When you first become eligible for Medicare you get a special 'Introduction to Medicare' appointment with your doctor. It takes an hour or so, includes extra tests, and discussion of different topics. People might not be 'waiting for Medicare' but instead may simply mention things in this more detailed appointment, or get extra tests, that they wouldn't normally.
In Brazil, a poor 3rd world country, we diagnose that on public healthcare without problems, at any age. I guess money is not the problem, just deciding how to allocate it.
For those who have insurance, yearly complete checkups are a thing for any adult, and the most basic insurances you get at work you would only pay the first $20 out of pocket for a doctor appointment and a few basic tests.
But if you don't have private insurance, you would still get appointments and tests if you have any symptoms, and the doctors are probably going to order a few tests if you didn't do a checkup for more than a year.
BTW: in my 15 years as diabetic there, I think I only bought insulin out of pocket 2 or 3 times - because I traveled and either forgot one (it's 2 insulins) or it went bad. Also, most of the time didn't pay for the test strips either. All paid by government. Saves them A LOT of money if diabetics don't get more sick and are able to work. In the times I had to buy, a pen cost like, $10 for the cheap, $30 for the expensive one?
Aren't you guys second world? With that darn acronym Bric? Not to be pedantic but approaching $2k per capita per month is a materially different life and culture than perhaps other comparable cultures at sub $1,000 per person per month
The late Hans Rosling had a good update to the old conceptions of 1st, 2nd, and 3rd World. His take was to classify based on income levels on a log scale (well, 'log-ish', anyway). Hence the classifications of Level 1 (<$2/day), Level 2 (<$8/day), Level 3 (<$32/day), and Level 4 (>$32/day). This is my preferred way of mentally chunking the world and her people. Mostly because a lot of people are moving on up!
If you've not played around with the stats on gapminder before, go grad a cup of coffee and have some fun! The visuals are good and the interface is one where 4-D data is well presented. In messing around with it, you can see that the world is very much on an upward trajectory, but also has a long way to go.
> free healthcare and preventative screening but not everyone takes advantage of it.
Sometimes these things are explained by looking at them from the other side. People aren’t taking advantage because the system wasn’t geared towards them or excludes them, or did in the past.
I have no idea what it’s like in Canada but the New Zealand healthcare system has some dark history and a history of institutional biases that are still a hinderance today.
Despite being identified a long time ago, large gaps in healthcare exist here between various population groups.
https://www.health.govt.nz/system/files/documents/publicatio...
That is definitely true, but don't underestimate the number of patients who aren't all that interested or motivated to do what their doctor tells them to do. I worked in healthcare and even for very serious diseases, patient adherence to say taking their medicine regularly, is pretty atrocious (even when it's free).
Some of the things that have happened here are atrocious.
It a while back now, but involuntary enrolment in a cervical cancer study occurred, where some patients were left to develop cancers to see if invasive cancer did actually occur.
More relevant though, and ongoing are the regular stories and findings that New Zealand is doing poorly with Maori health, with cancers found later and worse outcomes when treated. This persists after 20+ years of effort that was supposed to address it. It’s really bad as the differences in outcome are huge.
I think most people wouldn't "normally" get a checkup like this because it's extremely expensive to not just go to the doctor, but also deal with any issues that may be diagnosed.
FYI: Thanks to the Affordable Care Act, many annual wellness checkups are covered without copay or coinsurance for anyone with insurance. Anyone concerned should check into these benefits.
Obviously, those without any form of health insurance still fall through the cracks.
Many providers will code those appointments differently if they depart from "preventative care".
So like if you mention that your knee has been hurting, they will diagnose that and charge based on the diagnosis rather than the preventative care appointment.
There are a thousand ways for unscrupulous providers to turn what you thought was a wellness checkup into whatever they want.
I'm new to this, but on my first attempt at a "wellness checkup" the practice gave me a form to sign when I arrived explaining why they would be billing me: it wasn't really a "wellness checkup" because I might ask the doctor a question.
My point was that it’s not the checkup that costs a lot, it’s the treatment of what’s discovered that keeps people from wanting to get diagnosed in the first place.
My wife (a senior consultant, and director of medicine at a major Australian hospital) took her sabbatical at Stanford Medicine in part because of the elevated level of stage IV cancer presentation in the US.
Key quote: "these are cases we hardly ever get to see at home".
The financial disincentive to seek care is strong.
To restate this for US folks who aren’t familiar with cancer -
The reason they rarely get to see stage 4 cancer in Australia is because their health care system would rather treat it when it’s at stage 1, and patients are able to seek that treatment without fear of bankruptcy; but in the US, public health care isn’t generally available until you’re 65, leading to a huge spike in “I couldn’t afford to see a doctor sooner” stage 4 cancers.
EDIT: Please do review the replies below, as they offer legitimate questions/doubts about my comment.
As a cancer survivor myself, the US loves to tell you "early detection is the key to success!" but then loves to not test people. I had to go through 6+ months of "please test me" before they finally agreed to. One you get to the oncologist, it becomes great. To quote mine when I asked if it was true Thyroid cancer was the "easy cancer", she said, "people say that, but it isn't true. In your case, yours was going places". To translate, it was headed into my brain. Only because I insisted on testing was it caught early.
I am jaded enough to wonder if it is because the medical industrial complex makes more money off late stage cancers.
My SO has a condition that is a bit hard to pin down. Getting MDs to actually run tests took years of fights. I remember one particular phone call where my SO, myself, the insurance company rep, and the MD were on a 4-way call together. The MD was refusing to run a specific test, as it was not 'needed'. Eventually the insurance person became incredulous on our behalf (a near miracle in itself) and stated that the particular machine that does the test routinely, as part of the standard panel of tests (like, it'll always spit out the pH, salinity, blood-type, etc). As in, the MD knew the results of the test the whole time and refused to tell my SO.
The US system is beyond maddening!
I'll say it until the cows come home, the US 'system' is broken, has been for decades, and will remain so for the future.
Where in your case does doctor intransigence come from, when even insurance companies voice reason? What part of the system incentivizes withholding test results to what benefit? What law?
It’s a good reason to leave and immigrate elsewhere, even if one has to pay US taxes and gets paid less income. You cannot put a price on your health.
