "health insurance lawyer to burger flipper", but overall, many good people will suffer in transition, many powerful people too, which make such transition unlikely.
I don't understand why we always pay attention to only the jobs side of decisions like this. Why is the main concern always preserving existing jobs? The extreme version of that is obviously silly. The savings is real and lowers prices, increasing social mobility and spending elsewhere. How many people are locked out of moving for a job that matches them better, or taking some training for a better job and so on just because of medical debt leaving them no flexibility? And if we could save that trillion by eliminating jobs, doesn't that kind of imply those jobs (or at least the system requiring them) were terrible allocation of human capital?
I am not saying it is a bad thing. What I am saying is that when we are talking about trillions we are talking big changes, and big change doesn't come without suffering, and people don't like suffering.
Usually big change doesn't happen without a catastrophic event, like a war, a coup, or an economic crisis, or maybe more optimistically, a technical or scientific breakthrough. So when an article mentions trillions without hinting at such an event, to me, it is incomplete, or wrong.
The French revolution would be an extreme example. It is a win for freedom and democracy, but the period following it is called "the reign of terror", for good reasons.
Americans are already suffering under the broken healthcare system. Overall suffering would decrease as a result.
Yes, but it's a different group of Americans, and the ones who are currently thriving in this broken system will fight tooth and nail to preserve their way of life.
They're killing people, and they're driving others into bankruptcy which is also killing them.
I see. But I think that's kind of the same diffuse vs. visible problem that underlies a lot of impedents to progress. The jobs thing is one example. We focus on one set of workers because we can picture being in their position. We can't internalize and "feel" the diffuse but greater benefit of a more efficient healthcare system, which I'm 100% would be a net positive, just spread out over the whole population.
I don't know the solution, but do you agree that the problem is basically one of individuals not being able to accurately model the tradeoffs in their head?
We're quick to want to automate trucking, manufacturing, even knowledge jobs and say "ooh but the horse shoe maker became the tire installer" but the pointless middleman jobs making everyone's health worse seems to be the line in the sand for job automation.
You can't touch the legions of people who exist to make things more expensive.
This seems a lot like the parable of the broken window but for inefficiency rather than destruction per se.
I mean there's flavors of contributions to gdp. Spending money on make work for people digging holes still counts. I wouldn't mind 1 trilly being freed up for more effective use. I imagine we could get pretty good returns on it just paying it against the debt as a simple idea, effectively a tax cut.
>Hospitals have an operating margin of 2-5%.
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
Every country with nationalized healthcare systems has lower wages for clinicians. So the notion that this wouldn't lower salaries is just ludicrous. That might be an acceptable trade-off but let's not pretend it doesn't exist.
In practice what we would see under a single-payer system is that many doctors would opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
Those countries also just have lower salaries for all sectors. The USA is just exceptional in salaries for many professionals. Just look at software engineers pay in Europe Vs US....
Switzerland has the system closest to the US in my experience, but with universal coverage.
As individual, you buy basic insurance costing roughly $500/month with a $2500 yearly deductible (LAMal/KVG). Applicants must be accepted even with pre-existing conditions. Post-deductible, you pay 10% co-insurance capped at roughly $800/year (no medical bankruptcy). Insurers operate basic plans as non-profit. They make their profit on optional supplemental insurance (private hospital rooms, extra benefits...) The state subsidizes basic premiums for low-income individuals. A doctor's visit is a $150 minimum, similar to the US.
What was most surprising compared to here in the US is employers pay $0 toward premiums. Funding is entirely decoupled from employment. You don't lose coverage or change plans when changing jobs.
On the negative, basic insurance does not have dental, so dental stuff is out-of-pocket and expensive.
In terms of stats, the US spends 18% of GDP on healthcare vs. 12% for Switzerland and the gain is lower stress too. Not perfect but maybe the best of both worlds.
Monthly payment depends on Kanton as well - in the German part you can still get basic insurance for 250 USD/month.
So basically as long as someone is alive in Switzerland they need to pay an insurance company $500/mo?
Yup. Premiums change depending on the deductible you choose[1] and your age.
[1]: If you have the CHF2500/year deductible, premiums are cheaper but you have to pay that amount out of picket before the insurance company reimburses your expenses
Obama tried this and America lost its mind.
You have to pretend it's free, in America. People don't want to support themselves.
Isn't this how socialized healthcare works in every country? Whether they realize it or not the principle is generally the same, an amount (usually bundled under "social contributions") goes from people's gross salary to pay for the health insurance.
In other EU countries it's the same or even worse: you just pay it as a part of gross and gross-gross taxes.
Thats too much trouble. In India, there is a new scheme of "ayushman bharat" 500K inr which is quite a lot of money, per family. No co-pay, you show the card in supported hospitals or government hospitals and you are in.
There are "problems" but overall it has had a net benefit with poor people who could not afford medical treatment just get it. If you are having an emergency, they just do whatever is needed and you are golden. I know hundreds of people in my neighbourhood who have had surgeries done on "card" and most could not otherwise afford it.
What I've read about government hospitals in India is that they're extremely overcrowded, with people crowding the hallways and waiting rooms to be seen while bleeding out or dying from illness, without even air conditioning in a lot of places. On the other hand, this was reported by a young Indian doctor that wanted to get to the UK ASAP, so not sure how representative his accounts are.
>A doctor's visit is a $150 minimum, similar to the US.
It's $20 to go to the doctor on similar priced insurance in the US.
Your $500/month is just a tax for healthcare. Your only advantage over the US is that it's not tied to employment. Ours is both a tax and a cudgel to force people to work.
We have the worst of all worlds because ours is a tax and a cudgel, but then we also have to pay tax to the state to fund the healthcare for others who can't or won't work. I wouldn't call yours the best of both worlds. It sounds like you're getting fleeced to a lesser extent, but still not great.
Where are you getting the 150 to visit a Dr. in the US? The copay is usually much, much lower than that.
I thought you were going to say out of pocket costs are much much higher than that.
I’ll be lucky if I get a specialist for under 500 until I meet deductible of 3k+ for a family of 3. One emergency room visit and we reach it in one or two days.
Depends on where you work. And what "see a doctor" means.
Really depends on your insurance, and whether you're visiting for a yearly physical or for an actual concern.
I think they do asses for pre-conditions, if say you enter the country via immigration.
For families, do children also cost $500/mo?
Much less, the average monthly cost is about 123 CHF (less than 150$). Source: https://www.bag.admin.ch/de/newnsb/d2okh_kUK_OFhmMDfpyiy
Same in Germany: private kids' insurance costs a fraction of the one for adults. Apparently it's very unlikely that they require expensive healthcare.
Based on what I found, you pay a lower rate for children, but you pay for each child, they don't do a fixed rate for the whole family.
We've been down this road. ACA was predicated on studies like this, to no avail (it turns out that intense opposition chips away at it over time regardless of these studies).
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
ACA has saved tons of lives. Due to the intense opposition, it was not structured in a way that could save money, but rather structured in the way that it could get through congress.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
>Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
ACA is horrible for the middle class. The only reason it retains any type of popularity is because the media refuses to associated ballooning cost to cost redistribution that it enables. Preexisting conditions? Middle class family picking that up. Subsidy? Middle class family picking that up.
This is unfair to the ACA and factually incorrect. ACA subsidies (median household size) [1] are designed to start above the 50th percentile (income) [2].
The details matter. If you're a single person living alone at an income of $70,000.00, you're below the median household income and "picking up" other people's subsidies, but that's not indicative of the country.
[1] https://www.healthcare.gov/lower-costs/
[2] https://www2.census.gov/programs-surveys/demo/tables/p60/286...
In a wealthy and civilized society we have a moral obligation to care for all of our citizens. Some of them have pre-existing conditions and can't afford to pay market rates, so the middle class is going to have to subsidize them one way or another. Whether that subsidy comes in the form of higher insurance premiums or higher taxes hardly matters.
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Before I went indie, prior to ACA requirements I researched private insurance and found plans for around $3K. This year I’ll pay over $20K for a bronze plan for my family. 700% increase in less than a decade. Aetna left the marketplace input state and no pediatrician in a 10 mile radius takes the most cost effective ACA plan. The pediatricians we found are actually just GPs who have training in pediatric medicine, but we bring in the only minors they see. This is in a top-5 market based on population.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
Who is it better for?
I think it's generally gotten better for insurance companies, at the expense of both end customers and providers (with the exception of providers that have vertically integrated into the ecosystem, e.g. Aetna/CVS, etc. to capitalize on the advantages that brings).
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
> Who is it better for?
People with pre-existing conditions. They were literally uninsurable before the ACA.
The insurance costs are also skyrocketing in the employer-sponsored insurance.
If that’s the only benefit couldn’t that have just been made a law and left out all the rest? Healthcare system is worse than ever, I don’t know the cause but with its current prices I can’t imagine subsidizing it further being the answer
Out of curiosity what state are you in?
Arizona
Without the ACA it would have been even worse. And by worse I mean that even if the premiums were lower, we would still have horrible limitations like maximum lifetime coverage amounts or exclusions for pre-existing conditions.
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.
You are paying more because a lot more healthcare is being delivered, to people who never used to either due to exceeding maximum benefits (we have the opposite today with out of pocket maximum), or being denied for pre existing health conditions.
So to answer:
>Who is it better for?
My 4 year old, who has received hundreds of thousands of dollars of cancer treatment, and will need a bunch more over the coming years.
> ACA premiums are literally taxes, the price you pay has nothing to do with your health risks.
Then turn it into a tax and be done with it. I don't shop for my tax collector and I don't pay taxes to companies with the biggest buildings in the city. Companies that don't actually provide health care, but just collect their pound of flesh from patients and providers, driving up costs for everyone.
I'm glad your child has received care. I'm very much behind the idea that pre-existing conditions should not preclude anything from receiving _care_. I'm completely opposed to mandating a private 3ᴿᴰ party be between me and my provider.
>Then turn it into a tax and be done with it.
Democrats tried, they did not get 60 votes in the Senate between Jan 2009 and Jun 2009. What we have is because at least 41 other legislators, including all Republicans, decided not to offer the US public this option, and since then Democrats have had nowhere near the numbers to enact any further reaching legislation, except the No Surprises Act in 2021.
https://en.wikipedia.org/wiki/Public_health_insurance_option
This is effectively Medicare for All.
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I agree with you about the ACA (as an opponent of single-payer). Prior to the ACA, members of my immediate family were uninsurable on the individual market --- not insurable at a higher rate, not insurable with exclusions, but literally uninsurable: their only options were employer-provided group coverage or state catastrophic safety net coverage programs. The twist: neither has any chronic health conditions. The underwriting refusals were based on symptoms reported in previous engagements with the health care system.
> These are life-changing possibilities, especially for entrepreneurs.
I would quit my day job and completely focus on my side business if I didn't have to worry about healthcare.
And this is precisely why nothing will ever change. I tell everyone who will listen to me on my soap box, we will never get universal healthcare until we divorce healthcare from employment (by that I mean, make it to where businesses cannot offer benefits at all).
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
Maybe this is the purpose of it? To keep us working like cattle.
I also think about people stuck in bad relationships they'd otherwise leave.
I was wondering one day why it seemed like so many YouTubers were Canadian.
The "well of course" moment took me a day longer than it should have.
Then you should consider emigrating to a country with universal healthcare such as Canada.
Funny enough there's a very good chance I'm a Lost Canadian. I filed my application for proof of citizenship in February and am still waiting to hear back. Hopefully soon.
Keep us posted. Seriously
Part of the reason why there is no effort to fix this, to keep you a slave to a job that provides healthcare. Imagine the reduction in labor supply and increase in labor costs if healthcare did not require employment. On can, in many cases (facts intensive), bail to a developed country with healthcare if you want to realize this dream earlier than whenever the US will achieve the outcome (and your life situation supports doing so). It could potentially takes years, if not longer (~5-10 years), for the US to fix healthcare as the situation continues to degrade for those who need affordable healthcare today.
https://news.ycombinator.com/item?id=47161587 (expat resources for those potentially interested)
https://relocateme.substack.com (a product of andrewstetsenko here, no affiliation, I just like resources that can help humans achieve their success criteria)
https://healthcareinfusion.org/ (for healthcare workers interested in Canada, likely does not apply to many here, but please share with others who might be seeking a path)
(i see this problem as a vulnerability management and exposure exercise to attempt to solve for, ymmv, no affiliation with any resources recommended)
That's not how this system came into being. It's a path-dependent quirk of the tax codes of the 1940s. We got into this predicament because of WW2-era wage controls (a dollar spent on health care by your employer was literally worth more than a dollar in wages).
This is one major reason why most of the world's universal systems make private insurance work, and it doesn't blow up the way ours does. But I don't think employers are any happier about it than you are!
You are of course correct on how we got here, I argue we are still here for many reasons, one of which is what I stated. I mean, there is no will to fix healthcare, but lots of will to spend $100B+ to go to war with Iran, right? I simply do not see anyone who cares enough to fix this exceptional mess, even taking into account the coordination problem of doing so. We could treat this as an emergency requiring a fix, but we don't. Why? We can certainly find this will for, "low ROI nation state actions".
Can we afford it? Doesn't stop trillions of dollars for DoD spending for middle east wars or tax cuts for the wealthy, so that isn't an argument, that's subjective cover for not fixing it, we do lots of things we cannot afford (current sovereign debt outstanding is ~$40T, as of this comment). Can't be done? Almost every other OECD country has solved this in some way. Therefore, as a scholar of systems, the root cause I am left with via Occam's razor is "This is an active choice to not fix this suboptimal system, where the fix would be both more economically efficient and humane, For Reasons while the electorate is lied to or paid lip service."
Employers, who supposedly are unhappy with their healthcare costs, could form a coalition and lobby for legislation and fund PACs to fund candidates who would fix this state by state with universal healthcare systems (Canda's universal healthcare system started in a single province as an experiment, for example). Why don't they? Are the costs not high enough yet? They can't argue they don't have enough power, they already, in many ways, bend the US government to their will. They have the power, they actively choose to not use it to fix this system failure.
https://en.wikipedia.org/wiki/The_purpose_of_a_system_is_wha...
https://en.wikipedia.org/wiki/Five_whys
We spend more on pension and benefits than we do on wars. The United States government is a benefits manager with a standing army.
The evidence shows we could spend less and deliver more within the scope of healthcare delivery (this piece). We actively choose not to. The Pentagon hasn't passed an audit eight years in a row, I hear little that "we cannot afford to keep funding the military at these levels and with such inefficiency."
https://usafacts.org/government-spending/
https://usafacts.org/articles/how-much-of-the-federal-budget...
https://www.militarytimes.com/news/pentagon-congress/2025/12...
I don't want to sound like I'm fundamentally arguing with you, because if I could swap our system with Germany's I'd do so in a heartbeat. But (a) the "money that should be going into health care and education is going to military" argument is highly rebuttable, so I'd be careful hanging my hat on it, and (b) everybody, literally everybody (except the AMA) agrees we're spending too much on health care --- the problem is that money goes to practitioners, so it's very tricky to talk about clawing it back.
> except the AMA
What an idle comment - where is the AMA on record saying that we should spend more on healthcare? Here's all the work they do to describe our increasing costs:
https://www.ama-assn.org/about/ama-research/policy-research-...
Also, when people invoke the bogeyman of 'AMA' they treat it like the lobbies that tech companies belong to. The AMA is not enriching physicians or hospitals (which have their own lobby!) but generally espouses consensus perspectives among doctors while making money from administering things like a residency program application system.
It's frustrating for someone like you to make this statement which feels quite divorced from any fact when you would not do the same about a security topic.
The AMA orchestrated the capping of residency slots through CMS/Medicare, which is the primary structural impediment to increased supply. Doctors in the US make integer multiples of what they do in Europe in part as a result of this.
I have to say: you can go either way on the AMA, I guess, but it's a weird hill to die on, isn't it? They're a trade group, not a public health organization. They exist for the benefit of their members.
I really would love to see the sources you have on this. As someone who has been in medicine for decades now, I have never hears this. This may be the result of a game of telephone but I'll comment as I can:
> The AMA orchestrated the capping of residency slots through CMS/Medicare,
This has very little to do with the AMA, though it is true that in 1997 the AMA was predicting an oversupply of physicians. CMS funding is the role of Congress and the AMA has supported increases in residency seats since the prediction of oversupply was found incorrect.
If there's a problem with an advisory group suggesting that the US not overspend, then I think we'll not agree on much.
I take their 1997 position as one in good faith; the graduate training component of medicine is very resource-intensive (and honestly dangerous!) so it should not be expanded without good reason.
> Doctors in the US make integer multiples of what they do in Europe in part as a result of this.
Doctors in the US make mulitples of what they do in Europe because we do not have a single-payer. You even say this earlier in the thread!
> They're a trade group, not a public health organization. They exist for the benefit of their members.
I assure you, no physician feels their needs are reflected by the AMA. It's an odd duck that probably made sense in the era of PCPs owning their own firms. The AMA has several structural roles in medical training (they administer application programs, primarily) so they're not going away any time soon, no matter what I may wish.
Start here:
https://www.hrsa.gov/sites/default/files/hrsa/advisory-commi...