I naturalized as a citizen elsewhere over US healthcare because I know it is only going to get worse long term. With 2 rare neurological diseases affecting my peripheral nervous system, plus type 1 diabetes (autoimmune and insulin-dependent), I want to stay alive long term, and so that was the best possible choice I could make.
I am extremely well versed in immigration, acquiring citizenships, healthcare systems, and healthcare delivery and logistics, and so if anyone wants help or advice, feel free to email me (see my profile).
What's the best combination of close to the US, high living standards, good healthcare, and feasible to immigrate to as an American with a pretty normal professional career?
If you want a decent public answer, then I need to know which continents are off limits to be able to help you. You are being way too vague here. Also, a lot of the help I can give is only useful when discussed privately. I obviously do not want anything to do with confidential information, and I do not need that to help people. It's just that posting certain details about yourself online is not appropriate via public websites. That is why I give my email (see profile).
Typically getting citizenship in /any/ European Union + European Free Trade Association country (minus Liechtenstein--has an immigration quota) is the best deal for an American.
The reason why? Becoming a citizen of one of these countries confers you EU or EFTA citizenship (let's just call it EU citizenship). Once you become an EU citizen, you have the right to live/work/retire in about 30 different countries. You are also always seen as "The American" with your American educational credentials and American work experience.
So, if you can just spend like 5-10 years in one of those countries (sometimes a less desirable one), get the citizenship, you can then move to somewhere more desired that is much harder to obtain citizenship in--permanently.
Usually the place to go for Americans is Ireland, where you can get citizenship in 5 years. Ireland also permits dual citizenship. Not only can you live/work/retire anywhere in the EU+EFTA: because of ties to the UK, having Irish citizenship gives you rights to live/work/retire in the UK.
Also, pay attention to who is top on this list (5 of the top 10 are in the EU + EFTA):
This means that they do not have to get their employer to do a skilled work test, which means they would otherwise have to prove that they are "not taking away a job from an EU citizen", which is a very high standard to meet.
The problem with Australia, New Zealand, and Canada, is that they have medical inadmissibility clauses in their immigration laws. This means that if you or anyone in your family is expected to (or do) cost more than $19,500 CAD/year, $8,000 AUD/year, or $7,500 NZD/year in medical or social services, or both, as an individual: you and your family are medically inadmissible to those countries and will be denied entry. If you or a family member goes over that threshold at any point, your entire family will be forced to go home and leave, even if working full-time and otherwise fully contributing and integrating into society. I would not be surprised if the UK does something like this post-Brexit.
This statistic has been corroborated by other studies (search: "third leading cause of death medical errors US"). You cannot evade statistics like that by going to the "best hospitals", or by "having good insurance", or being "able to pay for it".
I nearly died at age 22 from multiple medical errors over the same hospitalization. I am in my early 30s now. It still haunts me. I nearly died from severe diabetic ketoacidosis (blood pH got down to 7.03) from the hospital messing up insulin dosages (I have type 1 diabetes), and then I had to get a central line in my neck for treatment because I was so dehydrated. I got sepsis from the central line placement, which is never supposed to happen. I was not even hospitalized initially for any of the above mentioned reasons!
Then there are things like this: Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer (42% of newly diagnosed cancer patients exhaust their life assets, with the average losses being $92,098)
Then if you have a rare disease, which 7-8% of the general population collectively has, you often have to rely on orphan drugs (like me). There are 8,000 or so rare diseases. I actually have 2 rare diseases, and one of them is so rare that it will not be cured without personalized medicine.
One of the things which made me give up hope in the US was stuff like this, where very rare diseases become treatable, but the yearly cost of the drug (under contract via insurance) is ~$2 million/year, and it has to be taken for life. This is a new trend, and it makes me distraught.
Currently, the country I am a citizen of (besides the US), is about to have the same lifespan for females as the US (which I am female). The country went through a nasty war with the breakup of Yugoslavia. I am proud of my country, I mean Croatia. I also have the EU to fall back on. With the US, there is very little that can be done to protect me, from a work and insurance perspective.
I guess this entire thread is a dumping ground for other grievances, because nobody's able to explain how the GP comment's urge to vote connects with their experience, despite my asking.
We do not know explicitly how, but we have shared a mutual experience trying to get things through the US healthcare system, one way or another.
Things like prior authorization (getting a bureaucrat to give you permission to take this medication), prescription formularies (exclusion lists--you cannot take this medication under any circumstance), and step therapy (you must take a less effective medicine--and fail--before trying a more expensive and more effective medication. This occurs even with serious conditions like cancer and multiple sclerosis), quite literally kill.
I know an American in Japan who is on 3 biologics there. In the US, all 3 would require prior authorization, and 2 of them would be denied, because you can only get authorization to get 1 at a time. He could fight for coverage, via ERISA, through his employer, in court, but he would lose his colon before he would win. Then, when he loses his colon, he cannot sue for damages because of ERISA.
Dude, conversations break down on forums all the time. I use a screenreader and braille to read posts. I read things linearly because of this. It's not like I do not notice a coherent breakdown of conversation as the posts go further down the webpage.
Honestly, none. My mother had been diagnosed with kidney cancer, and in my stress I had become a "cybercondriac", freaking out about all kinds of things. Randomly, I became worried about my throat and happened to be feeling it when I swallowed and noticed a lump. "Just a thyroid nodule" my doc and then my endocrinologist and then my surgeon said. It wasn't.
The “yearly medical checkup” at your primary care doctor (GP doctor) is largely an American healthcare phenomenon.
People around the world, who live in highly industrialized countries with guaranteed-issue health insurance coverage (whether it be national/public/private health insurance) go to their doctors at a rate much higher than Americans. We are generally talking about a multiplicative factor on average when comparing the American population to another country’s entire population.
There is a direct relationship between seeing a doctor at a minimum X interval regularly (while in excellent, good, or fair health) versus costs to the /American health insurer/ (or employer paying for the insurance if they are self-insured).
That is why you see ads on TV saying “make sure to schedule your annual checkup with your primary care doctor, brought to you by Aetna!”
You are generally supposed to go to your primary care doctor (general practitioner) every year, at minimum, as an adult.
Infants go to see a pediatrician at much shorter shorter intervals, which is also due in part to vaccines and the need to check for developmental issues. Young children go in for checkups more frequently than adults to spot developmental issues (parents need to know developmental milestones backwards and forwards--and also log when they occur) along with vaccines. School-aged children generally go in yearly to the pediatrician, where checks on development occur, with the exception for certain vaccines like the HPV vaccine.
No matter what, the first 5 years of life determine a lot in life when it comes to the future, so it is crucial that developmental milestones are being met. If not, these problems can often be resolved with therapy, of various sorts, and children often catch up without issue. It is important that developmental milestones occur at appropriate times at older ages, too. But, there are basic crucial things that must be done for young children like nurturing your child, socializing your child, getting an early start on education, getting top-notch healthcare, etc. that keep the child healthy (also things like personality disorders are often caused by parents not properly socializing their children at a very young age). Investing in the first 5 years of life, as much as possible, has the most potential for a family (also a society) when it comes to their children and their life outcomes. So, it can be argued that parents should have substantial paternity leave so that the human potential of society is fully realized in the future (I am not a parent myself, and I cannot have kids, due to health problems).
I had a primary care physician that was terrible at diagnosis, but knew his limitations. So he said it was nothing to be worried about, but referred me to an endocrinologist just in case. The endo was the bad one, and I was stuck with her for 6 months until she admitted it might be something weird. Then a surgeon that was going to take out the "perfectly typical thyroid nodule". The surgeon performed a "frozen section" during surgery, and saw it was cancer and had gotten into 9 lymph nodes. Then the oncologist got involved - she was awesome.
Weird side notes. My primary care physician died several years later randomly driving off the expressway into a bridge support pillar. My surgeon was someone I had worked with to develop a surgical simulator. My second oncologist was an asian man with a weird accent. Took several minutes for my brain to register the accent - because he was australian. Life is ... odd.
> My second oncologist was an asian man with a weird accent. Took several minutes for my brain to register the accent - because he was australian.
I had a similar experience: Back when I was swimming laps, another swimmer was an Asian-Australian physician, and I initially had a hard time understanding his Ozzie accent — I surmise that here in Texas I was unconsciously expecting something different from someone with his facial features, so my brain had to parse through the "disparity." (I soon got used to it, of course.)
That is an odd mix of characters! Sorry you got delayed for a while with the endocrinologist who didn't know what was up. Like I said, glad that the doctors as a total cohort got you here.
36 when the process began. 37 when I had my surgery and radioactive iodine treatment (I was given a pill in a lead canister, then had a Geiger counter pointed at me to make sure I was radioactive!).
That might not be the exact mechanism, but the issue of medical bankruptcy in the US is very real. I have seen figures which suggest it accounts for up to 60% of all bankruptcies in the US.
For context, before we got public health system in australia, the no.1 cause of bankruptcy was medical. Now medical bankruptcy is almost non existent.
Out of curiosity, does "medical bankruptcy" include "I got sick and lost my job, even though I had no medical bills" bankruptcy?
Americans famously don't have $400 for emergencies. I don't know if other countries do better, or if there are national plans to help them out in the case of illness, regardless of the costs directly related to the treatment.
>does "medical bankruptcy" include ... I had no medical bills" bankruptcy?
Well, no. But clearly bankruptcies usually include multiple financial stresses. More likely, "i got sick, i had medical bills, i lost my job, my car broke down" kind of thing.
Worth noting the (up to) 60% figure i noted was from a harvard study during the GFC. The more conservative figures have tended towards 20-30% for medical bills being the primary cause of bankruptcy. Even then it seems to still be one of the more common (avoidable) causes of bankruptcy.
I'm not sure where you got that Australian bankruptcy fact but Australia has had universal healthcare since 1975 (and maybe before not sure of the scheme before)
I got it from a talk by a professor of public health, Jim Gillespie. So sorry, no links. Take it as you will.
You are right, it was a long time ago. But the 1975 system was brought in the by the Whitlam government was only universal in that it brought in a single payer system, but not free and not unrestricted. (Before that we had a hodge-podge not unlike the US before the ACA.) After the coup against Whitlam, the subsequent government further restricted or watered that system down, until Hawke brought in a universal healthcare system in 1984, medicare.
Still, with each period of right wing government in australia, we still seem to get a slow death by a hundred cuts to the medicare system (medicare levy, indexation freezes, closing of bulkbilling clinics etc etc etc).
It likely depends on your risk profile and age. E.g., if there is family history for breast cancer, yearly or once a couple of years mammograms. For prostate cancer, PSA levels yearly beyond a certain age and so on. The other part is just watching out for any changes/lumps and getting to a doctor before they get out of hand rather than hoping they solve themselves. The longer you wait, the worse outcomes are though for some really slow growing cancers it may be okay to leave them in because the interventions can have higher risks than the cancers themselves.
Colon cancer will be blood tests and recurring colonoscopies. Standard offering fro everyone above, I think, 50 or 55 in germany. Earlier, if there is family history. In that case, you can start as early as 10 years before the age the close relaive was diagnosed. Which means my children will have their first tests aged 16. Pretty cool, because polyps are easy to remove, ideally before they become cancerous.
> The reason they rarely get to see stage 4 cancer in Australia is because their health care system would rather treat it when it’s at stage 1, and patients are able to seek that treatment without fear of bankruptcy; but in the US, public health care isn’t generally available until you’re 65, leading to a huge spike in “I couldn’t afford to see a doctor sooner” stage 4 cancers.
That explanation fits what people probably expect, but it's not borne out by the data. The US actually has a higher 5-year survival rate for most common treatable cancers than Australia (e.g. breast cancer, colorectal cancer, prostate cancer).
The very study referenced above undermines the claim it is supposed to support.
It does not assess the distribution of presentations by stage, it notes a 14% gap of US population coverage (i.e. people entirely unaccounted for in the survival statistics), and if you refer to tables 6 & 7 it's clear that the US overall has slightly worse net 5-year survival rates than Australia for some cancers, and slightly better for some.
In practice, the standard of care available in both countries is very high. It merely remains to present for treatment in time, or whether the system sees you at all.
I must add that focusing on death promotes the repugnant idea that mortality is the only cancer outcome worth assessing. It is not. Taking a moment to considers humans as people, not a pile of potential corpses, will I hope trigger consideration of the quality-of-life consequences of late presentation: people suffering unnecessarily for considerable time, where the incentive for them to suffer instead of seeking treatment is socioeconomic.