It's weird to hear someone in medicine say this, because it was a big deal at the time and it comes up in many health care economics discussions (it's a commonly stated reason we can't just make more medical schools to create more doctors, and in that way bring the cost of medical education down). And: if you feel that physicians are alienated from the AMA, OK, why are you defending the AMA?
"Single payer" can't be the reason doctors make more here, because they make far less in systems like Germany which aren't single payer. There's a really widespread misconception on the left in the US that "universal care" elsewhere in the world automatically connotes "single payer", but most universal systems aren't single payer.
A quick caution: if you write to me as if I'm a defender of the US system, you're going to miss me consistently, because I am not that. I just think the reflexive position that the answer to our problems is to universalize medicare is bad policy. We could do guaranteed issue, community rating, price transparency, and means-tested subsidy and land essentially where Germany is without essentially ratifying permanently the perverse protectionist premium paid to providers.
I appreciate you keeping me honest on this topic.
Back atcha!
No system that saves money can pass in congress: that's the real problem that we cannot actually avoid. Forget pressure from large companies: So many of US costs come from very high salaries, and a lot of bureaucratic positions that don't exist elsewhere. Every dollar we pay goes to someone, and it's not just some random mogul here or there that will be OK anyway. Reform that really lowers prices means loss of jobs, which them will be blamed on the politicians who signed the bill into law.
Pre-ACA, I could afford family insurance. My family premiums went up ~$500 a month post-ACA, while the coverage worsened.
My afib ER trip three years ago cost me $7k out of pocket even though I left the hospital still in afib.
Today in my 50s, my deductible is now $8,500. My partner doesn't have insurance because she's not poor enough or rich enough.
We had an insurance rep come to my work last year who said after ACA they had some people whose premiums went up 900%.
So yeah, ACA is better in your world, but not in mine.
Yeah, since the ACA my coverage has remained the same while my costs have risen 10x; I'm in my 30s and my medical insurance costs 3x what my mortgage costs, and I still have $$$$ sized bills after a round of strep throat.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
Your blame is misplaced. Costs are increasing in spite of the ACA, not because of it. Pre-ACA your family insurance policy was likely worse in some key ways: it probably excluded coverage pre-existing conditions and had a lifetime maximum coverage limit.
But then the blame might be correctly placed? If he had no pre-existing conditions and was on a no-existing conditions plan, that plan might have saved him a lot of money.
Imagine car insurance regulations changing in such a way to force underwriters to blanket-assume everyone has had a couple speeding tickets this year. I understand why we do it. We are ok with speeders paying more for insurance, and not ok with someone born with diabetes forced to pay more for health insurance. But it is the end result in any case.
Pretty much everyone who lives long enough will end up with some sort of pre-existing condition.
It's almost like the real problem is hospital and medical costs versus cost of living.
)which is why as a percentage of GDP, Americans, European costs are remarkably similar, just distributed differently).
So you support single payer where none of that exists?
Yep. We were promised it would save us money. Instead, healthcare care costs skyrocketed thanks to Obamacare.
ACA also greatly increased costs. As an entrepreneur at the time, insurance premiums increased 25% overnight for the same plan. Many people had similar experiences.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
No it didn't. The ACA slowed cost growth, which was already skyrocketing by the time it passed.
You are both sort of right and wrong; based on a quick analysis, knowing this isn't perfect due to how plans have different characteristics, and states had different characteristics..
in the 2000s (pre ACA); * Employer plans averages 6-10% increase per year * Individual plans averages 10-15% increase per year
Rollout (2010-2017) * Employer plans averaged 3-5% increase per year * Individual plans averages 0-10% the first couple of years, but spiked hard to 25%+ from 2016-2018.. with lots of volatility (one stat I found shows 130% increase between 2013-2019)
Post (2018 to today) * Employer Plans averages 4-6% increase per year * Individual plans were generally stable but with huge volatility; also expansion of gov't subsidies absorbed much of the increases for those earning up to 400% of fed poverty level
The sharp discontinuity in insurance costs over a single year for many people when ACA went into effect isn't explained by your dismissal.
All the stories I've heard about that came from people with bad insurance (for instance: insurance programs that could rescind coverage if you were diagnosed with something serious, and that functioned mostly as billing processors for routine care, which is where ~none of the expense in the system is). The ACA did effectively regulate those plans out of existence, so if you had one, and relied on it, it raised your cost.
But when we talk about the ACA's impact on cost, we're always talking in a macro sense. Every program has individual winners and losers.
Insurance prices _dropped_ in NY after the ACA was enacted. Not "slowed down the growth" but actually dropped in absolute numbers.
That's because NY had enacted a coverage mandate even before the ACA, so insurance companies were forced to offer policies to everyone. This resulted in a runaway spiral where only sick people were getting insurance.
The ACA forced all large employers to buy insurance, greatly increasing the risk pool.
I don't believe you. It wasn't the "same plan". I guarantee that the plan you had before the ACA had a lifetime benefit limit, perhaps as low as $1M. Read the fine print. A single complex episode of care could easily blow past that limit and leave the plan member functionally uninsured.
I lost my individual healthcare plan, and I couldn’t afford the new ones. Remember when they said you could keep your plan? Yeah, that’s the one I lost.
Would you have been able to keep your plan under the system before ACA? There’s a lot of context missing in your comment.
There was never a guarantee that you were going to keep your plan anyway, was there? Insurance companies are changing plans from year to year.
The plan was cancelled because of ACA requirements. I had had it for several years prior. Yes, plans change, but this was different.
Which requirements made them cancel it? Was it a high deductible scam plan?
It was a high deductible insurance plan, not a monthly subscription to all your healthcare needs. Why would you call that a “scam”?
And for the record, it was not as high a deductible as most “silver” plans on the exchange currently.
> It was a high deductible insurance plan
Why do you believe that the ACA would have wanted such plans cancelled? There's a very straightforward public health reason that's reminiscent of why states require drivers to have car insurance.
> And for the record, it was not as high a deductible as most “silver” plans on the exchange currently.
The plan would have been in effective over 18 years ago. Does your internet plan look the same now as it did 18 years ago? Your cell phone plan?
> The plan would have been in effective over 18 years ago
This is such an important point. There's been ~40% of cumulative inflation over that period.
Also, anyone who was already buying insurance for years before the ACA knew the price has always gone up every year, often by double-digit percentages. Simple compounding plus the fact that insurance is always more expensive for people 18 years older are confusing a lot of people in this discussion.
You act like I’m an idiot. It was cancelled immediately when ACA was passed, and I couldn’t afford the new plans the same year.
My point about the current plans is that if you want to call them a “scam” because they are high deductible, you have to call almost all current plans scams.
I was responding to someone else, not addressing your situation directly.
It’s reminiscent of the screeching about how single payer healthcare would have death panels deciding who lived or died like that’s not a word for word description of insurance company actuaries or financial employees making the same decisions.
I'm curious as to how your experience actually using the plan for more than preventive coverage? IIRC, plans before the ACA had a ton of customer unfriendly provisions which made the insurance far less usable in practice. E.g. denying coverage for preexisting conditions.
Keep in mind, I made no value judgement on ACA at all, just suggested that we learn about its opposition and, as you rightly point out, the difficulty of passing such legislation that can last over time.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
Let’s be honest, it was DOA. Even Gruber admitted to it later. The whole thing was basically a scam.
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
> I will never understand why people think ACA was so great.
I would never have healthcare without it due to pre existing conditions from childhood. I literally was going to be locked out of healthcare barring becoming wealthy enough to afford everything out of pocket until it passed. And that’s really wealthy not just software engineer money. I know a lot of doctors are offering routine services for cash at a discount in increasing amounts but if you need anything with a hospital or a specialist it’s a nightmare to even find out the price before agreeing to the service.
>ACA has saved tons of lives.
The ACA has killed a whole lot more lives than it has saved by causing healthcare costs to spiral up.
If you begin with something that is obviously incorrect and trivially debunkable, perhaps that's indication that you should review your priors.
> ACA has saved tons of lives
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
[0] https://news.uchicago.edu/story/new-research-shows-medicaid-...
Your linked to article does not demonstrate what you claim it does. Your reasoning is wrong.
Medicaid expansion was a big part of the ACA.
> Medicaid expansion was a big part of the ACA.
Well see, first you narrowly define the ACA to be "everything that didn't help"...
> "Findings suggest Medicaid expansion under the Affordable Care Act saved about 27,400 lives between 2010-22, including among younger adults."
> "Their findings show that Medicaid expansions led to a 12% increase in enrollment and significantly reduced mortality—not just among older adults, but also younger ones, who accounted for nearly half of the life-years saved."
Huh? Did you read it? My point was that we could have just expanded Medicaid to achieve this.
> we could have just expanded Medicaid
Laws need votes.
If we are going to be unbound by reality then we could "just" put a medbed to cure all diseases, reverse ageing, and regrow limbs using quantum space-age tech in everyone's home.
Too many people think snark is a substitute for insight.
The major GOP complaint about the entire thing was that it was the federal government forcing people to buy a product from companies. The Supreme Court ruled that it had that power.
The ACA was the Republican plan until championed by Obama. The Republican goal was to say anything to denigrate their own plan. Romney later became the nominee for President and it was his plan that the ACA was largely based off of.
Republicans fought hard to discredit their own plan. They just wanted to move to the right of whatever it was that the black man championed.
I missed the part of your insight where the GOP would have voted to expanded Medicaid to all.
If they are down for it, I can make a call and it would be a near unanimous vote.
It was the Medicaid expansion that has been cited as saving lives [0].
Medicaid expansion saved lives. That is true and not in dispute. Other lives were saved too. It wasn’t just poor people who obtained life saving care from ACA. In an alternate world where only Medicaid expansion occurred fewer lives would have been saved than were saved with ACA as it exists now.
Paid for how? The expansion of people not on medicaid to be paying in was supposed to be how expanding medicaid could be achieved.
The Feds pay ~$150 billion a year and the states pay ~$20 billion a year for that Medicaid expansion. Those are increases on top of previous spending.
How are we paying for that? Debt.
On top of that, the ACA provides $100 billion a year to subsidize the healthcare markets.
> An expansion that has almost nothing to do with the rest of the ACA.
That's a very strange assertion, it's literally "the ACA medicaid expansion" and was a key part of the whole thing.
I'm saying most political argumentation is dishonest and not intellectually rigorous, and that's what the comment was doing. It wasn't arguing based on facts or data or actual specifics, but rather according to vague political ideologies.
That's one reason that I believe politics are discouraged on HN. It turns off our brains and we start using less interesting or useful ways of thinking.
"Saved lives" or "Could Save Lives" is a ridiculous, un-falsifiable, and unprovable claim.
First, it involves twisting correlation and causation into an Escher knot. Secondly, it's not even what cited source says.
Yes, "reduced mortality along a timeline for a certain demographic" is a good and desirable statistic, but there is no way that it translates into the self-aggrandizing and sensationalistic "ACA/Medicaid saved tons of lives" (whatever "tons" is supposed to mean, in terms of lives. Perhaps grossly obese people died less.)
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Yikes, can you please stop crossing into personal attack? You've been doing this repeatedly and even egregiously:
https://news.ycombinator.com/item?id=49335212
https://news.ycombinator.com/item?id=49334249
https://news.ycombinator.com/item?id=49324512
https://news.ycombinator.com/item?id=49323758
https://news.ycombinator.com/item?id=49323061
https://news.ycombinator.com/item?id=49322063
We ban accounts that won't stop doing this. I don't want to ban you since you also make good contributions. If you would please review https://news.ycombinator.com/newsguidelines.html and taking the intended spirit of the site more to heart, we'd be grateful.
Alright, heard, I will be less snarky and aggressive.
However, in this case - https://news.ycombinator.com/item?id=49323758 - if HackerNews guidelines allow for someone to defend torture and call it “life affirming medical care” but don’t allow someone to wish for turnabout, then this site isn’t compatible with my worldview and you should just ban me. Because I do not intend to ignore such heinous things when I see them.
The real problem with universal healthcare is that it immediately completely eradicates religious charity.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database. Everyone's getting free shit no questions asked.
I don't know that "inclination to judge" is a necessary component of religious charity. Religious charities beyond healthcare give out a lot of "free shit no questions asked," and usually without any attempt at proselytization. Catholic hospitals are not known for turning down patients due to moral judgements.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
Where is the problem here? Religious charity exists in places with universal healthcare.
Republicans finalized things to address medical costs and chiseling at hospital billing - regulations promulgated during Democrat regimes - so I would say there is bipartisan consensus for the actual arguments, if people listened to the actual arguments instead of seeing a no-vote as an opposite nonsensical ideology.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
These types of studies, and the goals they aim to support, always frustrate me as solving a surface-level problem rather than root cause.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Saving $1,000,000,000,000/yr is directly addressing how damn expensive it is.
The problem with models is that depending on your assumptions you can show just about anything. In general I think the foundation of a good argument, and good science, is assuming the minimum and seeing if your idea still works. They assume:
- hospital reimbursement drops to medicare rates ($296 billion)
- pharma prices decline 51% ($378 billion)
- administrative overhead way down ($286 billion)
- fraudulent billing way down ($286 billion)
- people stop going to the ER and stop being hospitalized as frequently, so the expanded use of services only costs $198 billion
Those seem like extremely optimistic assumptions, and the paper gives 0 consideration to most knock-on effects. For instance I don't think it's reasonable to cut hospital funding by $296 billion, increase the access to these hospitals, and assume everything will work out just fine. They at least acknowledge not acknowledging this, but that one factor alone already is likely to dramatically reshape things. And there are many others.
(1) we don't know the claims of the study will be accurate if implemented and (2) we would need studies modelling cost savings of alternative approaches to actually compare anything.
Obamacare made wild claims about cost savings as well. That didn't work out for many reasons that could show up again with another universal healthcare push.
There's a multitude of evidence that points to the success of the ACA from a cost perspective (among other things).
Cost of healthcare for individuals is not a good metric to judge by. The ecosystem of hospitals, patients, doctors, insurers, health systems, and the federal government is complex and you're not going to get a clear picture of the overall impact of the ACA by looking as something as simple as cost savings.
One example, hospitals are required to treat patients whether or not they hold insurance. The hospital foots the bill for that care and it's a major reason why hospitals shut down (especially in underserved communities). Getting more people on insurance plans was a direct factor is keeping many struggling hospitals and health systems afloat.
https://www.statnews.com/2019/03/22/affordable-care-act-cont...
https://www.networkforphl.org/news-insights/the-affordable-c...
https://www.cbpp.org/research/health/chart-book-accomplishme...
If the ACA was so successful at reducing coats we wouldn't still be having discussions like this about the excessive costs of both care and insurance in the US.
We will never know how costs would have changed if we didn't implement the ACA, and cost is not the only metric of success. But it clearly hasn't led us to a place where people feel okay with what the industry costs.
The purpose of the ACA was to get more people to sign up for health insurance by creating plans everyone could access regardless of employment status or income. Solving the healthcare crisis in this country from top to bottom is going to take more than an act of Congress.
Also necessary to remember the ACA was only passed because of Democratic support in 2010. Republicans hacked away at the proposal before it became law, kneecapping any real institutional changes it had contained, and have effectively killed it since becoming the majority in the House and Senate in 2024. That bipartisan support piece is required in order for anything meaningful to happen.
Making healthcare more affordable was literally in the name. I agree they also aimed to expand coverage, but cost reduction as a top line item and my point was simply that it didn't land that goal.
At a minimum since we don't know what prices would be today without the ACA, prices have risen dramatically in recent years to a point that I think most agree its unaffordable.
1. Do any of the cost savings recommendations you address come close to $1T/yr impact? This is the scale we should be aiming for.
2. If you think this modeling is inaccurate or incomplete you can directly discuss that. That would be a much more interesting discussion than "it might be incorrect."
That's a great question, and one that should receive similar funding and attention to properly compare.
My hunch is that (a) this study over estimates on the cost reduction side and would not pan out, and (b) improving health should always be a better cost savings than reducing corporate overhead (especially given how piss poor our average health is today).
The point of nationalisation is to address those underlying concerns. But it’s fair to say that in practice, nationalisation doesn’t always solve those problems.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
I don't think our problem is a lack of regulation though. If anything its a lack of market competition, and that is caused by over regulation and legal protections that make holding companies responsible difficult or impossible.
I think the high upfront capital required to start out in the industry is a much much bigger hurdle than the regulation.
You see the same problem in IT with hardware startups vs purely software ones. The moment you need to own something more than 1s and 0s, the risk grows exponentially.
Reducing regulation doesn’t solve that problem.
And that’s without even considering all the shady tactics that the incumbents can do to drive new ventures out of business.
It's also caused by absurd nonsense like how doctors can't tell you how much anything they're proposing to do actually will cost (a necessary condition for entering into a contract!), but then the system makes up arbitrary bills after the fact - with fraudulent amounts that nobody actually pays! No other industry works like that, as it's not the foundation of a market in the first place. Imagine if going to the grocery store involved "paying" some token amount at the cashier for their time to put your items in bags, then for the food you received shakedown bills for years afterwards, that you had to spend time going through your old documentation to refute and bargain down. Absurd.
Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.
That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advance. The current HIPAA adopted standard transactions don't allow for sending a prospective claim. So all they can realistically do is perform the procedure, submit a claim to the patient's health plan, wait for it to (maybe) be paid, and then send a bill to the patient for the balance.
https://www.cms.gov/priorities/key-initiatives/burden-reduct...