Moreover, irrespective of eventual outcome, such cases are more time and resource-intensive, which (along with rent-seeking organisational cliques) is a contributory factor to the fiscal inefficiency of the US health system.
The 14% gap in US population coverage is from Illinois, Nevada, Arizona, North and South Dakota, Maryland, and Kansas not providing data to this registry. Canada is only at 76.5% of their population included. If you're going with the premise that people in the US present with higher stage cancers like other posters in this thread, then it paints US cancer care in an even better light that they are able to have comparable 5 year survival despite their average cancer presenting later and having a worse prognosis.
I have trouble seeing the reason for your argument about mortality. This is one paper that looks at 5 year survival across many countries. The authors may have chosen this outcome measure because it is the easiest and most objective outcome measure we have. Other papers can look at disability adjusted life years or quality adjusted life years. Those measures just were not used in this paper.
Quite so. My entire point is an anecdote relating one doctor's observations re. proportion of late presentations and their availability for study, and attaches that to a comment on US socioeconomic incentives.
Trolling in this thread has attempted twisting that to be a statement about outcomes of treatment, including offering up a paper that, as you note, has essentially nothing to say about the histogram of stage-at-diagnosis. One of these even told me (the OP) to "read the OP", then misquoted my own words to me.
I decline to be gaslit by their intentional misrepresentations, straw man restatements, badgering and sealioning; sadly, of course, that just makes the trolls angrier.
From the abstract the US has 0.7% higher survival rate than Australia. Which I wouldn’t be surprised turns out to be within the margin of error.
Regardless, in Australia fewer will reach that cohort because preventive measures through universal health care are in place. That means widely available cancer screenings will catch malignant tissues before they turn cancerous.
Additionally those screenings will be lower cost than the US model and the patients will have a better quality of life.
It’s hard to go through the actual study on my phone to find the appropriate context for that statistic but keep in mind cancer is a disease that will cause a drug to get a standing ovation at a presentation for increasing life expectancy 2 months. In that context, seemingly small improvements matter
That reminds me. A loved one died of cancer. All involved would have preferred that they died in 6 months instead of 2.5 years. Because the final 2 years of their life was filled with painful treatment that left everyone involved stressed, anxious, and saw a loved one slowly decline.
Optimizing for those extra 2 months is not a goal we should be striving for.
There have been some really interesting articles around this on here in the past, particularly around medical doctors dying. If you Google “How doctors die Hacker News” you get a lot of good threads. Here are two I found interesting.
I’m sorry to hear of your loss and that experience. This is an important discussion. A while back Peter Attia had a guest who spoke to this. Their stance was we aren’t aggressive enough about what we consider “success” especially if those last two months are spent shuttling back and forth to painful treatments.
The problem is as patient's we've never gone through the experience before and are totally unprepared for what it's going to be. From the beginning all we know is that path A ends too soon, and path B has a chance of having a good outcome. We hope beyond what's rational that path B will have an exceptional outcome for us and go down that path. Only later do we realize how painful and miserable the experience can be for everyone.
> Regardless, in Australia fewer will reach that cohort because preventive measures through universal health care are in place. That means widely available cancer screenings will catch malignant tissues before they turn cancerous.
This is an assertion that you're stating as fact, but it's directly contradicted by both the aforementioned study (it's not true that "fewer people reach that cohort") and by existing domain knowledge about how cancer screening actually works.
As explained below, screening people for cancers earlier actually doesn't improve mortality rates significantly. In fact, survival rates are actually roughly flat when adjusted for detection time, because earlier detection mostly catches cancers that wouldn't actually progress to be fatal in the first place.
> Additionally those screenings will be lower cost than the US model
You have this backwards. Screenings for early asymptomatic cancer are actually the textbook example of gratuitous costs.
Yes there can be gratuitous screenings. Something that, I understand, happens often in the US system due to risk of law suits and patients with good insurance demanding they take every precaution possible.
But I’m quite confident that we have enough data to establish guidelines on what circumstances to screen. And health insurance coverage shouldn’t be a factor whether to screen or not.
We do have guidelines provided by the US Preventative Services Task Force - https://www.uspreventiveservicestaskforce.org/uspstf/recomme... - and other specialty organizations may have their own. All medical students in the US are expected to know all of these screening guidelines and generally learn them during their Family Medicine rotation.
Here are the cancer screening guidelines - https://www.uspreventiveservicestaskforce.org/uspstf/topic_s... - You can see that many of these carry the D recommendation, meaning they should not be done because the harm outweighs the benefit of the screening. Screening only makes sense if the cost of the test is low, the test is very accurate, and the benefit of the treatment you're going to undertake after a positive screen is large.
The 0.7% margin is not within the margin of error for for that cancer (breast cancer). US is 90.2 [90.1-90.4], AUS is 89.5 [89.1-90]. US compares well to other countries on Breast cancer as well, UK 85.6 (85.4–85.9), France 86.7 (85.5–88.0). The Affordable Care Act has required insurance companies to cover the cost of mammograms (the breast cancer screening test) with no out of pocket costs. Same with colonoscopies (the colon cancer screening test).
The population of Australia is 25M. The population of the US is 328M. That 0.7% could just be the deviation inherent in the smaller population. Similarly, the SEER data only comes from 14 states (1), so there's a sampling problem with the US data. Additionally, this is only for the big 4, so there's another bias. Australia, for example, has an enormous burden of skin cancer relative to the US, so much that the world-recognized leading textbook on skin pathology is written by an Australian dermatopathologist (2, 3)
My comment doesn't discuss survival rates at all. Perhaps there has been a misunderstanding? I said that, for Australia's health care system, treating cancer at Stage 1 is cheaper than treating it at Stage 4. Could you talk more about how you went from treatment costs to survival rates?
EDIT: I didn't state that clearly enough in my original comment. I'll leave it unedited and let this reply serve as clarification.
The other commenter is pointing out the flaw in your argument. You're claiming that Australians are less likely to see stage IV cancer than Americans due to a worse healthcare system in America. As the other commenter states, that's a very believable argument that fits the narrative about America's healthcare system. However, the data doesn't support that claim. If Australians truly see fewer cases of stage IV cancer because of a better healthcare system, then we should expect to see higher 5-year survival rates for those cancers in Australia. As the other commenter brought up, 5-year survival rates are higher in America than Australia for the most common cancers. So it's unlikely that your original argument is correct.
Sure, America's healthcare system is deeply flawed, but it's important to attack it on fair grounds. We can't solve a systemic issue by raising claims and arguments that aren't supported by evidence.
EDIT: Furthermore, identifying early stage cancer is an extremely problematic and difficult field regardless of healthcare system and country. In America, we currently screen asymptomatic healthy adults for breast cancer and colon cancer. We screen people with a smoking history for lung cancer. However, the benefits to overall mortality of these cancer screening tests is controversial.
While in theory identifying stage I cancer should result in improved overall mortality, the data doesn't clearly show that. Take a look at length-time bias (https://en.wikipedia.org/wiki/Length_time_bias). It's possible that a substantial portion of the cancer screening that's done in America (and the stage I cancers found in Australia) selectively identify indolent cancers that are unlikely to be harmful to patients.
> You're claiming that Australians are less likely to see stage IV cancer than Americans due to a worse healthcare system in America
I'm claiming that Australian citizens are more likely to bring cancer to their provider when it's still at stage 1, because the citizens do not risk bankruptcy when seeking diagnosis and treatment, resulting in treatment of cancers beginning prior to their reaching stage 4.
This would, if true, create a scenario where:
In Australia, the few stage 4 cancers seen are the cancers that failed treatment at stage 1, stage 2, and stage 3; they are extremely likely to be fatal, as they've already failed essentially every treatment available.
But in United States, the stage 1-2-3 "this is treatable" filtering out isn't occurring, because patients with cancer are waiting for age 65 to seek diagnosis, and so our stage 4 treatment success rate is higher because we didn't treat the treatable cancers earlier in the stages.
Do the above comparisons of AU vs US 'stage 4 survival rates' take into account the successful treatments at stages 1-3 that would presumably be occurring in AU? Do they take into account the incidences of 'this would have been treatable if diagnosed in stages 1-3' that are presumably occuring in US?
EDIT: Do they hold true for each individual type of cancer? Do they hold true when normalized for spending on a given type of cancer as a percentage of all cancer spending?
I'm aware that these are not easy things to compare or assess, and I understand that it's preferable to some to make no statement at all rather than make an approximation that doesn't hold up to a full-power statistical analysis. If someone does know of such a thesis, I suppose my most compact question would be:
"For each type of cancer: Does the Australian health care system tend to diagnose earlier than the United States health care system, provide care at a higher or lower total cost of treatment, with a higher or lower rate of success?"
> I'm claiming that Australian citizens are more likely to bring cancer to their provider when it's still at stage 1, because the citizens do not risk bankruptcy when seeking diagnosis and treatment, resulting in successful treatment of cancers prior to their reaching stage 4.
I understand your argument: you're saying that by treating stage 1–3 patients early on, the stage 4 patients will have a shorter survival. But in the US, stage 4 patients also include many patients that would have been stage 1–3 in a different country, and because these cancers may not be quite as aggressive as the other stage 4 cancers, the 5-year survival will be higher. I'm on board with this part of your argument.
The part that doesn't hold up is patients regularly coming in to their doctors with symptomatic early stage cancer. In early stages, many cancers are completely asymptomatic. Even when we screen completely asymptomatic patients for early stage cancer in the US, we don't actually see clear cut overall mortality benefits. So how is it that these Australians are presenting to their doctors so early on with cancer symptoms?
EDIT: The holy grail of cancer screening has three features:
- Identifies dangerous cancers shortly after they form
- Perfectly separates cancer from non-cancer
- Patients live longer
Medical science itself (regardless of healthcare system and country) can't reliably meet the above three goals. So I'm skeptical that patients having easy access to medical care like in Australia would result in improved cancer survival.
Perhaps Australians present to their doctors early for all symptoms, and it is the doctors who diagnose cancer? I can't speak for everyone in Australia but for me, if I am sick I have to see a doctor in order to get 'sick leave'. I have unlimited paid sick leave provided a doctor has recommended it. It also doesn't cost me anything to see a doctor or get any kind of test or treatment/surgery done - it is all covered by work.
Sure, I'm confident that Australians wouldn't hesitate to see their doctors given the low barrier to access. But the real question is how does any doctor in any country diagnose an early stage cancer?
This isn't a trivial problem. These patients are often asymptomatic, and objective physical exam findings are not easy to elicit or entirely non-existent. At this point, the only thing a doctor can do is screen every patient coming through the door for cancer via CT, MR, mammography, colonoscopy, etc., but this doesn't translate into clear cut clinically meaningful benefits that helps patients live longer. You often end up irradiating non-cancer patients and creating new cancers, or you selectively diagnose non-aggressive cancers (length-time bias) and unnecessarily put patients through surgery, chemotherapy, and radiation (i.e. over-treatment). Some fraction of these patients then go on to live shorter lives as a result of the over-treatment. This particular issue we're discussing is more of a medical science problem than a healthcare system problem.
Anecdote from med school: on my surgery rotation, I had a ~70 year-old patient recently diagnosed with early stage colon cancer on a screening colonoscopy. He had undergone chemotherapy and was now about to have the cancerous part of his colon removed. Surgery was a success, and the patient recovered in the hospital for a few days before we sent him home. The day after he goes home, we found out he died from a massive pulmonary embolism, likely a post-operative complication from surgery.
Alternatively, had this patient not had a screening colonoscopy, we never would have found his early stage cancer. Based on his cancer stage, he likely would've lived another 10–15 years without treatment (age ~85-90). Instead, our interventions killed him a few months after diagnosis.
Is there some analysis that goes into deciding to operate on someone of advanced age? The records of all births, deaths, and surgeries are known. Isn't it possible to compute the life expectancy of someone with or without surgery and simply select the best outcome? What benefit does surgery have if someone is likely to live to 85-90 without it?
Generally, these guidelines do exist, but they're made on a case-by-case basis by individual research groups. So there are parts of medicine where we have great research and other parts where we don't know much. In the US, the USPSTF consolidates the latest research into national recommendations (https://www.uspreventiveservicestaskforce.org/uspstf/recomme...). There are additional organizations like the American Cancer Society (https://www.cancer.org/healthy/find-cancer-early/american-ca...) that also offer their own recommendations, but these are often contradictory.