The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.
Nothing stops a doctor or an office from saying "treatment X costs $Y."
Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.
Right, and as I already pointed out below, cash pay patients have the right to demand a Good Faith Estimate (GFE) from providers under federal price transparency rules.
That shouldn't be limited to cash payers though. Insurance companies should not be part of the process of care providers pricing their service, nor should they be able to deny a charge after the fact.
Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.
One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves will charge for anything. The problem I'm describing originates completely with them - no escaping blame here.
(And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
Feel free to blame doctors if that makes you feel better but the reality is that in most cases they literally have no way to accurately calculate a patient's out-of-pocket cost in advance. Like there's just no technical way to do it.
If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act.
https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/...
You keep misinterpreting "how much [a doctor] themselves will charge for something" as "patient's out-of-pocket cost". I'm certainly not asking for the doctor to get involved between the patient and their health plan [0], but rather what the doctor charges, regardless of who might pay. In other words, the straightforwardly-legible prices that exist in every other market - even markets where insurance companies often pay (eg auto repair).
I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless.
[0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
Are you perhaps unfamiliar with existing price transparency rules? Patients paying cash already have the right to demand a Good Faith Estimate in advance. Those using a commercial health plan can see the negotiated rates for every participating provider.
https://www.cms.gov/medical-bill-rights/help/guides/good-fai...
https://www.cms.gov/priorities/healthplan-price-transparency...
I'm aware of them, but I'm not familiar with them as they seem like band-aids that add even more patient self-administrative bloat, rather than fixing the core dynamic - making healthcare pricing work like every other industry. The word "demand" is a tell, showing that this is not the normal course of the relationship. Another tell is that it's two prongs - why can't everyone receive a "good faith estimate" from a provider? Note I'm still not asking the provider to grok the patient's health plan - rather to be upfront about the prices they themselves are choosing to charge.
Also the ambiguous place between the two cases - "you have a health plan but we didn't do the work to actually bill it" - is a common source of the fraudulent shakedown bills, and this does nothing to constrain those types of fraudulent bills!
In general, I don't need to request a "Good Faith Estimate" from a grocery store about my upcoming food purchase for when I go later in the week, nor for an oil change down at the mechanic. If I go to the mechanic with "something is making a noise", then they are upfront about any fixed diagnosis fee, and then give estimates routinely in terms of a shop rate and book hours. If there are still unknowns about what might need to be fixed/replaced, they are up front about that and readily communicate with the customer. All of this is straight up missing in the medical industry, even when you try to engage. Rather they shove "consent" forms at you that say nonsensical anti-contractual things like "we can bill you whatever we want and you're responsible" and when you start pushing back on them they look at you like you have three heads.
(and just to head off the inevitable drive by comments like "It's not practical to shop around while you're in an ambulance" - the vast majority of medical care is scheduled ahead of time rather than on an urgent basis)
Sure, I'd be all for such reform. Those are the kinda of changes we can and should make before even considering nationalizing an entire industry. If nothing else we'd want that setup anyway under a centralized system, and we could change pricing regulations now with much less controversy unless you ask the lobbyists who would fight it tooth and nail).
This paper is based on numbers from the CMS NHE. Here are those numbers summarized (up to 2023):
https://nationalhealthspending.org/
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
Universal healthcare would cut down on the paperwork needed and provide opportunities to simplify it
medicare is basically the biggest culprit for the "too much paperwork" stuff. A m4a plan that doesnt involve capitation would have even more paperwork than the current system does.
"The problem with US healthcare isn't who pays for it, its how damn expensive it is."
And also how much is required. I bet a study investigating how much money and lives could be saved by reducing obesity would have 2x numbers
Exactly. I'd at least want to see similarly funded studies comparing solves for underlying causes beyond just insurance companies not being nationalized.
Similarly we could look into the likely cost of over medicating our people, and the atrocities we call food in grocery stores.
We never attempted to solve the issue of distorted price signals that occur when customers aren't the ones paying for something. We're still charging $600 for a bag of saline.
Especially when the buyer and seller are the same huge monopoly entity, but the payer is “somebody else,” the incentives are completely perverse.
Americans just consume a lot of healthcare services. Any substantial cost savings requires providing less healthcare service.
That's not necessarily true; fewer limitations on who is allowed to provide health service and manufacture medicine and health technologies would also drop prices. Competition in healthcare is very, very difficult because it's often illegal to compete.
You're actually talking about the same problem. Competition in healthcare is heavily restricted by stuff like certificates of need because there is little cost-sharing with utilizers so you get overutilization & induced demand. This is Roemer's law [0]. A large part of the reason for competition restrictions is because of a hacky attempt to control overutilization without direct cost-sharing.
0: https://en.wikipedia.org/wiki/Roemer%27s_law
In some cases they are provided healthcare services without a choice, so they're not really "consuming" those services. E.g. tests that don't change outcome but do cover a provider from a legal risk.
Something like 20% of healthcare services are "low value care" which aren't justified by evidence-based medicine criteria and may even harm the patient. Regardless of the financing system we could free up a lot of capacity and slash costs by eliminating that low value care. Of course in practice it's difficult to do that at scale.
https://www.bloomsbury.com/us/price-we-pay-9781635575910/
Citation needed (per capita please).
Given that people constantly, literally AVOID care because they can’t pay for it until it’s such an absurd problem that it’s very, very expensive, I struggle to believe this, at all.
And money amount doesn’t matter in this evidence because, again, Americans regularly avoid care until it’s catastrophic because they literally can’t afford it and/or have to wait for insurance to meet a certain harm level threshold where it literally can no longer be argued (emergency care)
The wonders of American healthcare really mean that it's all more expensive, and at the same time, more is consumed, because so much of what is paid is done past deductible. If you look at so many standard of care situations vs, say, Spain, the American system will do a whole lot more. Even for preventive care: For instance America wants colonoscopies every 10 years from 45. Spain will give you a non invasive fecal test every 2 years, and only consider colonoscopies after the test is positive. Every time I send my american prescribed intervention list, given my symptoms, to my family members working in the Spanish public caresystem, they look at it with their hair on fire. Very different standards. You might think US insurance is restrictive regarding what needs to be done, but most public care system are significantly more restrictive than that. It'll be for better reasons, instead of defaulting to no on everything, but ultimately still far more cautious regarding their spending.
So we fail both ways at the same time: We avoid interacting with the medical system, but when we do, far more is done, at far higher price per intervention, so we end up with more interventions for the same outcome, even though we avoid doctors more!
The people who avoid care they need because they can't afford it are a very small portion of the population that gets an outsized share of attention on the issue.
Until public healthcare advocates understand this and make actual attempts to convince the majority of people who are satisfied with the current system that there are benefits, the status quo will remain.
I'm not convinced that your assumption that they are a very small portion of the population holds up, but I only have the same anecdotal evidence you likely have.
Yes it's anecdotal for specific statements, but I'm roughly basing my statement on surveys like this one: https://www.nbcnews.com/politics/politics-news/poll-are-sati...
I find it hard to believe that people who would like to seek care but are unable to do so because of limits on their existing coverage would say that they are satisfied with their medical insurance.
Half the population does not vote. This is the problem socialists have- how do you get the underclass to exercise their power against the bourgeois?
No, the problem socialists have is that most people are smart enough to realize they won't be better off under a socialist regime, to the chagrin of the self-selected vanguard.
I'm not sure most people can actually define socialism, let alone recognize it.
Exactly. Although even if you can avoid the words they don't understand or were told to be frightened of you'd still have the problem of getting them to vote, even for policies they think would be good for them.
I think a citation is needed for "Americans regularly avoid care ... because they can’t afford it."
I think there are other reasons, e.g. they don't like doctors, or it's too inconvenient, or waiting times are too long. I have good insurance and haven't seen a doctor in probably 20 years.
I know people who are visiting the doctor for every sore throat, ache and pain or sneeze and sniffle, and that's not me at all.
Here you go, a recent survey: https://www.jgwentworth.com/resources/medical-emergency
> The survey showed that over nine in ten (92%) of insured respondents had delayed or avoided medical care because of concern about cost.
> In fact, 95% of those surveyed said a medical emergency would likely put them into serious debt even with insurance.
An unexpected car replacement would put most people into serious debt. And there's no insurance for that.
People get so hung up on the idea that they should have to pay for health care, when you have to pay for every other necessity in life.
Why are you moving the goal posts? You asked for a citation and were given one and now you just change to a different argument.
So you didn’t want a citation after all. Alas.
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We want consumers to consider cost when evaluating what services to buy, though. That's a feature.
The medical emergency debt statistic is just the usual thing of people not really understanding how medical insurance works.
When I’m having a heart attack, or when I’m in anaphylactic shock - you know, some of the most expensive procedures that happen - I’ll make sure to confirm the ambulance is in network, the hospital, the specific first ER doctor, the specialist, the surgeon, the lab, the lab techs, the anesthesiologists and so on, while I’m either unconscious or actively dying.
Every insurance plan I've ever had makes exceptions to the in-network requiremnts for emergencies like that.
I’m glad that’s worked out for you. Not everyone has good plans.
> We want consumers to consider cost when evaluating what services to buy, though.
A lot of medical care involves inelastic demand because your options are 1) pay this or 2) suffer and/or die.
"The market" does not function correctly with inelastic demand curves.
Yet another reason to socialize healthcare.
This is the crux. Capitalism doesn't work here and a fair bit of people like to pretend it does.
Then there's the people who bemoan "paying for someone else's healthcare" while completely ignoring that's what they're doing in the current system anyway.
It's extremely challenging to go after high costs in the current system, because the doctors who charge them are popular and the insurance companies who pay them are hated. There was a 2024 story that stuck in my mind (https://www.npr.org/2024/12/05/nx-s1-5217617/blue-cross-blue...) when Anthem tried to negotiate down the rate of certain anesthesia procedures; the public was absolutely outraged, successfully demanding that Anthem must back down and accept whatever the doctors feel is the appropriate pricing model.
The disconnect between prices and end consumers is itself a huge problem. I should know what care costs before I get it, and I should know how much my instance company is paying on my behalf before I get care.
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
I think that’s a reasonable model to want, but it’s what we call “preauthorization”, and many patients along with most doctors absolutely hate it. In order to know with certainty what your care will cost and how much your insurance company will pay, the doctor has to contact them in between deciding what treatment you should have and giving you the treatment.
You can and I do solve that annoyance with an HMO, where the doctors and insurance can communicate more effectively because they’re part of the same organization. But that also means it’s difficult or impossible for me to get the kind of care that a normal insurance company would hesitate to approve.
Preauthorization is a bit different, and yes I can see care providers hating it.
Its possible for a provider to know ahead of time that providing a saline IV costs $60, for example. Its also possible to have health care policies that approve any treatment deemed necessary at any healthcare provider, or at any healthcare provider in network if that concept was still a thing.
We don't have to have a preauthorisation step where doctors are expected to ask insurance companies if they will approve a certain treatment for a certain patient before it can be done. That is a particularly terrible implementation if you ask me.
I have a strong dislike for the industry as a whole. There's too many ridiculous situations I've been subject to, along with hearing of some from my friends.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
No, it’s not a question of who pays for it but who benefits.
You could have universal health with zero additional spending by the US government, but all that administrative overhead is someone’s income.
No one benefits when there's a single player in an industry. When that single player also owns your taxes and military, its a risk we should at least avoid if at all possible.
Let’s try and deal with actual facts here. If you disagree then you should be able to post some actual data in terms of lifespans or costs that says otherwise.
There’s multiple healthcare systems around the world, single payer results in vastly less administrative and thus overall spending and equal or better outcomes overall. So by objective criteria the average person massively benefits from single payer healthcare.
Companies don't hesitate to lay people off when their jobs aren't needed. I don't see why these parasitic insurance companies need to stay in business.
I agree that this proposal would not solve all of the problems; absent more changes you would still see the creep up of healthcare costs at too high a rate. But slashing $1 trillion off of a $5.3 trillion costs is a pretty big bite of the apple. Even if you go with the more conservative $663 number, that is still a great first step. And both of those numbers are after adding the costs of covering currency uncovered people. So we are collectively getting more for significantly less money.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I understand that theres an argument for removing private insurance companies in favor of thr government can cut costs. It can also increase them.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
>theres an argument for removing private insurance companies in favor of thr government
I don't see why you'd need to do that. Just expand medicare to everyone and if people want to also buy private insurance they can.
They'd just need to be more competitive and add significant value, which they don't currently do.
And then more and more providers would opt out of taking Medicare at all, so we would quickly end up back where we started.
No, you just make it compulsory to accept Medicare.
Actually I thought that was already the case.
The "just" is doing some heavy lifting there. Clinicians aren't required to participate in Medicare; in fact they have to go through a complex process in order to join. And there's no way that such a mandate could ever pass Congress, or be effectively enforced. Let's focus on reforms that are actually achievable in the real world.
https://www.cms.gov/medicare/enrollment-renewal/providers-su...
Seems to me you're more interested in finding problems than solutions.
Every other developed country has managed it so why don't you look to see how they achieved it?
Wouldn't you like to never worry about healthcare costs again?
> if your solution requires perpetual majority control
I think once universal health coverage is established, it amounts to political suicide to try to take it away again.
Yep. Nobody has repealed Medicare, for example
Social Security is another great example.
I don’t think “political suicide” exists anymore.
We still have Social Security for now. Entitlements are sticky for better or for worse.
Social Security in its current form will be gone within two years. Instead you will be required to pay a contribution (just as you are now) but the money will be managed by a private company who will charge fees and provide no guarantees. Current retirees will get to keep the current arrangement, everyone else will be moved to the privately managed Social Security option.
Is this based on something real happening within 2 years, or just a continuation of the 30 year sentiment that social security will be gone before my generation will get access to it?
People have been saying this forever. It will never happen. Republicans and Democrats alike love Social Security. All that needs to be done to fix it is raise the cap.
We're talking about healthcare, so you're essentially claiming that the reason the GOP has failed to repeal the ACA despite numerous opportunities is because they actually like the policy, not because they're afraid of the political fallout. Can you elaborate more on when and why you think that happened?
We still have Medicare, Medicaid, and social security. Even though each program has been weakened, none of them have been abolished and they can all be restored.
Heck, we still have SNAP, even though it's almost universally hated by republicans.
The Republicans have gone through two Trump terms now promising to repeal Obamacare and can't do it
It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty. For everyone else, political suicide is still very much a thing (see the various conservative republicans who've chosen to go against Trump over the years and have been cast out in favor of new loyalist challengers).
> It doesn't exist for politicians who hitch their wagon to Trump and MAGA; their base rewards loyalty.
These are the same ones who currently would be able to repeal the ACA tomorrow if they felt like it. You're essentially asserting that the reason they aren't is that they like the policy, and I don't think it's crazy to expect more justification for a claim like that if you want people to find it compelling.
ACA is not Universal Health Coverage. So this would be different enough. And you don't need perpetual majority control, only sensible politicians for about a generation (like FDR/Truman/Eisenhower/JFK) to lock in a popular entitlement.
FDR and "sensible" is always funny to me. The sensible politician that imprisoned Japanese Americans, destroying the lives of 120,000 of our fellow citizens.
Sensible politicians? In the US? In this era? For a _generation_???
I agree it would be very difficult, but still a lot easier than 'perpetual'.
It was pretty close until republicans pulled back Medicaid.
George Bush Sr. made a deal with Democrats to raise taxes and cut spending. Ever since then the Republican strategy has been to oppose pretty much anything a Democratic President proposes. The ACA was a Republican healthcare idea and they didn’t support it because a Democrat proposed it.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
> There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
Would that Obama, Jeffries, Schumer, and others felt the same way!
For what it's worth, Obama did actually initially consider a public option[0]; it was Congress who made it clear that they wouldn't pass it that caused him to pivot to what we have now.
[0]: edited from "single-payer" to reflect correction to a similar comment I made elsewhere in this thread
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
You mean like overturning Roe v. Wade? Can't ever happen, right?
"If your solution requires addressing the slow-burn civil war, your solution is just a campaign slogan".
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
> ACA was predicated on studies like this, to no avail
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
You mean obstacles from politicians who took money from the healthcare industry. That’s how we ended up with PPACA and they used it to justify massive cost increases and consolidations. They passed that junk to save face and now healthcare is far worse. But we “closed” the donut hole, right? Quite literally made everyone worse off and no one wants to talk about it. I still can’t believe they allowed payors such as UNH to buy up everything without ANY proper investigations during that period.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
My favorite part of the ACA is that the nickname, Obamacare, was created by Republicans, thinking it would fail and the nickname would make that failure stick to Obama better. Problem was, the ACA helped a lot of people, particularly people in red areas. So, then Republicans started complaining that Obama and the Democrats were being arrogant for putting Obama's name on the ACA.
There's been tons of short interviews showing MAGA people having no idea ACA and Obamacare were the same things. They cheered when Obamacare got repelled even though they were beneficiaries of it. MAGA propaganda is powerful
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> …if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I suspect Social Security would have met that definition at one point in time. Perhaps even paid overtime, the 40-hour work-week, etc.
Sort of. They were not campaign slogans though. They were battle cries, by militant labor, insisting on what they deserved.