> The records of all births, deaths, and surgeries are known.
Actually, this is not known (at least in the US). There is no central medical database or significant communication between hospital systems. As you can imagine, this is problematic for obtaining meaningful data. In order to answer the questions you raise, researchers have to begin collecting new data prospectively or look retrospectively at the incomplete records contained within their hospital system. The retrospective method is easier and probably more common, but there are serious biases with a retrospective approach, including small sample sizes and non-random sampling (many US hospitals serve specific demographics).
"There is no central medical database or significant communication between hospital systems."
I find this somewhat astonishing and deeply troubling. How can patients or doctors truly make informed decisions if they are not in fact well informed? This is not right at all.
In my opinion, this is partially the flip side to prioritizing data privacy. HIPAA has been very successful in getting hospitals and healthcare organizations to take patient data privacy seriously, but HIPAA has also disincentivized these organizations from sharing data in a reasonable way even for truly altruistic purposes (e.g. research). And the idea of creating a central medical database just feels like a massive legal headache with huge consequences if anything goes wrong.
The other party responsible for the lack of centralized data is the EMR vendors (Epic being one of the largest). They're incentivized to lock-in their clients (i.e. hospitals) by making any kind of data sharing at best a pain in the ass and at worst entirely impossible. For large health systems, I've heard the cost of changing EMRs is in the tens to hundreds of millions (USD).
Besides the detriment to research, this does lead to real patient harms. Where I went to med school, there were two major hospitals systems about 5 mins from each other in a major city. I worked in the emergency department at one hospital where I would frequently see patients coming in after car accidents and heart attacks. But often, some of these patients had received all of their care at the hospital 5 mins away. We had zero records for these patients. Meaning, we had to work them up from scratch and any important medical history would be unbeknownst to us. This obviously led to poor care and duplication of medical tests, which can be harmful (e.g. radiation from CTs). And requesting medical records from the other hospital was infeasible in emergencies. Realistically, these records were only available 9a–5p on weekdays via fax at the other hospital's leisure.
America has higher 5-year survival because America tests earlier and more often than most other countries. That's likely attributably to a lawsuit-happy society and liability fears. However, that doesn't necessarily impact your likelihood of dying from the disease much of the time. This is called early detection and overdiagnosis bias [2].
Further, 5-year mortality rates can be affected by palliative care philosophy too - do you keep giving chemo to folks who won't recover?
In fact, if you look at the mortality rate for most cancers instead of the 5 year survival rates, they're basically the same across the Australia, the UK and the US.
Prostate cancer in particular is interesting because the US continues to advocate for early screening and PSA antigen tests, but the NHS has found that there's no scientific basis for this, and PSA screening for prostate cancer actually does more harm than good [1]
There's currently no screening programme for prostate cancer in the UK. This is because it has not been proved that the benefits would outweigh the risks.
This is just a misinterpretation of the data.
tl;dr: 5 year survival rates measure, in a lot of cases, the rate of early detection, not cure. At least, that's the inherent bias. Your study uses 5 year survival rates not mortality rates, hence this is illustrating differences in testing philosophy not efficacy. More, early testing is not necessarily better. It's often worse.
> The US actually has a higher 5-year survival rate
Take a bunch of people over the age of 50 and then screen them for thyroid cancer. Then don't provide them any treatment at all for that thyroid cancer.
You haven't changed when those people die, nor what they die of, but your 5 year cancer survival rates look good because most of these people will live for more than 5 years with their cancer.
And because there are small risks associated with treatment, if you treat large numbers of people you'll harm small numbers of them. Your 5 year survival rates look good, but your all cause mortality looks worse.
I think people are waiting too long. And hospitals are probably not unhappy with that. I bet there is way more money in late stage cancer treatments vs early stage.
Exactly, that's one reason why government paid social health care is aligned with this: The government benefits from doing prevention programmes as it is cheaper than late treatment.
Germany had all kind of preventative help/medicine when I lived there.
According to the World Health Organization these are the cancer mortality statistics comparing US to Australia.
US
Number of deaths: 612,390
Crude rate: 185.0
ASR (World) per 100,000: 86.3
Cumulative risk (0-74): 0
Australia
Number of deaths: 48,236
Crude rate: 189.2
ASR (World) per 100,000: 83.3
Cumulative risk (0-74): 0
These numbers seem fairly close, while other countries have much larger differences. The Australia numbers for incidences are higher, perhaps indicating that they catch it earlier or their population suffers from a naturally higher incidence rate, but that does not equate to significantly lower mortality.
There is only one problem with healthcare in the US: misaligned incentives.
Medicare would likely save money by having free screenings and yearly bloodwork for all Americans starting at say age 40. The cost of some of these experimental cancer drugs is very very high not to mention surgery/chemo/radiation/etc. Additionally, it would create more incentives to find cheaper/faster/newer tests for these diseases knowing that there will be a HUGE market for them forever. My guess is that after some small number of years, this would actually save Medicare money. Obviously, there is the human upside as well.
My boss less than a couple of years ago died of stage 4 cancer in his early 40s. Apparently didn't notice symptoms until it was too late and died within six months of diagnosis.
Maybe there is a piece of info missing but this comment had my bullshit detector going off big time. There are plenty of stage IV cancers in Australia. There is no screening for lung cancer so 80% in Australia are stage IV. Even with screening 20% of colon cancer in Australia is stage IV.[1]
Plus California has more people than all of Australia and the worst cancer patients try to go to Stanford, so if expect huge numbers (more than all of Australia even if rates were similar).
Do the arithmetic: according to that very reference, the Australian stage-IV-at-diagnosis statistic for lung cancer is not 80% but 42%, and it seems this is unchanged since 2011 [1]; notwithstanding which, cherry-picking lung cancer (notorious for late presentation) hardly invalidates the much more general observation being made.
It's only 42% because ~30% isn't even staged (those might or might not be stage 4). Drop that and 80% is stage 4.
And no, a general observation of "we don't see stage 4 cancers in Australia, we have to go to the US" is clearly invalidated by this data. There are plenty of stage 4 cancers in Australia.