I would never have had healthcare as an adult without the ACA due to an illness as a child that was expensive enough that I’m sure some insurance exec was only able to get a 26 foot yacht instead of a 30 footer.
It was a great success for people in my boat(no pun intended)
It seems far more plausible to do this at state levels. NY teased it recently and then backed off.
> If your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
Describes everything the GOP offers as “solutions.” Theirs tend to strip rights while Democrats tend to provide rights.
We’re still waiting on the GOP’s “concepts of a plan” for healthcare promised on the last campaign trail.
can someone tell me this. Right now level of care is rationed by type of insurance you can afford. eg: northwestern in chicago downtown is inaccesible to ppl below certain income level.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
You're right, it's not just that people opposing it are stupid or brainwashed: Some of them, to your point, are selfish and don't want others to have access to the nice things that they have.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
> Can you explain why those people DESERVE access to better care?
i dont get why ppl responding to me think i do when i already said this
> I am not saying this is right
i am merely saying that the angle i described should be considered because a big portion of population thinks along those lines ( my guess)
> Now the acess to best hosptials is gated by a queue?
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
Sadly, this is a better comparison than you probably intended, because access to school lunch is still not universal in the US.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
Fair enough. I imagine it's probably not hard to guess that I would similarly be in favor of fixing that!
right. my point is last line of my comment.
most of the society doesnt operate in the way that you described.
Most of society also doesn't require paying for indirectly via employer subsidy (driving up the cost to people who are between jobs or have money by other means).
If your objection is to a system that operates differently than the rest of society, it's not clear why the hypothetical healthcare system is more of a bugbear than the very real one that doesn't resemble pretty much any other way that things get purchased. I don't really understand how you think spending time arguing against something that has very little chance of happening based on principles that ostensibly conflict with the actual version that genuinely does exist is a sign that people are not being misled by those with incentives to distract them in that way or otherwise are struggling to reason about an issue logically.
i think you are talking over me with some irrelevant nonsense. did you reflect on why you are being downvoted?
From my perspective, what you're saying sounds like nonsense. I'm not sure why you're more concerned with my karma than I am, but since you're curious: no, I did not spend much time thinking about the one singular downvote my comment received. It's pretty common for people to downvote for any number of reasons (downvoting for disagreement in particular is controversial but not against the HN guidelines), so I didn't really read into it at all. Sometimes a comment I make that receives a downvote will end up with upvotes a few days later, and sometimes it won't; sometimes a comment I make that initially receives some upvotes will end up neutral or worse. At the end of the day, I comment because I have something to say, and while others' opinions on that is potentially useful feedback, and a single upvote or downvote is literally the smallest possible signal that can exist about whether what I said has merit.
no idea what you are harping on when i clearly said
> I am not saying this is right
in my original comment.
I mean, the original plan for what became ACA was single payer. They didn't have the votes from the moderate democrats though, which is why the "private plans on public exchanges" became a thing instead.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
They had 59 votes from Democrats for the public option, not single payer. Public option is to let people choose either a non-profit government insurance plan or private insurers. They needed 60 votes to break a Republican filibuster. Joe Lieberman (Ind-CT) said he would filibuster the public option but would vote for the ACA without it.
Whoops, good correction, I did misremember public option versus single-payer, and I guess technically Liberman was not a Democrat at that point, but he had been for a while up until shortly before then and still had committee chair positions from the Democrat leadership, so it mostly feels like a distinction without a difference.
I still think this is an important historical detail that seems to go under the radar a lot; if anything, it gives me yet another reason to disdain the filibuster!
This is exactly the argument that gave us the Affordable Care Act. It was literally a republican plan from Massachusetts. It was supposed to be broadly acceptable and that's why it was implemented with a billion compromises.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
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> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
Universal Health Coverage has a lot of other benefits:
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
As a Canadian, I would caution against the kind of universal health plan we have. But yes I agree there should be some kind of public healthcare. Perhaps more as a government owned hospitals and clinics alongside the private ones rather than the fully public system we have here which comes with its own host of problems.
I think it's easy to shout free healthcare as a slogan but I think the important bit is how it's implemented.
I don't think anyone really envies the American system. We have all the capacity problems that you guys do up north, and we pay a lot more out of our own pockets for the pleasure. Our results are also worse.
I don't think anyone from any country thinks their healthcare system is perfect or even sufficient. It all kind of stinks although some countries it is easier to solve problems with above average money (but not if you are average). We need to fundamentally figure out how to do more with less, automation (AI) could help out a lot here and I don't care about purists who want hand crafted artisanal advice about how they need to lose weight or they will die of a heart attack. But otherwise, a lot of problems exist just due to bad incentives.
I'm curious how Taiwan operates. It's a public side insurance system with mostly (if not all private hospitals). Obviously very different population case though, much smaller island.
The US is far too broken for such a thing to ever come to be. Politicians are bought and paid for, and the impact on the insurance companies and their profits make this impossible.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
Sounds nice, though.
The US has gone through a lot of changes since it's inception, so there's no reason we can't change this. Preferably to a system where people have the freedom to pay out of pocket for whatever level of care they want when they can afford it, avoiding the "death panels" and extended wait times that exist just about everywhere that already has a universal health system.
Universal healthcare brings the cost of private healthcare down.
I would still get private insurance for VIP car but it would cost less than what i am paying now.
When I was a kid, my parents would say “with that attitude, you’re right.”
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
You notice this?
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
Producing political apathy and learned helplessness is an explicit purpose of the "Flood the zone" propaganda strategy.
It's a serious requirement for despots. You don't need a large and supportive group. You don't need 80% of the population expressing support for your acts.
All you need is like 20% of the population absolutely Ride-Or-Die levels of support for you, willing to do violence and hate on your behalf, and everyone else just kind of apathetic, unsure, or oppressed enough to stay down.
> We have problems, too, but we are not powerless to fix them.
Indeed. Even as some of the more mainstream methods to address our current problems become less effective, we should be open to other ways change can come about. Among your list, many of those achievements had their roots in various approaches that didn't involve legislators.
Sadly so much of that, people are actively trying to undo it.
I'm earnestly curious what the alternatives to CU look like and what that would mean for for-profit companies like The New York Times?
Nobody, including congress, gives a rat's ass about insurance companies and their profits. The truth is that someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision. After the CEO of United Healthcare was gunned down in the streets for doing that thankless job do you think congress is saying to themselves "hey, maybe we should get into that business"?
> thankless job
His annual compensation was over $10 million.
That's their point. Congress isn't going to get $10 million from providing universal healthcare (at least for any system that is any good), so they have no incentive to pass it. The year the ACA passed, Democrats suffered one of the worst legislative defeats in history. Nobody wants to be the person to tell millions of people that they can no longer see their chiropractor for free or that their healthcare is not longer paying thousands of dollars a month for weight loss medications.
https://en.wikipedia.org/wiki/2010_United_States_elections
There’s a disconnect between what people say they want, and what people actually want.
People say they don’t like the ACA. But if you try to revoke its grants, it’s political suicide. Which is why republicans don’t even try.
Bring back denying insurance for pre-existing conditions? Lower the age for parent-child plans? Can you even grasp just how wildly unpopular either of those would be? Or what about marketplace plans? Congratulations, you’ve just destroyed every small business and entrepreneur in the country. I’m sure that will go over well.
The ACA is universally loved. Yes, everyone likes it. They won’t say that because they don’t know exactly what it gave them, and they’ve taken it for granted. Many of you would be uninsurable without the ACA.
And that’s why, despite people complaining, the republicans do not dare repeal even parts of the ACA. It’s too popular, whether people know it or not.
I suspect a single payer system would be equivalent. It would be contested hard, but once it’s passed, it’s passed. It would become so unbelievably popular for a majority of the population that suggesting a repeal would immediately end your political career.
> someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision
That's another lie you've been told and believed.
With Universal Healthcare the government just provides the funding. Medical decisions are made by Doctors.
Nonsense. In every nationalized healthcare system there is care rationing performed by government bureaucrats. Regardless of a doctor's opinion on medical necessity, some treatments involve long waiting lists or third-party reviews or are simply unavailable. That might be preferable to our current system in certain ways but let's not pretend that there are no trade-offs.
For example, let's say you're in England and your doctor decides you need Enhertu or proton beam therapy. That decision is meaningless because the NHS won't pay for them.
The lie you're believing is that the decision is made by government bureaucrats.
See my other reply in this thread.
>With Universal Healthcare the government just provides the funding.
And what makes you think that they fund everything? I support universal healthcare as well (I'm literally Canadian), but I can accept that there are tradeoffs associated with it.
They don't fund everything. They don't fund anything in particular.
They provide the funding and the medical professionals decide how best to allocate that funding for the best results.
It's a bit different in Canada to my situation in Scotland since there is also the choice of private healthcare here if you want to pay more to skip queues etc.
Huh? NICE sets a cost-effectiveness threshold of about £20,000-30,000 per QALY gained from a drug[0]. There was even a controversy where a drug for pancreatic cancer was denied funding for this very reason[1].
[0]https://web.archive.org/web/20110925050527/http://www.nice.o...
[1]https://web.archive.org/web/20151225115559/http://www.pancre...
NICE is an independent body consisting mainly of medical professionals. It's not made up of MPs.
That's exactly my point. How on earth are you still missing this?
I would love to know how universal healthcare works in your head
It's not how it works in my head: it's the reality of how it works here.
To quote from my other reply:
They don't fund everything. They don't fund anything in particular.
They provide the funding and the medical professionals decide how best to allocate that funding for the best results.
Man I wish I could downvote a comment. This is what you’d see on Reddit.
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
You would never see content like that on Reddit as it is far outside of the political valence there.
> "Man I wish I could downvote a comment"
I mean, you can do that here. The system just restricts what you can do until you've spent more time commenting.
In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits? How many small businesses are crushed by the cost of providing healthcare to their employees? It would be great for business to remove any involvement they have in personal healthcare.
But I suppose they are the party of big business, not the party of business in general.
The Republican party is not a Conservative party, its a Reactionist party of capital, so generally anything that threatens the interests of capital will be absolutely crushed.
As a reply to Helloworldboy (sibling comment marked as dead), the US is not even in the top 10 of best countries to live in terms of quality of life. It's not even close to the top in any QoL metrics: life expectancy, child mortality, education, poverty/wealth gaps, air pollution, food quality...
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In what world is the Republican Party pro entrepreneur/small business enough to make these rhetorical questions meaningful?
When they make campaign promises, they go to small towns and talk about "Main St" businesses. Not sure why anyone believes them at this point (for the reasons you mention), but it is what they campaign on.
Oh dear. They make those statements for the benefit of people who don't own small businesses, but are "low information voters".
That wing of the Republican Party does not exist anymore, they are now centrist Democrats.
As a sibling comment points out, the world of… 1974
https://news.ycombinator.com/item?id=49333468
I think republicans could get behind some measure of portable health plans between employers. What they could not get behind is universal, in the sense of "everyone living in USA" health care footed by the US Government. The objection would be about centralization of health care funding and about, you know, who would get the benefits.
People of color?
I doubt POC would be the main issue. I do think immigration status would be front and center. They do overlap, but not entirely.
They used to be, before Trump and the MAGA clowns destroyed the party. So prior to 2015 or so.
A more sane world, you say? How about the Nixon administration, where Nixon proposes a universal healthcare system to Congress?
https://kffhealthnews.org/news/nixon-proposal/
The original universal healthcare plans were promoted by the GOP until Hillary got involved and it became a political football.
… in Massachusetts. New England Republicans are not the bulk of the party, and that’s not all bad - remember, the phrase was “banned in Boston”, not “banned in Bakersfield”.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
> In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits?
Oh hi. That is me.
Decoupling health insurance from your job and going single payer are separate things. You can have one without the other. You can have a very healthy system with private insurers (like in Switzerland) and you can have completely dysfunctional single payer system (like in Poland and I guess many other countries).
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
Republicans are the party of pulling up the ladder behind you.
They don't give any shits about free market economics or struggling entrepreneurs. They care about protecting their own money.
And it isn't about big business; that's the Democratic Party. It is about hoarding wealth and gaining more.
BigCorp gives money to politicians and gets to depress worker wages because they can't leave — sounds perfectly sane to tie your insurance to your employer under capitalism.
The party in the pocket of BigCorp, that party...?
The insurance companies had substantial input to the specific text of the ACA. I'm not sure how you can imply the ACA was not a BigCorp bill when BigCorp wrote it.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
The Parties and Capital have multiple tools for disciplining Labor, health insurance tied to your employment status is one of the more effective ones.
If they published the plan, it was a normal rational one without carveouts for their friends, and they started pushing specific legislation now to implement it, they'd crush the Democrats, and Trump could declare himself God-Emperor.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
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Legislate transparent pricing for all medications and procedures first.
Paying 40 dollars for lozenges in the ER is insane.
Right now the system has an opaque pricing structure which makes no sense.
Force hospitals to expose API's with transparent pricing.
Fix the principal/agent problem by decoupling health insurance from employment by not having health insurance be paid for with pre-tax dollars.
I 100% want it decoupled from employment. But it doesn't magically make very sick people capable of comparison shopping either.
It should never be shopping in the first place. I live in Canada, my family has needed the hospital and the ER a few times and we never ever had to even reach for our wallet.
Your example is an edge case. Presumably sick people were once healthy. When people are spending their own money, they become a lot more discriminating.
Also, if you're looking for treatment after you're sick, that's not health insurance.
I'd tend to think the majority of healthcare is sought after something happens - car wrecks, cancer diagnosis, sports or exercise injury, stuff like ear infections or strep throat...
Healthy people without concerns aren't looking for treatment, they're visiting their PCP once a year.
For hospitals (where the majority of US healthcare spending occurs), pricing transparency has been the rule for more than 5 years:
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
>Legislate transparent pricing for all medications and procedures first.
This is an impossible ask. Truly impossible. The medical care providers have spent the last 50 years or more honing the art of making costs inscrutable. Not really to make it harder for you or I to know the costs, but for the insurance companies to know the cost. 50 years is a long time, that's not just one set of workers who have done this, it's 4-6 career spans now... the first to learn it taught it to their underlings and coworkers, who invented new sophisticated techniques and bureaucracies and taught that to the third career generation, who did the same and so on.
Even if we had universal healthcare, you're not getting rid of that. It's now a culture. A transmissible, everlasting culture.
For any political ask you might come up with, absurd and difficult and even intractable as it might be, this is light years beyond that. God himself couldn't make these prices transparent.
> Force hospitals to expose API's with transparent pricing.
Unless you're uninsured (which is a whole separate clusterfuck), the hospitals aren't the ones who decide how much you pay for any service - the insurance companies are. The sticker price that hospitals charge is almost meaningless and is intentionally high because it's used as the starting point for negotiations, which always bring the price down (never up). There isn't any expectation that any insurer is actually going to pay the billed amount as-is.
It should be illegal to charge different prices for the same thing to different customers.
That's how virtually all industries work though. The computer you are typing on right now probably costs a different amount depending on which retailer you bought it from, even though it's the same manufacturer.
The fact that it's already common doesn't mean it shouldn't be illegal.
And I'm talking more specifically about a single entity selling to multiple customers. If two different retailers want to charge two different prices of course that's fine.
It's how they negotiate? otherwise you get take it or leave it deals with insurers.
Hospitals shouldn't have to negotiate with insurers. It should be illegal for an insurer to not pay for a necessary procedure at the hospital's standard rate.
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Yeah I'd like to see this before universal healthcare. I think we can do better than universal healthcare if we start with transparency on pricing to kill graft.
Just had a kid, navigation all the procedure codes and everything was insane. I just wanted to figure out what they were charging us for. I just gave up b/c we thankfully hit out out of pocket max for this year.
Also legislate transparent negotiated pricing for medications and procedures for each insurance plan, as well as rejection rates for medications and procedures.
Oh yes, and patient/coverage drop rates
Won't matter unless service providers are forced to have one single rate for all payers. Which we can't even manage at grocery stores.
>A single-payer universal health care system could cover every American, save more than 100,000 lives a year, and still cost $1 trillion less than the system it would replace, according to a new preprint study led by researchers at the Yale School of Public Health.
FWIW, the methodology that produced this particular result is known to have significant issues. The claimed effect disappears after correcting for them. It also isn't the first time that these authors have published similar studies with these issues. They are not a credible source.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
"known" by whom, and documented where? if you're going to just parachute in and say this paper by domain experts is dead wrong, at least link to what you believe shows this to be the case.
> result is known to have significant issues.
So well known you neglected to state or cite them? I'd invite you to do so now.
ok so we're just dismissing the paper with zero substantive counterclaims then?
Please cite and explain what those significant issues are. As it is your post is a "trust me bro", and is not contributing to the conversation.
$1 trillion less profit.
$1 trillion more efficient in allocation of resources, freeing up money for consumer spending on everything.
They don't care about this stuff
The non-healthcare sectors of the economy do.
I dunno my perspective is they seem to almost entirely place value on profits today.
As long as that does not translate to good short-term profit, the shareholders won't budge
Are you saying the government is an efficient allocator of resources?
Per the study we are discussing -- as well as the results from every single other developed country I believe? -- more efficient when it comes to healthcare, yes.
If the government is so efficient, why don't we just have them run all our industries?
Because both studies and real-world results from every other developed country show gov is more efficient at healthcare, is your argument that means gov is more efficient in every field?
The government does not have the peverse incentive of putting private profit above all other concerns.
The perverse incentive of the politician / general / bureaucrat to favor their personal interest over the public interest is identical to the perverse incentive of the CEO to favor his personal interest over the same.
I would argue the government case is actually much worse because at least the CEO has the feedback mechanism of revenue because the company <> customer relationship is entirely voluntary on both sides. The public vote is supposed to restrain the government in the same way, but in practice it seems to be much less effective in restraining politicians than the customer is at restraining companies.
The government is just corrupt politicians and lobbyists. You're fighting to give them more money and power.
The government is more directly accountable to me. The only way I have to influence what insurance companies do is through the government.
You can switch insurance companies, no?
I can if I want to switch jobs too. Probably not a good idea given the current economic conditions. I'd be all for forcing a decoupling of these things, but I don't see that anywhere on the table, and it would probably run afoul of politics anyways.
No, you can’t.
In many cases, no.
Sounds like a Ron Swanson quote
If that wasn't the case, DOGE would have found any waste worth looking at.
It was not for a lack of motivation or a lack of cut-throat pursuit, consequences be damned.
it's that it's 1 Trillion less in incentivized middlemen. A la Graeber.
Total profits for US health insurance companies in 2025 were $50 billion. The other $950 billion has got to come from cutting:
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
And overhead of running the insurance company like salary and office, then wasted time for doctors.
Have you ever dared to dream of something that sounds impossible but isn't?
The average Georgian plumber has higher purchasing power than the average German doctor. In order for the United States to balance its medical books, doctors will have to be paid dramatically less than they are at present. Perhaps there’s a deal to be made where doctors take the hit, but all of their debt is paid off by the state. Going forward medical school is free, but like in Germany you have to qualify, I mean really qualify to even get your foot in the college door. That’s an expectation change for the United States population on all fronts. We don’t do well with expectation changes.
Yeah, a lot of these issues are felt in other fields too so it feels like there's a need for a larger, wider schism.
Like I would love to go to law school but I can't afford it. So many possible but inherently unattainable futures. We'll get there.
You can afford to go to law school if you're willing to prioritize it and make some sacrifices. There are plenty of law schools that have part time night or online options. Take one class at a time and you'll eventually get through.
$1 trillion less middle-men.
Not profit, just income
And most of that income is salaries to existing healthcare administrators. Quickly ending the employment of the people working those jobs would be a significant shock.
Not really. Private health insurance would still exist alongside for the more wealthy (including nearly everyone on HN) that doesn’t want to wait a year for their public system MRI. Same thing that plays out in other countries. The U.S. already has a form of this in so-called concierge / premium providers too. Lots of profit to be made.
This isn’t true of the Medicare for All Act, for what it’s worth. That would ban private insurance altogether. Personally I think that’s a bug, not a feature, but if you’re very concerned with fairness then you probably think the opposite.
Having the machine capacity to get non-urgent MRIs in hours is part of why US healthcare is so expensive. Anyway, the average (again for non-urgent MRIs) where I live in canada is 9 weeks, which is i am sure skewed due to the rural population. In the city it’s like half that.
Yep, in the US my wife had to wait a day. She could have gotten it the same day, had her injury been a little worse.
There's this idea that there are no upsides to the American system, only downsides.
If private health insurance was allowed, UHC would be stillborn. It only works if providers don't have better options than medicare reimbursement rates.
> It only works if providers don't have better options than medicare reimbursement rates.
1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
2. Less importantly, in this world where everyone has medicare, but a smaller fraction have private coverage, your argument is that the existing healthcare providers would choose to give up most of their (medicare) patients? If so, why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
> 1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
Mainly, expectations. I understand that UHC in European countries doesn’t cover all the things Americans assume it does.
Japan apparently keeps costs down by not using cutting-edge drugs. That’s not going to happen in the US.
The US Congress just isn’t good at keeping costs down.
> 2. ... why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
They absolutely do. Many providers don’t accept Medicare. Very few providers accept Medicaid. The payments just aren’t high enough.
The US is dead last in terms of health outcomes among every developed country (despite spending far more), but you believe expectations will cause every other developed country's system to fail here? I guess your argument is that the propaganda machine pushing the idea that America's healthcare is not the worst in terms of outcomes (while also being about the most expensive), would prevent Americans from accepting no longer having the worst results and the highest costs?
> Many providers don’t accept Medicare. Very few providers accept Medicaid.
1. About the same percent accept Medicare as private insurance (85-90%, while ~70% accept Medicaid - is that "very few"?).
2. "Medicare for all" is one of the primary proposals being discussed.
3. Previous smaller expansions of government healthcare resulted in expanded provider capacity to handle them, not less, but your argument is that we'd see the opposite results from further expansion?
4. And in this new world where everyone had Medicare or similar, your argument is that providers would choose to ignore most patients, where they don't under the existing system where government-sponsored healthcare makes up a significantly smaller portion of the customer base?
5. And your argument is that if the government finds that healthcare providers contract to the point that outcomes remain the worst among every developed country, as they are today, that the government would be unwilling to make any changes (such as reimbursement rates) to address this?
> The US is dead last in terms of health outcomes among every developed country (despite spending far more), but you believe expectations will cause every other developed country's system to fail here? I guess your argument is that the propaganda machine pushing the idea that America's healthcare is not the worst in terms of outcomes (while also being about the most expensive), would prevent Americans from accepting no longer having the worst results and the highest costs?
The argument is that the US system has a much lower floor, which leads to the bad health outcomes, but also generates a lot of people who expect and demand more than most universal healthcare systems would give them. An Uber driver with the cheapest marketplace plan he could find would benefit greatly from any universal healthcare system; a guy with really bad ulcerative colitis (https://www.propublica.org/article/unitedhealth-healthcare-i...) would likely not be able to get a prescription for a cocktail of drugs at non-FDA-approved doses costing $2M/year.
I’m saying the US won’t implement anything like what other countries implement. I honestly think Philip Greenspun’s proposal ( https://philip.greenspun.com/politics/health-care-reform ) makes sense but has no chance of being implemented. Americans asking for some kind of single payer system are expecting something better than basic health care.
I remember when President Obama suggested “maybe you’re better off not getting the surgery but taking the painkiller” ( https://youtu.be/rin4h4cRs6Y ). That seemed to surprise many of the people who wanted a single payer option. He stopped suggesting that kind of cost-cutting that very quickly.
I also remember when a few people received anthrax in the mail. Every news story said that people who had any contact with the letter had received Cipro to avoid developing an infection. After a couple of weeks, the government actually announced that other (cheaper) antibiotics were effective against anthrax, but it was obvious that no company was going to hand their employees something other than Cipro.
Incidentally, my autistic adult son has Medicaid. I don’t think I’ve yet found a doctor who will accept it. Luckily he’s also on my health insurance.
What are you proposing happens to providers who freely contract with patients at rates above Medicare reimbursement?
That would be a massive hit to our GDP.
Just think about the boost to our GDP by having healthier consumers who live longer, don't go into medical bankruptcy, and continue to buy stuff.
In all seriousness, this would be a massive stimulus to the economy. Americans are consumers at heart. All the money saved on insurance and/or other healthcare related costs would then be spent elsewhere.
Cars, clothes, TVs, Labubu dolls. People will use the savings to buy things. In massive quantities.
There is also some indirect bonus: if people's healthcare is not tied to their employer then it's easier to look for a new one. Also if the system is done well, then many companies would lose the incentives they currently have for not giving full-time employment.
Some would, but some would just put that money into savings and investments instead.
From a retirement standpoint I keep hearing that not enough Americans are saving for retirement, so this would still be a win for me.
Not necessarily, over the long-term. That's $1 trillion more in disposable income.
Not at all. Reducing a cost means the payer can spend the money on something else
https://en.wikipedia.org/wiki/Parable_of_the_broken_window
Presumably not; the same national income would just be redistributed from shareholders to insurees (or shareholders of companies that pay for employee health insurance).
Are you implying you would decide to sacrifice citizens health for a few GDP points, a somewhat useful but oversimplified metric that doesn’t reflect anything tangible?
Think of all the insurance jobs that would be hit, too. Unfortunately we've bloated the healthcare industry to have a lot of employees
Somehow I doubt there would be fewer jobs in healthcare if the government takes it over.
Studies: Investing in green energy would reduce our reliance on the middle east for oil and create jobs locally
America: Sounds like communism
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and what about the third yacht? who could afford the third yacht then? huh?
Most of the problems of the US system aren't really a matter of who pays, but the fact that so much is paid for services, at every level. Any really significant savings, cutting bureaucracy and pressuring providers to make costs resemble those of other developed countries, are taking money out of someone's pocket. Many hundreds of thousands of them, if not millions. This makes any significant reform very difficult, as those people vote, and will know exactly who made them worse off, even if the country in general was made much better off.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
It’s also geographically distributed. Substantially all congressional districts count a healthcare system as a top-5 employer. Those 70k/yr butts-in-seats admin jobs are occupied by voters, making them difficult to eliminate nationally. You’d have to go down to the state level at least to get anything done.
I think it’s because Americans been taught that were democracy, not a federal system, but that’s exactly where we expect to do these kinds of reforms. The federal government could reasonably set certain regulatory requirements. The states would need to make sure that any provider within it conforms to the federal levels, you know like auto manufacturing and exhaust emissions. Seems doable. Unfortunately we’re gonna have to wait for the boomers to die because they’re the ones that have gotten theirs and they’ve screw everyone else. Also, unfortunately, the millennials are gonna have to take it on the chin like we have for so much else and realize there is going to be some lost jobs.
What about quality of care tradeoffs? In Canada, for example, you are forced to use the government system, and if it doesn't deem you important enough, there is no private option.
Interesting. In every European country I know of, the private option is still available. Just vastly cheaper and more beneficial due to having to compete with a public option which covers basic necessities, surgery etc.
Canadians can (and do) just cross the border and use private US health care. The vast majority of them live near the US border.
Yes, this is what I find a little odd about the US proposals. I've lived in UK and Spain and in both they have great free public healthcare for everyone, and if you (or your employer) want to layer private insurance on top you can. Wouldn't that be a much more appealing proposal to Americans?
Perhaps, but given the current shortage of healthcare providers we would probably see many doctors drop out of the public healthcare system and only accept private insurance or cash payments.
Is this quality improvements including or ignoring the 30-ish percent rejection rate of the most popular healthcare system, including such gems as insulin and pre-authorizations refusing surgery for necrotic tissue when “maybe they could PT it, have you tried?”
PT? Luxury! My daughter had PT referred by her pediatrician, then the insurance didn't pay all of it and when I asked the insurance company for the EOBs they said they were not allowed to give them to me because it would violate my daughter's privacy.
Our insurance paid for the bill from my wife's surgeon but spent 8 months refusing to pay for literally anything else, including the anesthesia. They said it was "medically unnecessary".
There are private options for lots of things in Canada, depending on the province.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
Yes, roughly 30% of health care in Canada, from dental care to cosmetic surgery, is privately funded.
Same here in the UK. If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
This is frequently true in the USA as well. My provider's dermatology department is pretty backed up and couldn't make me an appointment for an excision until November. Fortunately it's not urgent.
Agreed, it was 2-3 months wait to get to see an ENT for me last year. My daughter's regular eye check identified a problem and it's 3 months to get her into an eye specialist to review it.
Somewhat related: a couple years ago my spouse had cancer, and the doctor could do surgery either 5 days after our insurance was changing companies, or 2 months after that, those were the next two openings. The insurance said that if we proceeded with the surgery, without the new insurance company giving us approval, but they couldn't start approving it until the insurance started, and the pre-approval from the other company didn't give us anything. We finally decided to go ahead with it and take on the risk of ~$70K if it was denied. Which we decided to do rather than my spouse spending a few months worrying. Turned out that was a really good call, because when they did the surgery it turned out that instead of the expected slow growth, it was actually growing extremely fast. That was probably the difference between it being fatal and it being treatable.
The US system is far from smooth.
Do you have any more evidence than this anecdote - pretty much any specialist is available this week in my area. Did you check ZocDoc?
https://healthjournalism.org/blog/2024/08/in-the-u-s-wait-ti...
https://www.chiefhealthcareexecutive.com/view/hoping-to-see-...
ZocDoc isn't reflective of availability as a whole. It has a lot of depth in certain areas, like dentistry, dermatology, and primary care, and less in other specialties. Many of the providers are not physicians, they're NPs and PAs. Perfectly qualified for certain kinds of issues but not others.
ZocDoc is also, obviously, working only with the providers who are willing to pay for new patients, such as newer practices trying to build a patient base. An established practice that is booked out for the next two months obviously isn't going to use such a service.
Finally, you're not considering insurance and continuity of care.
So yeah, in an urban area, you can probably find someone to see you sooner than later if they're in network or you can afford to pay, and you're okay with seeing someone you might never see again or with whom there might not be continuity of care.
I'm a Kaiser member, so I have to use their providers. The same restriction would hold for any HMO that has a closed provider list.
You should see how long their surgery departments are backed up!
Are all of those specialists "in-network"? Have you tried contacting them to see if they truly have availability? It's common for providers (or the insurance carrier), at least in my area, to claim they take new patients when in fact they do not.
(For those not in the know, out of network means costs to the patient are much higher).
Anecdotes aside, here's some data:
https://benchmarkcanada.org/Governing_Healthcare-Wait-Times....
The US does far better than the UK and Canada.
That's AI slop published by a think tank, not to be trusted. It's not primary source data.
I'd love to see some other data. But afaik it's basically not contested that the US has shorter wait times than the UK and Canada
I agree with the main point. The thing is, in the US, wait times are a function of how much you're willing to spend. You can always pay for priority. But most people won't pay more, and the reality is that most healthcare systems have far less provider supply than demand, particularly in dense urban areas where most people live.
> If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
My mother needed to see a Alzheimers specialist. I called around large metro area....wait times were 6 months minimum.
That's not at all unusual in the US. My dad saw a neurologist for chronic severe headaches. It was very common for us to go to an appointment, have the doctor request a follow up appointment in 3 months, then be told during checkout that the earliest available time was in 5-6 months.
That is absolutely the case for many private healthcare providers as well. It depends on where you are and what care you need
Hah, even with "platinum" healthcare in the US, urology referral, 4 months. "You should start PT immediately" after a car accident, "we can see you in 5 months".
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
I got my urology referral last week and had an appointment this morning...
It depends on your region, insurance company, and plan.
This was my experience too. GP referred me to a gastroenterologist and the appointment they offered was so soon it was almost inconvenient.
Lucky you. Maybe they had a last-minute cancellation, or you live in an area in which supply of urologists exceeds demand.
Yeah, I think we have a lack in our area. Years ago when I had a kidney stone, the L3 Trauma Center hospital a few minutes from me had to load me up on dilaudid and ship me from their ER across town via ambulance.
The US is not much different. We don't have a wealth of specialists available to see people right away.
I've flat out been rejected from a specialist because they had no availability at all. I actually tried again and got to be seen, but an appointment is months out, always.
I don't know about Canada, but here in Spain you have both. You have public health guaranteed, but many people also have different levels of private coverages, usually to get quicker appointments.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
I'm in Canada. The only time I ever needed a doctor in my life it was denied. I ended up having an issue that took ~5 years to resolve, which could have been prevented easily by any competent doctor in a 30 minute session.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
Does American private insurance pay for everything? And if you say "but they can pay out of pocket", well Canadians can come to America and pay out of pocket too.
No.
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
> For a lot of people it very much doesn’t.
It was a rhetorical question. I'm aware it doesn't.
The private option is medical tourism to Buffalo or whatever.
The number of ridiculous claims in this thread...
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
I think the tradeoff is that in the US, on average one gets to spend about $4000 more per year and live about 3 years less when compared to Canada.
https://commons.wikimedia.org/wiki/File:Life_expectancy_vs_h...
The differences in life expectancy are due entirely attributable to vehicular accidents, homicide, and life style factors. It has nothing to do with medical care.
My dad, in the US on Medicare (one of the government funded systems), was denied a test. Because we have the option and had the money, he went and got the test himself on his own dime. That kicked off a series of events that led to a quadruple bypass, avoided an impending heart attack, and likely added many years to his life and his ability to remain and functioning member of society.
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
The availability of universal healthcare does not preclude the availability of privately paid healthcare as well.
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What about them? The Canadian healthcare system has better outcomes than the American healthcare system in several areas. Most simply, Canadians live longer.
I'm 29 and when I was a kid, getting a family doctor used to be an easy task and if you needed to see your doctor you could get in that day. Now all the doctors are so overworked, they're fleeing to America where they can get paid a reasonable wage for a reasonable amount of work. If you can even get a family doctor, if you want to book an appointment, they'll ask you which day you'd like 4 months from now.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
Can you reconcile this with skyrocketing Canada to US medical tourism?
Those with money and those without.
Gap between Canada and US life expectancy overall: ~3 years in favor of Canada
Gap between Canada and US life expectancy for top 10% economically: ~0
Life expectancy is a function of demographics, which averages ignore.
Income is also an assertion not supported by data. For simple procedures such as a knee or hip replacement, many people earning under $80K CAD opt for US treatment.