Take a look at the US Seer data it appears more is diagnosed earlier in the US.[1] 50% are not stage IV and only 2% are unstaged.
No-one said "we don't see stage 4 cancers in Australia", so I'm afraid your so-called "bullshit detector" is broken.
On the other hand: intentionally misrepresenting people's statements, and crudely and inappropriately manipulating statistics, sets off my bullshit detector.
I am the OP, so along with your "bullshit detector", I'm afraid your eye for details may also be due for a service.
A stage IV of any single one of the myriad subtypes of cancer is not a representative example of all cancers, let alone a guide to their stage distribution. Cherry-picking one, and then grossly distorting its stats, tells us nothing.
The simple fact is, a very senior doctor, whose job is to diagnose cancer, observed that US institutions have a disproportionately large collection of late-stage presentations to study.
That’s why I said “there must be data missing” and I gave an example of a fully screened cancer (colorectal) that still has stage 4 prevalence in Australia. So pardon me if I’m struggling to figure out what cancer this is when the details are sparse.
So since you’re the OP, do you want to share the tumor type that “you rarely see stage 4 in Australia” but is apparently super common at Stanford? Since I work in healthcare I’d be super interested to know.
I will not be bothering the doctor quoted with this sealioning-by-proxy.
Had it not come on the coat-tails of such bad-faith misquoting, cherry-picking, statistical manipulation, misrepresentation et cetera, perhaps I might. Instead I bid you a good day.
Thank you for questioning this. I'll take your evidence and the evidence provided elsewhere in the thread (CONCORD-3 trial, a trial including millions of cancer patients in the US and AUS) over the secondhand anecdote of one physician. Is Stanford even the safety-net hospital for the Bay Area?
Stanford is absolutely not a safety net hospital. This is proof that even people with "good insurance" (especially since they are going to Stanford) are falling through the cracks regularly. UCSF General Hospital would be the safety net hospital in the area, though. Safety net hospitals are for the uninsured or poor typically.
Australia has no safety net hospitals, because everyone legally resident in Australia has health insurance. All hospitals in Australia have very high quality of care.
While we (Americans) may have comparable 5 year survival rates, it does not mean that there is not unnecessary death via the American system. There are deaths (mortality) and adverse conditions (morbidities) due to amenable and non-amenable medical errors in all healthcare systems in the world. The unique aspect about American healthcare is that there is another category that is not prevalent in other highly industrialized countries: mortalities and morbidities due to a lack of care (lack of ability to pay for care), which happens easily, even if you have money.
I can assure you that while we may have comparable 5 year survival rates, there’s more to the story here, and that there is so much unnecessary death in the US healthcare system.
I have studied health systems worldwide, country-to-country, via the open-access peer reviewed publications posted on HealthData.org.
I live abroad, basically over the American healthcare situation. I have 2 rare neurological diseases affecting my peripheral nervous system plus type 1 diabetes (autoimmune and insulin-dependent).
I am a US medical student so I am in a hospital or clinic almost every day. Our hospital is a tertiary care safety net hospital and all the patients are sick as hell because they have poor access to healthcare. So I know what that looks like, and I'm not arguing that the American "system" is good. I just think you can't say that patients present with higher stage cancers in America based on what's presented in that paper. America likely has worse health outcomes for lower income people, and my guess based on what I've seen is that that's driven by untreated diabetes, hypertension, and higher rates of smoking leading to increased incidence of MI, stroke, and kidney disease, but I have no data to back that up. I would also guess that the reason you're not seeing higher stage presentation in those papers is that poor people who would have had those later presentations are dying of heart disease and CKD before they can develop those cancers. Just my suspicion and I am happy to be proven wrong by data. It is just frustrating to me when people on this site who are generally more educated than your average person will toss anecdotes and unsupported claims around, particularly about healthcare.
Here’s a fun fact for you. When I talk to my wife, and she tells me things about work, I don’t say “citation needed”; nor would I change that in response to whinging demands from the peanut gallery, and doubly not as followup from that of a comment/opinion/anecdote-driven website as riddled with bad-faith weasels as this one.
Which is, of course, in part, why I’m still married.
Alternatively, for a related experience, since you're on rotation, try going up to your CMO and demanding evidence for some off-the-cuff remark they've made about their own professional choices. Good luck.
Adding personal invective to your litany of misquotations, misrepresentations, straw-man arguments, and sealioning, as in comments passim, is not an inducement to further discussion.
As for my personal situation, one of the rare diseases that I have is believed to have caused the autoimmunity that caused my T1D. It is a form of autoimmune autonomic neuropathy, and it showed up 6 months before the T1D diagnosis. We also believe that I am susceptible to other endocrine and neurological immune-mediated diseases through the anti-peripherin antibody. It’s the common denominator relating most of my health problems together, but there is no commercial test available for it at the moment.
In the US, we have a nationwide public healthcare system called “Medicare”. You generally only qualify for Medicare once you’re 65 except in special circumstances. Many of our citizens can’t afford to be diagnosed with cancer at an earlier age, as it will increase their non-Medicare private insurance premiums^, result in denied coverage for unrelated issues, and potentially send them into bankruptcy if treated. So they wait until they turn 65, and only then bring in pre-existing conditions for diagnosis and treatment, confident that they can no longer be bankrupted by doing so.
^ Insurance premiums average $300-$700 USD per month per person nationwide, when not available through full-time employment or (65+) Medicare. ~75.000.000 US citizens age 18-64 are employed full-time, which compels their employers to subsidize their monthly health insurance costs; the remaining ~127.000.000 citizens are not employed full-time and thus do not qualify for mandatory employer-provided insurance.
EDIT - Military veterans, poor people, and so on often have access to additional free public health systems other than Medicare, offered either nationwide or by member states of our union or by non-governmental organizations; degree of subsidy and quality of coverage varies wildly among them.
# The above estimates were constructed using napkin math and the below links.
Health insurance is now guaranteed affordable (8.5% of income or less) in every state except Wyoming, Wisconsin, South Dakota, Texas, Kansas, Louisiana, Tennessee, North Carolina, South Carolina, Georgia, Alabama, Mississippi and Florida (Medicaid gap).