Likely because Canada has extremely bad waitlists which are continuing to deteriorate. That coupled with a lack of specialist medical options and lesser quality.
In Canada, a woman with breast cancer could be waiting 2 months to even start treatment. In the US, you'll be starting next week.
It's just because America is big and has a lot of hospitals and has changed dramatically many times over the past 100 years.
There's lots of places in America with spare hospital capacity. In those places, locals still cannot get affordable treatment, because our health insurance system is bad.
Meanwhile, plenty of places in the US have the absurdity of our broken healthcare system, and get to wait 4 months to see a doctor after having a stroke, like my mother had.
Or like my ex, who had to wait TWO YEARS for an MRI and neurology appointment, and that took so long that by the time her appointment was coming up, her situation had changed and needed other investigation and that appointment was not really a good fit anymore.
The situation is so mediocre in most of the US, that you have to travel hundreds of miles to see specialists anyway.
Nearly every single person in Maine who needs to see a specialist is waiting months. If you are in northern maine, you will have to wait months and travel to southern maine, or wait a year for a traveling specialist who has to fit a hundred patients into a timetable meant for 20. If you need to see a special specialist, you will be triaged on the same list as the entirety of New England for the one doctor in Boston who can actually do anything for that condition.
The same guild system that keeps US doctor compensation high is also keeping supply low! Someone is going to be waiting to see a doctor! If they weren't, US doctors wouldn't be paid as much!
6 month median wait time for treatment, as in the case now in Canada, is not something I'd trade the American system for.
I also feared this, until I read that some US citizens avoid going to the doctor until it is unbearable. Take this examples: here in Spain you go to the doctor because you think that mole is slightly bigger than past year. They point you to the dermatologist in january 2027, a terrible 6 months waiting. In the US a lot of people thinks "hey, doesn't look that bad, and it could cost me $5,000". Five years pass, and now the mole is five times bigger, it bleeds and... well, it is a full blown melanoma: you get to the dermatologist 1 day after consultation, yet is too late.
The difference is wealthy people get the care immediately in the US while the poor can go to the ED and get a bankruptcy.
In New Zealand we have private insurance and universal health care. Insurance kind of fills the gaps and usually has faster turn around time, like 1-day vs 1-month for an MRI. But like insulin is free for everyone, so nobody is going broke while dying here rationing it.
There's problems with every system, but as a Canadian, it doesn't sound like you know anything about our health care.
This is what is never mentioned. Quality of care, access to cutting edge treatments, timely access to care are never discussed when moving to universal healthcare. There are examples of private and public systems out there, which would be a much better model.
So the government provided healthcare covers everything then? If not, you cannot legally get it by paying for it by yourself? Curious.
My understanding is that a clinic or hospital can’t legally charge you for a procedure that’s universally available through the provincial healthcare system.
So you’re free to pay for anything else if you want.
They have also started recommending patients just kill themselves too
There have been studies like this for decades, going back to at least the Clinton administration.
And nothing will come of it. Too many entrenched interests, regulatory capture, and lobbying + political donations.
If spending drops by $1t, it will come out of someone's paycheck. Yes, some are greedy folks who will be just fine making 20% less a year. But many will be nurses or hospitals or some combination of providers.
That you actually believe that is so sad. No, the money would come out of the pockets of insurance CEOs.
it would not because the margins in the insurance industry aren't high. The OP is entirely correct, insurers are a source of payment, not a driver of cost. Insurers don't benefit from hospitals charging them high prices, they try to negotiate cost down, that is their service. They don't enjoy paying hospitals more money.
What is driving the actual cost is the high expenses hospitals have, and the biggest source of that is labour cost, as in any other industry. American healthcare workers, doctors and nurses, earn about 2-3x as much as their peers in the developed world.
One of the biggest benefits of a national healthcare system for consumers is that the government becomes a monopsony buyer of healthcare workers. The British system is half as expensive because the government gets to set the prices for its healthcare workforce and that gets passed on to the patients.
I'm sure the army of middle been between patient and doctor have nothing to do with it.
they don't, for the simple reason that if they did all you'd need to do is go to the hospital and pay out of pocket, most US states don't require you to have health insurance. (or switch your insurance provider, as you pointed out there are many).
There's no logic in what you're trying to argue. Healthcare providers charge for their service, insurance companies negotiate that cost down, next to risk management that collective bargain power is the reason you buy insurance in the first place. Again if what you're saying is true all you'd need to do is just buy your healthcare from the hospital directly, if you end up in the ER take a look at the bill and tell me how that went
The doctor's bill the government directly for a set price. You don't need a negotiation on every medical procedure. There is no need for a middleman.
The United States government does not set prices for doctors bills, what are you talking about? Healthcare providers in the US operate privately and set prices based on market rates. Again, if you want to, you can go and purchase whatever healthcare you like already without a middleman, the point is, it isn't going to be cheaper, which is why people, voluntarily, purchase insurance.
That's how it works in civilized countries.
As I understand it - ~30% of US federal spending is on health care.
In the UK it's about 20%.
Yet apparently the UK is mostly nationalised under the NHS, while in the US there is huge additional spending on private insurance.
Can somebody from the US explain to me how that's the case and why American's still put up with it?
Because the US buys medicine at absurd pricing. Something that should cost dollars, costs hundreds. [0]
[0] https://aspe.hhs.gov/reports/comparing-prescription-drugs
Don't believe that - not that the US doesn't pay well over the odds - that's clear - but it's the major cause to overall higher healthcare costs.
Typically health care is massively human capital intensive with like 50% on wages, and only 10% on drugs.
I suspect the blame lies with a broken market and inflated prices costs across the board ( ie the higher drug prices are a symptom of a wider systemic problem ).
You can believe whatever you want, but the facts are pretty clear.
It's not the entire reason, but when America pays 2-3x more for the same drug, it can blow out.
Reading the source I attached helps. "In 2022, U.S. prices across all drugs (brands and generics) were nearly 2.78 times as high as prices in the comparison countries. U.S. prices for brand drugs were at least 3.22 times as high as prices in the comparison countries, even after adjustments for estimated U.S. rebates."
Read my post again.
I accept that the US pays over the odds for drugs. I don't accept that's the driving force behind overall health care costs - as 2.78x cost for something that's only 10% of overall costs doesn't get you to doubling the overall spend. ( If overall cost is 100 - then a 2.78 increase in 10% of that is = (10 * 2.78) + 90 = 117.8
That's a long way from double the cost - ie 200.
My contention is that the higher drug prices are a symptom, not a cause - and that's important to understand if you want a cure. Simply targeting drug pricing alone is an exercise in whack-a-mole.
The problem with insurance systems in markets that aren't operating properly is that it's actually in the insurance companies interests to increases costs.
Why? Because in the absence of proper competition in the market, insurance companies profits scale with the size of the thing they are insuring against as margins are % based.
So I would argue there is indirect collusions between all the parties involved ( insurance companies, doctors, hospitals, middlemen, pharma etc ) to escalate costs to increase the money flow they are all feeding on.
The idea of free markets driving ruthless competition is fine on paper - however in the real world there are all sorts of reasons why they don't happen in practice - so they have to be actively managed or in some cases acknowledge it's just not the best way - but that's a much longer post.
US federal budget is 23% of GDP, while UK is 44% of GDP. You can't compare fractions of the fractions directly. (Total spend is something like 11% vs 18% GDP.)
Sure it's difficult to compare - but from your figures - the 11% is UK and the 18% is US ( total spend )?
With the UK spend roughly 80:20 government:private and the US spend about 50:50.
So as percentage of GDP government spend is about the same percentage of GDP but the much bigger private spend in the US what makes the difference.
We hate it and are more and more powerless to change it every day. The parties are entrenched and swing districts are becoming increasingly rare. Those competitive districts that remain are flooded with unlimited campaign funds from big business and plutocrats, thanks to Citizens United.
The mortality numbers in this paper appear to be extrapolated from an observational study of 9,000 cases from 1988-1994. That paper distinguished between "privately insured" and "not privately insured". This paper distinguishes "adequately insured", "underinsured", and "uninsured", and applies the original paper's hazard numbers to everybody but the "adequately insured", with a coefficient modifier for the "underinsured" that they came up with themselves.
Of course it does, but only one country has to keep commissioning and ignoring studies to work out a group of 300million people can get better prices for everything if the incentive for the government is to decrease the price rather than increase it for their buddies
As a person living in Germany I find it insane that this hasn't been solved by the US of A. What the actual hell is going on?
I think it comes down to the healthcare trilemma: cost, access, and quality (or "cutting-edge-ness"); the US optimizes for quality and access, while countries with universal healthcare optimize for access and cost. You can only pick two.
Plenty of bribes to go around. For politicians, press, "think-tanks".... They make sure system is not changing.
Regulatory capture of our legislature and regulatory bodies, intense bribery, proof of need legislation, and people consistently providing an obviously corrupt system with more money and power thinking that somehow, magically, the people who’ve obviously been corrupt and dishonest will be made angels when given more money and power.
As a Canadian ex-pat I've seen the following:
1) 2 friends had to wait over a year for gallbladder surgery.
2) A friend with autistic child had to wait 2 years for any type of therapy. He couldn't afford the $80k/yr for private care. Ontario has 70,000 autistic children on the waiting list for treatment.
3) Another friend had to wait several years to find a PCP in Ottawa, the capital city of Canada. He has a golf ball sized lump on his head and he can't see anyone without a referral from his PCP but he has none and no one was taking new patients. He put himself on a list to get the first PCP available anywhere in the city. After that he has to wait a year for a consult and who knows when surgery is.
4) Another friend had to wait 9 months to get an MRI for a pain in his neck. After that it was another 4 months to see a neurologist.
You don't pay in money but you pay in time and suffering.
Healthcare worker shortages are a problem in the US and other developed countries with universal systems. The type of system doesn't really influence the waiting time.
It's crazy that universal health is the political third rail in most modern countries but for the opposite reasons
In most of the world it's the policy that cannot be touched, just in Europe, Canada and Australia its _existance_ is invoilable, in the US the _introduction_ seems to be the unwinnable war
Very good point. In the UK, the NHS is on the same level as a religion.
The NHS can NOT be meddled with whatsoever.
Complete political suicide.
Medicare is the first scare campaign bought up in any Australian election
How much would it save if you account for the fact that half of congress would sabotage it in to oblivion?
And if not that.. healthcare then becomes monopolized.
Maybe extreme but what prevents that entity from becoming the decider regarding who lives and dies?
Since when has a government projection of costs ever been in any way realistic? The estimates for the costs of Medicare when it was established were low by a factor of 10.
Last time I joined a discussion about US health care on HN (years ago), the picture looked bleak: secret chargemasters in every hospital, no realistic way for patients to compare options because the options are too complicated, and lots of people still falling through the cracks.
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
Link to the preprint https://www.medrxiv.org/content/10.64898/2026.07.22.26358689...
There are many studies from reputable sources (one being the CBO) that say it would result in almost no savings or potentially even higher costs, just like there are many studies like this one that say there will be massive savings with no reduction in quality of care.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
There aren't enough Physicians, they don't make much and they all seem to be working 12 hour days but being paid a salary that would equate to an 8 hour day.
Doctors see downsides of a universal coverage are mostly about loss of autonomy and increased demand because when care becomes free demand rises along with pressure to expand access without extra staff.
There are not enough physicians because we have limited the number of physicians. This was done, in part, by limiting the number of residency positions.
[1] https://petrieflom.law.harvard.edu/2022/03/15/ama-scope-of-p...
Most other countries don't even have a residency system. After graduation you simply apply for and work as a junior dr. for some number of years. No federal funding of a 'residency' position necessary.
Yeah, having lived under universal care, the dark side of it was atrociously long waits to see a specialist and having a GP who is obviously overworked and barely spends any time seeing you.
That may be your experience, and I’m sorry to hear it, but that is not the universal experience.
I’m in the hospital right now. My two year old had her tonsils and adenoids out this morning. Regular Dr visit lead to an X-ray on the same day, specialist appointment 3 weeks later, surgery 2 months later (would have been one month, but we pushed it back because timing and life).
Just talking about how my wife is coming off 18 months of maternity leave. Before that she quit and just didn’t work for 3 years because burn out. I’ve been self employed for 10 years earning about $20k a year.
This whole thing cost us exactly nothing. Would be the same if we’d never had jobs.
Mum got stage 4 cancer in another country where she lived. 2.5 years of radiation, chemo, X-rays, mri, and dozens and dozens of specialist appointments (which she got paid for transit and free accommodation in the capital city) not to mention the mountains of serious drugs.
Total cost $0.
Anyone that argues against this is either not very intelligent (easily manipulated by the propaganda) or does not want to help others (“freeloaders”), or is getting rich from the status quo.
In America, anyone who earns $20k a year with with a 2 year old is going to get free medical care, too. I have several kids and my medical care is free up until we make about $55,000 per year. If we had no jobs, same thing.
A close relative of mine (who is single) also had cancer and had 100% of it paid for.
Transportation costs are also paid for, although we never needed overnight accommodation so far.
My prior experience was in Australia was a youngster under a particularly terrible universal care system in the 1989s, and then in the 2000s when I lived in Canada.
I get a little weary of the refrain about how American healthcare is terrible, esp. for poorer people - it’s actually very good.
Why are 27 million Americans without healthcare, are why is medical bankruptcy so common?
A massive percentage of the population don’t have and/or can’t afford healthcare.
By definition, that is not a good system.
1)People who choose not to buy insurance because we don't force them to. 2) Adults in the remaining states that chose not to extend medicare who don't earn enough to qualify for ACA subsidies. 3) Adults who qualify for subsidies but still can't afford relativly expensive ACA plans. 4) Others? Not sure if that number includes noncitizens who don't qualify for assistance?
That sounds extremely complicated and confusing to navigate.
We’re checking out of hospital right now after an overnight stay for my 2 year olds surgery.
Never a single piece of paper, and of course no bill. They’re sending us home with the pain meds we need for the next week, plus a stack of yogurt and jello for the little one.
Life is pretty simple when you want it to be.
[dead]
Well, by definition, someone who can’t afford it is eligible to apply for and receive assistance.
I know plenty of people who are eligible and simply don’t want to apply.
If you want to be seen immediately (even when triage determines it not necessary) you can just supplement with private insurance
But that’s not universal care. “Triage determines it not necessary” is a cold comfort to someone waiting years for a procedure they actually do need.
The triage is pretty effective though. In the UK on the NHS for example if you have cancer you'll be on chemo within 30 days.
And yet that's exactly my experience in the US healthcare system.
Indeed: https://arstechnica.com/health/2026/08/us-wait-times-for-can...
I would like to know if anyone has a method or resource to cover rough calculations on things like:
1) how much cost comes from "friction" like middleman, administrative bloat, shitty digitalization/note sharing, all the time the nurses and doctors have to spend on paperwork... Etc.
2) how much drug development is subsidized by the US patient via higher domestic vs. foreign pricing. Or even how much of the cost total is drugs?
3) how much roughly every added year of life past some marker of "high quality of life" is spent just keeping people alive. And if there's any trends there, cost going up or down total and per person.
4) some basic accounting of where the spend is actually going. A lot of people in this thread are talking about hospital margins. There's much more to health care than that. Labs, hospice, mental health, labs/diagnostics, drugs, r&d, nursing facilities and many things I probably don't even know about.
Basically an equivalent of david mackays "without the hot air" but for health care.
Also if anyone has some good reading on ideas around kind of SEZs for drug/treatment development where people opt in to riskier care. Not quite the same thing but I know for example that lots of medical device development and proving is done in spain to gather evidence for the FDA since the FDA process for devices is legitimately insane.
Oh and if there has been any proposals or even adoption of better health record management, digitization. Especially access to your own health record. Im not a crypto guy but it seems like maybe it could be an application for it?
I’m a physician in the US. In my experience main cost drivers are administration (documentation is part of it but the way billing works is you basically do the job, document what you did, then submit to the payer. This process can take 6+ months and they often just don’t pay for parts of it).
And then ICU/end of life. Way too many Americans don’t ever talk about what will happen when they die and what they do or don’t want at the end of life. Then they become incapacitated, family pursues all advanced therapies because they don’t know what to do and they spend a long time in the ICU getting things done for an unclear goal
Thanks! I half-jokingly want to come up with a mental health/memory + physical health test for myself where if I ever fail it my wish is to not be a burden, don't extend my life.
People talk about policies like they're something like can be picked up off the shelf at supermarket. If you could take the policies and Sweden copy-paste them to the US, then sure, we could save $1T and a hundred thousand lives. This would be a very difficult thing to replicate if you're a country without any existing healthcare system. It is impossible in a country with an extremely mature healthcare system, which accounts for nearly 20% of GDP.
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
The US already has a national health insurance network that pays the vast majority of all providers, and as far as I know it is widely popular and covers everyone legally present in the US for a portion of their life, Medicare. Old people experience just about every ailment young people do, we can just get rid of the age restriction on Medicare, it's already fully integrated with our medical system. No need to copy-paste from Sweden.
Medicare also isn't something that you can copy paste from covering only old people to everyone. For one, margins from Medicare patients are much lower and often negative for hospitals, and that money has to come from somewhere. Medicare doesn't cover a lot of drugs that people are already used to their private insurance covering like GLP1s for weight loss. Of course, a transition from point a to point B is possible, but there will inevitably be a lot of kinks and bugs to work out, which MFA proponents seem to be unaware of.
Lots of studies have shown that the US spends a much larger portion of our GDP on healthcare than other countries, there is plenty of money to solve this problem already allocated to healthcare. I am aware that Medicare does aggressively negotiate prices, and our current system is a complex mess of different parts of the system subsidizing other parts to keep hospitals somewhat solvent, but this is largely just to enable all of the useless insurance middlemen to take big chunks of the money for no good reason (and its not all yacht money, its also just bullshit jobs that accomplish nothing productive but are sufficiently complex to require expertise, training and pay decent wages in many cases).
And I do know that you mentioned a real material reason why this isn't pushed harder by either political party despite the nearly inevitable massive savings if we pull it off. Causing an upheaval in the job market by removing a bunch of unnecessary admin work has real short-term impacts that will be hard for any US political party to weather well. That being said, I do think there are very real paths to achieving this and rhetoric about needing to copy-paste big parts from other countries distracts from how achievable it is. 90% of the work is already there with Medicare, and expanding the list of covered drugs and having a price negotiation with hospitals to make Medicare a good customer rather than a burden in some cases is definitely possible with some political will. A public option if it had been included in the ACA would have likely moved us a lot closer to universal coverage, especially if the mandate was still enforced, and likely would have spurred some of these necessary discussions.
> rhetoric about needing to copy-paste big parts from other countries distracts from how achievable it is
When have you ever heard "rhetoric" that actually brings up the details of how universal healthcare would actually implemented in practice? If you have an idea at work and a coworker brings up a caveat that you missed, do you dismiss it as rhetoric? If you are to be worried about rhetoric, it should be about how the general public talks about policy like it's sports whereas corporations talk about policy like it's work.
It would fine if it were just internet comments. However, this article is talking about a paper from one of the most prestigious university in the world and yet it's devoid of meaningful analysis. It literally does the "copy-pasting" that I'm talking about.
> Hospital and clinical fees are paid at Medicare reimbursement rates, which are below the rates paid by commercial insurers and above those paid by Medicaid.
https://www.medrxiv.org/content/10.64898/2026.07.22.26358689...
Even if the headline claim is true (other people have already critiqued it), this would dramatically increase the federal deficit without massive tax increases - and as far as I know, none of the advocates of a M4A-style program have ever explained how they would pay for it.
Who's gonna tell the doctors and nurses that they get a 50% pay cut?
Cut their pay by 50% and get rid of malpractice lawsuits. Have some other system that doesn't incentivize lawsuits where doctors are still held accountable but I think that's a deal most doctors would take in a heartbeat.
You think they’re getting so much money from out current system that cutting out insurance companies would result in a 50% reduction in their pay? Have you ever looked up the size of the health insurance sector here?
That's literally the premise of the report. The savings comes from getting Medicare's current rate sheet for every patient in the entire market.
You're being dishonest if you claim otherwise. UK brain surgeons get paid less than a Walmart general manager in the United States, let alone a like for like comparison.
Do they need to get a 50% paycut? Dealing with insurance companies takes a ton of time and resources.
For the study, "which has not yet been peer reviewed"
Hard to believe, currently Medicare/Medicaid make up around 23% of the budget. If you opened that to all, there would have to be a huge tax increase to pay for it. I suppose if you are very poor then it would be good, but the middle class would be the ones having to foot the bill for this.
Cuba achieves similar life expectancy and infant mortality rates to the U.S. despite spending a fraction of the cost, focusing heavily on free community prevention.
Cuba has one of the highest doctor-to-population ratios in the world—roughly 6 to 8 physicians per 1,000 people: https://www.reddit.com/r/dataisbeautiful/comments/r468au/oc_...
At this point I'm 90% convinced that any kind of a healthcare system will work as long as the politicans and everyone involved is not corrupt.
Alas...
The real question is then: since corruption seems to be everywhere, which system is the most resistant to it in terms of the price + quality for the end user.
And the real real question is: what can be done so that every country has a political class that has the same strict rules of law for corruption etc... as Singapore does?
"You can have state of art Healthcare, or you can have Universal healthcare, you can't have both." -- Malcolm Gladwell
The way that universal health coverage saves money is by rationing care. You do not save lives when you ration care.
That's a very weird framework and dichotomy you have there. Try untangling yourself out of it by considering some empirical facts, for example, hospitals acquired by private equity often have worse outcomes.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
https://pmc.ncbi.nlm.nih.gov/articles/PMC10751598/
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
https://hms.harvard.edu/news/deaths-rose-emergency-rooms-aft...
This is certainly true to an extent, but it ignores some big problems with fee for service. The biggest one is that incentives between patients and providers are not aligned, which means more than 10% of healthcare provided in the US is wasteful stuff the provider knows is unnecessary but prescribes anyway because it makes them money. There are real opportunities to save money without making outcomes worse, in fact, if we stop doing useless stuff that leaves more time to treat people with real issues.
What's the point of "state of the art healthcare" if it's only for rich people? If Jeff Bezos and I get the exact same health issue - say, some form of cancer, we're going to have radically different treatments and mostly likely outcomes. His will be "state of the art", mine will (hopefully) be good, but definitely not be like his.
Malcolm Gladwell is a massive charlatan and hack. Seeing tech bros use him to discuss healthcare policy (Malcom Gladwell is neither a health professional, public health expert, nor has he worked in the healthcare industry in any real capacity, nor has he ever discussed the plight of workers in the US once during his entire career) feels on point for out of touch our industry is.
That $1T that it might save is currently hitting lots of quarterly or annual reports as profits. With that much on the table I think the chances of seeing Universal Health Care here in the US are not great. The ones banking that money now will fight hard to keep it flowing into their pockets.
Real lives don't factor into their decisions, even if there are more than enough to fill a large city in this country - every year.
The UK is the counter example to this analysis. The NHS was a marvel in the early years, now however it is bogged down with so many layers of bureaucracy it is massively inefficient.
1) U.S. healthcare spending subsidizes the rest of the world, much like U.S. defense spending. New drugs wouldn't be developed at the same rate if it wasn't profitable to do so, and it's profitable largely because it's profitable in the U.S.. Some proportion of the high U.S. spending relative to other countries is this. It's pretty stark. In revenue terms, for new drugs 2018-2023: 67.1% of total sales in the USA alone, 15.8% in Europe, 3.9% in Japan, and 13.2% for the entire rest of the world ( https://www.efpia.eu/media/2rxdkn43/the-pharmaceutical-indus... )
2) I believe the U.S. is willing to go to greater lengths to save people. So they will spend obscene amounts of resources keeping a cancer patient alive for an additional six months, or saving a borderline case of a premature baby, etc.
It looks like this does not even include the current disincentive for insurers to treat chronic issues effectively early on. Since people switch insurers so often the odds you will be their “customer” in 5 or 10 years is low, so investing if your long term health won’t generate a return for them.
There is already a healthcare program run by the US government and it's called Veteran Affairs. Veterans can't even access the care they need resulting in almost twice the risk of suicide.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
Who said anything about outlawing private insurance?
The UK has a single payer healthcare system but folks may purchase (or obtain through work) private insurance.
The deep problem is that insurance is a highly profit driven business in the US which basically go against what a good insurance should look like.
Profit-based, dividend paying insurance should be banned. Only non-profit insurance should be permitted.
If you think the solution to the world's ills is to organize businesses as non-profits, you're delusional.
It will never not be funny that whenever universal health coverage comes up, Americans will act as if it's some impossible task that wouldn't solve any problems when the rest of world seems to have sorted it out just fine.
For the most part, those countries aren't as corrupt as the US.
I think the evidence is quite clear that universal health care reduces aggregate costs, but the public cost in aggregate is enormous.
1. This means large new taxes for everyone. For those on lower incomes, they might end up better off. For those on middle-upper+ incomes, they will unequivocally end up paying more.
2. The U.S. already has unbelievably high deficits and debt. This would make that worse without significant spending cuts elsewhere, and without very large new taxes. And before someone says "just tax the rich!", even if every billionaire in the U.S. had all their wealthy confiscated today, it would barely cover U.S. federal spending for *one year.* Then the party's over and the government collapses. "Just tax the rich" is an absurdly superficial position. European taxation is broad and deep. Everyone pays high tax - even those who do not earn much.
3. U.S. society is built on rugged individualism. Acceptance of immigrants under the premise that they will work hard and contribute. For this reason, U.S. success at integrating immigrants is better than anywhere else in the world, by a wide margin. Our issues re immigration in Europe are numerous and unbelievably contentious. Should the U.S. become a "welfare state," like European countries, it would no longer have a natural filter for immigrants. It would realise the type of immigration that we get in Europe, where for many groups, a majority refuse to work - for life. For this reason, it would require a MUCH tougher filter on immigrants - much more so than what the current administration is doing.
I do not see the U.S. materially reducing spending in other areas, including the military. I do not see general public support for large taxation increases across the board. I do not see public consensus on strict new immigration requirements and enforcement. For these reasons and more, I do not think public health care is a realistic prospect for the foreseeable future.
> universal health care reduces aggregate costs, but the public cost in aggregate is enormous. This means large new taxes for everyone.
If the US could spend healthcare dollars as efficiently as the UK, the US could pay for a single payer healthcare system covering every resident using only existing Medicare + Medicaid spending.
Is the US willing to reduce the price of healthcare? I observe a large appetite in congress to increase the visibility into US healthcare spend. I observe rather more limited effort spent to use this data to reduce the aggregate costs (e.g. negotiating drug prices [1]).
The math:
The US spends $2 Trillion dollars on Medicare + Medicaid a year [2][3]. $2 Trillion dollars / a population of 342.7 million [4] = ~$5800 per resident per year.
NHS (UK's universal healthcare system) costs ~£3,500 or ~$4800 per person per year [5].
[1] https://www.kff.org/medicare/key-facts-about-medicare-drug-p...
[2] https://www.cms.gov/data-research/statistics-trends-and-repo...
[3] https://www.kff.org/medicaid/medicaid-financing-the-basics/#...
[4] https://www.census.gov/popclock/
[5] https://www.bbc.com/news/articles/cwy7zvp5xrqo
I think you did not understand my comment, and that is perhaps my fault. To be explicit:
1. Universal health care reduces the total cost of healthcare across the nation. If the bill is $x now, the total cost would be $x-0.2 (or whatever).
2. This is EXTREMELY expensive FOR THE GOVERNMENT. They would need to either raise taxes considerably (broadly and deeply, as in Europe), or deficit spend.
For some people, the increased taxes would be offset by not having to buy health insurance. For some people, they would be spending more.
Potentially I am misunderstanding you.
My point is that we already pay $2 Trillion dollars for existing single payer healthcare (Medicare/Medicaid). I think it's fair to call that extremely expensive.
You say that universal single payer healthcare would have a huge price tag, my point is that we are already paying a huge price tag ($2 Trillion) but just not getting universal single payer healthcare as a result of this spending.
My point is that we could have universal single payer healthcare without raising taxes if it cost less than or equal to ~$5800 per person per year.
UK spends ~$4800 per person per year on their single payer healthcare.
Note: This just considers existing taxes spent on existing single payer healthcare. This doesn't consider other healthcare spending. The majority of the US get's their insurance through employment-based plans. Some pretty reasonable percentage buy their plans directly through the marketplace. And some pretty reasonable percentage don't have health insurance.
Brought to you by the guys who said Obamacare would lower premiums.
This would be much easier to sell if everyone stopped referring to it in the context of “healthcare” and instead used “universal health insurance” or “universal health insurance rates”.
The number of politicians that conflate healthcare and health insurance (notwithstanding the actual convergence of the two through payers’ purchasing provider entities) is mind boggling.
Striking the word “healthcare” from the conversation would make this much more digestible for folks afraid of the “socialism boogeyman”…
Brilliant. I also like "health-related bankruptcy protection"
Won’t happen the big players make too much money the way things are, and that is more important than people’s lives or for our country
Baumol's cost disease is the simple answer. until healthcare stops improving outcomes and or we reduce labor cost will go up
The thing studies like this never take into account is the degree to which all of these administrative jobs are corporate welfare. The inefficiency means a lot of people get a regular paycheck for work that is ultimately nonproductive. If you kill off those jobs by eliminating waste there will be millions of people looking for a new job.
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
Administration is ~25% of provider expense; billing and insurance is ~8.5% of provider expense. Administration is:
* Billing and claims management
* Compliance
* Customer service
* Operations
* IT
You can drive billing all the way down to zero and you're still going to be spending a lot of money on administration just like any large enterprise does. Those jobs aren't really "corporate welfare" and they exist in every system, although the single-payer systems get a bit of a break on them because they can and do trade responsiveness off for customer service (at likely little cost to outcomes, to be fair!)
That ~25% is compounded at every step of the way. 25% of your doctor's office. 25% of the insurance company. Plus don't forget the brokers, which are almost all overhead effectively. 25% of pharmacy. 25% of drug companies.
The people providing actual healthcare end up being a minority in the system.
No, insurance spending is broken out separately in the NHE.
https://nationalhealthspending.org/
Very interesting reading the comments here from USAnians. You are really hurting, and your system is objectively very bad.
Inappropriate application of capitalism. A market failure of epic proportions.
Do something about it! You live in a democracy, act like it!!
What about all the new unemployed lawyers and bureaucrats that feed on the broken American system?
It boggles the mind when you hear people defend the US healthcare system in terms of efficiency (OK, granted, maybe people have long stopped doing that).
It has to be one of the most bureaucratic and paperwork overloaded systems of all time. It's hard to imagine somebody who've had an actual health crisis would think otherwise, unless they can afford people who can shield them from the BS.
Ok but it doesn't save the donor class anything, so it won't happen.
For the most part, any time one person in the economy saves money, another person loses money. So, what about all the insurance company, private equity, and hospital system profits that would be eroded by a system that better serves individual humans?
/sarc
If this were at all true, now read it like the big wig or law maker holding the on/off lever who’s eyes see “Universal Health Coversge Could reduce $1T in available/taxable income”.
Did you notice the gorilla walk by? They sure didn’t.
Should The Government Stop Dumping Money Into A Giant Hole? - https://m.youtube.com/watch?v=JnX-D4kkPOQ
This is hilarious.
What UHC proponents never honestly admit is that these headline figures require incredibly optimistic assumptions and also much more rationing of care than our current model. We spend a lot on healthcare because we consume a lot of services. To save money, you have to buy fewer services. Yes, you can squeeze providers a little bit ("Medicare-level payments to providers" -- which they will absolutely hate, by the way), and you get another little bit by disposing of insurance provider profit margins ("reduced administrative overhead"). But the vast majority is coming from rationing, which people hate. And it would also cost massively increased taxes on the middle class, which voters also hate.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
they're tryna convince the populace who don't like to read with useless studies.
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
How will the capitalists survive then, they would go extinct as a species. Healthcare and defense are the two prominent sectors where the options available are kept artificially scarce / high in demand (wars), thereby reaping money unfairly from both taxpayers and individuals.
Pretty obvious...
This is why almost every wealthy country and most middle income countries and many poor countries have universal health Canada,UK, Australia, almost every European country, Cuba, Costa Rica, Kyrgyzstan, Sri Lanka, and Rwanda.
There are a few minor weird oligarch run kleptocratic exceptions like America, but in the global context they are irrelevant.
Universal health care by country: https://en.wikipedia.org/wiki/Universal_health_care_by_count...
This doesnt need yet another study. Instead of narrating the problem we should figure out whats actually stopping it. And people saying the ACA was universal health coverage or even an attempt at it should stop intentionally derailing this discussion.
Democracy is the biggest obstacle to universal healthcare in the US.
A lot of people do not want it, and you've thus far failed to make them want it.
Cool system.
American living in Berlin: insane to me that in the US if I would rather stick it out in an abusive or otherwise terrible job just to keep my benefits.
Taxes here are high. They pay for a lot of things. Is it the best of the best? No. There’s private insurance for that. But does it work? Yup. And it’s just another thing we don’t think or care about while we take all of August off. ;-)
let's imagine an impossible country where somehow Democrats pull this off in 2029 and the 2030s start with actual healthcare for all and not just "insurance"
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
"You millennials and your obsession with public healthcare. Back in my day we just died."
How on earth have administrative costs been soaring when there have been so many healthtech startups propped up in the past 10 years to bring down the cost of administration?
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
_could_
I've become so cynical that I think even if universal health coverage would be passed, since it almost certainly would be run by the executive branch, it would become just another political football to be fucked with every 4 to 8 years.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
I'm honestly curious how we square this with the only experimental evidence we have on cost-sharing in the US, like the Oregon Medicaid Study and the RAND study which showed no impact on mortality or really any physical health outcomes at all.
UHC proponents are just excessively optimistic about impact on health outcomes.
No, they are excessively optimistic about the financial outcomes. Healthcare should not bankrupt people.
This study appears to just take observational mortality averages between insured and uninsured and then assume that UHC would close the gap. Patently absurd imo, but I guess I'm not a healthcare economist.
They're excessively optimistic (as in, unrealistic) about both. (Healthcare mostly doesn't bankrupt people -- the vast majority are insured, and the rest pay ~nothing.)
I don't want it. I don't want to pay for it either. anything the fed government does is utter crap.
That's basically my concern, too. If we had a "Medicare for all" system, would it end up like Social Security, a system that started out with great intentions, but has since ballooned into an expensive, bureaucratic nightmare?
precisely.
.....yeah
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But how can we support israel? /s
The Jews are obviously to blame for the lack of universal health care.
The USA spends the equivalent of about $10 per citizen per year on Israel. Medicaid spends about $10,000 per recipient per year. But antisemite math has its own rules.
Literally everything in the federal budget costs $10 or 10 cents per us citizen. Do you know calculus, or arithmetic? By this reasoning we cannot cancel anything.
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Bro nothing is free, if the goverment pays for all of us, then it is our own money being used for that, we have the most liberal tax code in the world, we spend the most in healthcare.
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The government provides your police force and fire department. Why not?
Look no further than the UK, with 24 month waiting lists, the shunning of experimental treatments (many high profile kill decision cases) and skyrocketing costs.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
The US, we ration too. We just do it in the most cruel way possible where the working poor doesn't get access to health care, because they can't afford it, and just lives with preventable and easily treated conditions until they die sooner and more miserably.
Why not take a look at Medicare in the US instead? The US healthcare system has way more money than the UK, so comparing to UK is not meaningful.
I'm British. You're incorrect.
On which point? Brain surgeon pay? [1] [2] Waitlisting? [3] [4]
There's literally over 7,000,000 Britons on a NHS waiting list right now.
Please clarify what I'm incorrect about.
[1] https://uk.indeed.com/career/neurosurgeon/salaries
[2] https://finance.yahoo.com/news/buc-ee-offering-275k-salaries...
[3] https://www.bma.org.uk/advice-and-support/nhs-delivery-and-w...
[4] https://old.reddit.com/r/ADHD/comments/1nz7dt2/if_your_in_th...
Right? What, are you all commies?
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You should probably be aware that Cremieux (Jordan Lasker) is a race scientist prior to repeating his claims. https://en.wikipedia.org/wiki/Jordan_Lasker
I did not know who that person was, but you seem to be saying none of his opinions could possibly be right?
I'm saying don't cite a neo-nazi if you want to be taken seriously, not that complicated
I think people should not use the word nazi so liberally if they want to be taken seriously; it's not that complicated either ...
> The first issue with this is that the gap between the uninsured and insured is not necessarily due to the lack of insurance. It could be due to factors associated with not having insurance, like living on the streets, being schizophrenic, being poor, and so on.
Made up perspective to justify his angle.
Not having healthcare access for a lot of people is 100% a policy choice. Waved off here by a list that really says why we should have universal healthcare; some people are mental and not aware they could have access without the stupid policy decision.
Just strings together sentences to ultimately make a reductive point about arithmetic and their own literacy.
Despite Yale's issues they're still a better source than random blogger with high school math literacy.
The point he is making is valid: these groups are not randomly selected and are not representative of one another. Hence, it is not that simple to extrapolate from one to the other.
Would free healthcare reduce deaths in uranium miners that are smokers? Probably some, but would it bring that to the same levels as non-smoking, non miners? Unlikely so. Hence it would be silly to pretend all the cancer deaths are due to lack of health care.
The smoking uranium miner example has a surprisingly realistic story, comes from real data; the dangers of radon in the basement were deduced from comparing cancer rates in smoking uranium miners with high radon in their basements, then they removed what they thought was the smoking and uranium contribution, then fitted to the general population.
It's valid within the argument structure but not to universal healthcare
My kid made a valid point that there was indeed a green MnM on the sidewalk next to the park.
Still didn't let them eat it.
It's a valid point in its own little bubble but other valid points mean more.
Stats are everywhere but stats that matter are rare.
> random blogger with high school math literacy
He's actually a well-known and widely promoted political activist on X. His niche is using technocratic language and a whiff of 'analysis' to advance MAGA policies.
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Quite weird to see such a study from Yale, Yale is the heart of the capitalistic western empire, and it exists to serve the oligarchy and the capitalists. So then what gives ? perhaps the person working on this report is still an innocent person and has not yet seen the reality of his situation :)
The last time we got similar results in the data (but not the text) was a Koch-backed study that a bunch of economists reviewed and went “so you’re saying we’d save 2 Trillion over 10 years relative the alternative?”
https://pnhp.org/news/the-mercatus-analysis-of-bernie-sander...
or that trillion in health care isnt going into the oligarchs pockets, and could be..
A perfect Communist economy could save even more money, eliminate most ads, duplication, and poverty. But they never figured out how to make it work.
I'm not opposed to a peaceful transition, but we'll need a big surplus and more idealism to make it happen.
"They" never intended for it to work and never tried.
Do away with the finance ledger.
Accurately measure where the people are.
Ensure enough resources flow there.
Special interests with a social moat to protect can pound sand or be hung from ports as a warning.
I would like to be free from hallucinated social belief Jeff Bezos is meaningful to humanity when mfer just gonna die and be forgotten like everyone else.
Ah yes, the claim free money would save lives!
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC8729831/
Yeah, but how much would it cost in profits?
That's the only thing that matters in Amerika.
Who Will Pay for Democratic Socialism’s $200 Trillion Cost?
https://www.cato.org/blog/who-will-pay-democratic-socialisms...
ah, the Koch brother's PR firm the CATO org. Brilliant spin org.
Shooting the messenger usually works.
You are the messenger. CATO is the biased, lying, and manipulative message creator.
How many employees trapped in a job for health benefits for their families would universal health coverage free up?
Quantify the impact on productivity
What makes you think they would no longer work? They still need money to live. They would either get another job or start their own business.
By "free up", I mean "allow to job hop until they find a comfortable healthy fit" like hermit crabs.
With their health expenditure potential liabilities reduced by universal health coverage, people would be more able to take good risks in developing small businesses for example.
Universal health coverage will asymptotically reach infinity costs (same as private health insurance).
This is the harsh reality. No system (private or public) can save all of the lives.
We are debating who will make the decision of who gets to get a chance to live longer.
impose universal health coverage & the jockeying will commence to see who is in charge of it. medical & diet fundamentalists will rejoice at the opportunity to seize control & force everyone to take certain drugs, eat or not eat certain foods or types of foods, exercise a particular way, surrender their organs at a particular age, or whatever else their hearts desire for everyone else. there have been so many rabbit trails taken, so much malfeasance, so much misinterpreting of data, etc., which has been uncovered just in the last decade or two to give anyone the ability to harm or control entire populations in this way. the increase in suffering will be great, & the long-term effects devastating.
Standard single payer insurance is not identical to 'seize total control of ever living body in America'. I shouldn't have to point this out.
The attempts by the current republican admin to seize control of certain 'illegal' bodies has caused so so much harm, I'd agree there. But even operating at 10x the nominal level of the past and ICE still haven't been able to exert temporary control over a single American city that resisted them, much less everyone in America.
You should figure out specifically what you are scared of and deal with that, rather than catastrophizing about things that cannot physically happen on any near timeframe.
Source on... any of that?
Fox News and 2010s Info Wars
It sounds like you have issues with people telling you what to do. Would you like a pamphlet on the virtues of Anarchy as a way of building community to survive in a terrifying world?
Because none of the things you said have ANYTHING to do with "universal healthcare" and everything to do with "bad actors worming their way into positions of authority to enrich themselves". Surly you can't believe that "let every induvial person figure it out themselves in an unbalanced capitalist system" is a better answer, right? This isn't just about "if too many people are in the system then MY healthcare quality goes down", right?
In what possible conceivable way is single-payer healthcare in any way related to any of that tripe? Seriously, what an atrocious post. You may begin by observing that countries in e.g. Europe with such systems are not totalitarian hellholes where "the gobmint" tells you how to eat with "devastating long-term effects".....
Universal healthcare works just fine in Europe without major issues like that. It's the American political system that is broken. Your de facto two-party political system lets idiots take total control way too easily, as we can see with current US administration.
My country has universal public healthcare, and nobody forces you, or even your children to get vaccinated, monitors what you eat, or any other form of control that you're worried of. Organ donations are voluntary too, you can opt-out easily. And if you think the system sucks, nothing prevents you from taking extra insurance and using whatever private healthcare provider you want.
WTF are you talking about dude - we average white collar/blue collar people are so desperate for a unified healthcare system in this country not tied to our (constantly unstable) jobs
We are so desperate that someone murdered a Healthcare CEO - ie resorting to violence
We are so desperate that many is (myself included travel to cheaper countries for dental and other healthcare)
Its a simple calculus but one that is obtuse to conservatives and richer people
I don't have a dog in this fight (I live in Japan), but I'm a bit disappointed to see the responses here refusing to engage with the assertion.
reply1: "The alternative is bad, and Trump is evil" reply2: "Uhhh, source for that? /reddit" reply2a: "I bet he subscribes to the wrong politics" reply3: "Americans are idiots" reply4: "I bet you have a personality disorder" reply5: "You're dumb but I'm not going to expound" reply6: "WTF dude" (proceeds to uphold a murderer as an example)
Can no one explain why the ideas the OP fears will not come to fruition? Can anyone explain the safeguards of the UHC system? Or do discussions about policy now all fall under the teamsport known as modern politics?
Is this what hackernews has become? It wasn't like this a decade ago.
I wonder how many people would be on board for a program to make Medicare available for free for households making over $100,000 annually with 1-3 children.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
That's a very funny way of looking at the world.
Many people feel that winners should be rewarded and losers should be punished.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
Ironic
Why do you limit it to people with children? Why do you assume that the children are beautiful and healthy?
> Medicare available for free for households making over $100,000 annually
Sure, why not try it? It's still 50% of America getting coverage.
After a few years maybe they'll realize that not having to think about health care insurance is a good thing actually (tm) and start supporting it for lower brackets of the population too.
First class citizens? Wow, that is both disgusting and sad. What do you do that you think is so important and irreplacable that sets you above the average person?
This is why it doesn't happen: politicians get bought.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Universal healthcare doesn’t happen in the US because a certain subset of the American population would rather have worse health outcomes than guarantee abortions, HIV prevention, and gender-affirming care.
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
There's also a racist element (I know that's a politically incorrect word here, but such things happen). People don't want to fund services to the lazy ______s - fill in one or more of many groups toward whom hate is promoted.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
Yes. Jonathan Metzl wrote a book about this: https://en.wikipedia.org/wiki/Dying_of_Whiteness
Another way of looking at is that some people are concerned about what happens to limited "free" healthcare resources when you simultaneously oppose any controls on immigration.
Can you name any politician or leader, of any signficance, who opposes "any controls on immigration"?
You can easily drop those from a universal healthcare system - look at the NHS and gender affirming care across the pond. So it can't only be that part - I think it's wanting the undeserving to not have healthcare.
It’s not that easy. You have to make it through the primaries to stand for election. Both parties are increasingly dominated by their outside wings. If you said “I’ll try to get universal healthcare done and I’ll build the coalition needed for it, even if it means accepting painful compromises like not covering gender affirming care” you won’t make it out of the democratic primaries. That’s why there’s so many common sense positions that have majority support yet never a majority in political bodies.
What I mean is that if the conservatives only objection to universal healthcare was these things, they could just leave them out. There's no requirement that a single payer system cover all procedures.
Ergo the reason they didn't support the ACA and won't do this is something other than it covering hormones and abortion.
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There are many reasons Jeffries might change positions; why do you say the reason was that he was bought? Is there evidence?
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
> why do you say the reason was that he was bought? Is there evidence?
Look at his health PAC contributions over time:
https://www.opensecrets.org/profiles/hakeem-jeffries/us_cong...
This could equally be explained by wanting to be perceived as more moderate/centrist. Which would make sense for someone in a leadership position.
> This could equally be explained by wanting to be perceived as more moderate/centrist.
I don't think anyone perceives a flip-flopper as anything except unprincipled. There's nothing "moderate" about corruption.
One of two major political parties, and the one that currently holds all 3 branches of federal government, has labelled it un-American and communist. And yet you point the finger at...a Democrat.
> the one that currently holds all 3 branches of federal government
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
> Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass?
I don't. However, if I were a betting man, I'd bet on the Democratic leadership to come around well before the Republicans. Not least because a significant, non-zero fraction of their politicians are already in favor of it (compared to the other side, which has close to zero).
Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen. So ultimately Republicans are the bottleneck.
> I'd bet on the Democratic leadership to come around well before the Republicans.
Jeffries was already around. He supported single payer but now rejects it, so he's moving backward.
> Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen.
Democrats had 60 during Obama's first term. They'll always find a rotating villain to oppose it, Joe Lieberman, Joe mansion, etc. Anyway, the filibuster can be eliminated. In 2013 Democrats eliminated the filibuster for most nominations, and in 2017 Republicans eliminated the filibuster for Supreme Court nominations.
> Democrats had 60 during Obama's first term. They'll always find a rotating villain to oppose it, Joe Lieberman, Joe mansion, etc.
So what do you propose? Is there a 3rd party that has a reasonable chance of doing it?
Maybe if you flip a few Republicans (to supporting UHC) it might go easier. It'll give their leadership something to think about at least.
> So what do you propose? Is there a 3rd party that has a reasonable chance of doing it?
No, I propose calling out Democratic leaders for corruption, removing corrupt leaders from their leadership positions, and running primary challenges against them.
As you said, Republican leaders are calling single payer "Communist". When the Democratic response is, "I no longer support single payer", they're essentially allowing Republicans to win the argument. That's political malpractice.
I would note that the Republican House Majority Leader Eric Cantor lost a primary challenge in 2012, yet as you noted, this hasn't stopped Republicans from taking control of the House and the entire government. "Vote blue no matter who" is not necessarily a winning strategy.
> removing corrupt leaders from their leadership positions, and running primary challenges against them
Godspeed.
> Godspeed.
Why even bother asking me what I propose then? What do you propose?
I can certainly understand pessimism, but if you're going to be a pessimist, asserting that there's nothing we can do, then at least be consistent in your pessimism. Don't pretend that you somehow have a better answer than I do. The only possible "plan" I've seen from you is "wait around for Republicans to support single payer", which IMO is vastly less feasible than challenging corrupt Democratic leaders, since the majority of Democratic voters already do support single payer, while the majority of Republican voters do not. And if the debate is one-sided, "Communist" vs. "I don't support single payer", then voters will never be persuaded to support it. Leaders need to lead, persuade, not just take a current poll. If you don't persuade, the other side certainly will.
I meant it sincerely. I wish you well.
> The only possible "plan" I've seen from you is "wait around for Republicans to support single payer"
That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged, nominally-independent voter hears that and assumes it means "don't vote D".
> I meant it sincerely. I wish you well.
I apologize if I assumed incorrectly.
> That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged voter hears that and assumes it means "don't vote D".
But how can Democrats possibly blame Republicans for not supporting single payer when the top Democratic leaders don't either? That's the dilemma. What's the "Do vote D" reason? Biden didn't support it. Schumer doesn't support it. Now Jeffries doesn't support it. And Harris flip-flopped too, supporting single payer in 2020 when she ran for President but as the 2024 nominee became a Biden parrot (which obviously did not turn out well). In 2016, Hillary Clinton sent her own daughter out on the campaign trail to fearmonger about Bernie's single payer plan. That's why I point the finger at Democratic leaders. You're correct that Democrats are the only hope for passing single payer, but the leadership of the party is actively hostile and working to prevent it from ever happening.
I'm not sure that the "disengaged" voter would even hear this debate, but in any case, voters seemed attracted to the "drain the swamp" concept, despite the irony that it was proposed by the swamp creature.
Come to a country with universal healthcare (England) and realise that if you work then you're paying 5x the market price for the worst healthcare imaginable. MRI scan - we don't know, one month wait, maybe two. Operation - are you going to die tomorrow with out it? No, ok then that could be years.
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
So the solution is get rid of private healthcare. I agree.
And we all sit on beanbags, sing kumbaya and write poems about our feelings.
I don't know why you thought this was a clever thing to say.
One of my favorite health care facts: there are more MRI machines in the state of Massachusetts than there are in the entire country of Canada.
I think this one might not be true anymore. Canada has 432 machines as of ~2023 (340 in 2015) and MA is on the order of ~300 (can't find exact figures). It's still a lot lower per capita (10.8 per million vs 42 per million).
So the new comparison is Canada and Illinois. I can remember that! :)
(Thanks for catching this! I had no idea.)
This is super weird, isn't it? Some of it is obviously overprescription on the US side, but also: Canada could just get more machines.
It's kinda weird, yeah! Not sure if Canada thinks the rest of the world overuses MRI machines in a cost x diagnostically inefficient way, or what, but I'm sure months-long waiting lists aren't optimal either.
I know that you tend to be balls deep in American Exceptionalism, but the truth is that reasonable countries with reasonable health care average 15-30 MRI machines per million inhabitants.
America is a wild outlier, and unless you have data to back that those machines are put to good use, I'd trust the rest of the world who decided the sweet spot is 15-30 mer million, not 60.
This statistic appears to have flown directly over your head. It is not an illustration of how awesome the United States is. The overprovision of MRIs in the US drives costs in a variety of ways; one of the most obvious is that routine imaging for things like back pain leads directly to things like spinal fusion surgeries, which don't work.
The gap between Canada and the United States is immense. Canada could add quite a large number of machines and not come even within the line of sight of where the US is.