Though: The article lists the poverty line as $51,520; 8.5% of the poverty line is $365/month, so that's well within $300-700. Mississippi has the lowest median income in the US at $45,081; 8.5% of that is $319/month, which is still within $300-700. You would need to make less than $42k/year, which is about 80% of the poverty threshold, in order to fall below the thresholds I napkin-mathed. Many do make less than that, and this will greatly benefit them.
Non-US translation for that last bit, though -
37 out of 50 of our member states chose to enforce an 8.5% of annual income limit on health care insurance premiums for citizens of their states; 13 refused to.
Just to clarify, that's ($51,250) not the poverty line, it's the (old) subsidy line. The poverty line is $12880 + $4540d, where d is the number of dependents. But yes, healthcare premiums do float above $300/mo for some people.
That seems simultaneously useless and more expensive than early treatment—since folks would just bring in a baggage of chronic illnesses, pretty much like the article says.
Some of the people who are least likely to have insurance are those who "retire early" aka lose their job in their 50s or early 60s and are unable to find a replacement job with similar benefits and pay. Other people in blu collar jobs can no longer keep up with the physical demands of their profession once they hit mid 50s. Sometimes they have enough saved to scrape by until they can collect social security, which they unfortunately often do at 62 and forgo 30% of their monthly income permanently. Medical coverage is a huge problem for these people. Fortunately Obamacare makes it so they can now buy coverage at this age (before they would be rejected for likely pre-existing conditions), but any plan with reasonable premiums has a huge deductible (up to $10,000) that needs to be exceeded before insurance kicks in. For many people they would rather do without insurance that doesn't cover anything that is not catastrophic and save on the premiums.
What about Medicaid for unemployed or under poverty level? I was on it briefly when I was out of work and everything was free from tests to meds. It was simply amazing not getting surprise bills or worrying.
I wonder if living in the US with Medicaid Is what it feels like to live in a different country with universal healthcare, does anyone know?
It's probably closer! I believe California leads the pack in that area — for example, if you're poor enough, you can get better insurance coverage for transgender care (as in, no-argument treatments and surgeries) than you can get with a $1000/month private insurance plan.
Seeing a specialist at a decent hospital can cost you over a week's paycheck out of pocket just for an introductory 15 minute meet and greet.
It isn't so much as 'waiting' as having no other option/getting stuck in some system where you've got no viable way to really figure out the cause of your symptoms.
Not to mention the 55-65 age range seems to be particularly bad for for disposable income.
With insurance, even. So many of even the "good" insurance policies have two or three thousand dollar deductibles, and things like specialists often get into byzantine co-insurance percentages.
I have great insurance, every trip to the doctor is a fun waiting game as you get bill after bill in the mail for seemingly random amounts, by organization you've never heard of.
Hmm... I went to Dr. Smith, I just got a bill from Sunshine Medical Associates for $37.82 and another bill from Kweil, Zatack, and Yttrium Health Services for $17.89
I guess I could call this number, spend an hour on hold, talk to someone, have them ask me if I know the procedure's billing code, go, "I have no idea what the billing code is" have them treat me like an idiot or skip that part and end up paying the bill because in the long run $17.89 is a small price to pay to not have your credit ruined.
I recently called my insurance to check on out-of-network coverage for something they have no providers for, it is covered at 70% after a $750 deductible, but only up to the "Allowable Price."
I asked them what the "Allowable Price" was for this procedure, and they responded that they couldn't provide that. Odd, it seems like when they go to bill me they will know that number, but I'm not allowed to know it before I submit the bill for reimbursement. Even if you spend a huge amount of time up front ticking off boxes and patiently being passed from one CSR to another, you can't figure out what anything is going to cost.
When people from the future look back, they'll call this sort of thing "corruption". This isn't the result of a free-market medical system, or a largely-socialist-at-different-points-but-not-here medical system, or any medical system at all; it's just a cynical way for the middlemen to make a few bucks, and as long as that's the incentive, nothing will get fixed for the sick person who needs healthcare.
I had an ipsilateral recurrent DVT in my left leg. Kaiser failed on so many levels: at the ER I should've been treated with some kind of thrombolysis or mechanical thrombectomy, but was only offered Lovenox and Pradaxa. The internal medicine physician I had failed to refer me to a specialist for follow up, and without care and investigation, I developed post thrombotic syndrome in that leg, which means I spend the rest of my life in some degree of pain with the possibility of developing ulcers.
The specialist I went to see at Stanford, Lawrence Hofmann, was very clear that had I presented within the first two weeks, he could have simply removed the clot, but since I saw him 5 months after the event, the thrombus was chronic and wouldn't respond to treatment.
In the end, I had to leave the USA and get a proper diagnosis by surgeons in Italy: turns out I had a congenital compression of my left iliac vein which was causing the clotting and a stent was placed to open the vein.
The lesson here for anyone in mainstream computing, is that strongly typed languages are better than weakly, or untyped languages. The reasoning being that early detection of problems is cheaper, and better in terms of outcome, than delayed detection.
To be more on point, This effect can happen outside of the US too. Many people (like me) who laud being in a full-service health system economy don't talk about how optical and dental services are excluded from "full" and incur excess costs. You have to meet income tests to qualify for free, and if your health cover is not sufficiently generous, (yes, even with full service public health we are encouraged to have private cover, and we have co=pay costs, simply 2-3 orders of magnitude less than the US and basically discretionary for many things: either wait, or pay, but if you do wait you will be treated) then delaying service until you are on a pension is a bad, but sort-of rational choice.
I know people who say "I'll wait until I retire to deal with that"
I really wonder what the eventual end state is of many problems in the US that really seem so glaringly apparent (i.e. the US healthcare system is the most expensive in the world with some of the worst outcomes compared to other 1st world countries) but also politically unfixable.
> I really wonder what the eventual end state is of many problems in the US that really seem so glaringly apparent
We just had a pandemic with 500k lives lost, which almost all experts agree could have largely been avoided with a strong response. Yet, millions of Americans still voted for the person most directly responsible.
So what happens to the country is quite clear. Morons get elected and run the country into even more crises until it gets so bad that the fundamental structures of social arrangements collapse. We've seen this happen in many civilizations; society seems incredibly stable, people can't imagine a world different from what they're used to and then one day some crucial piece of the very delicate threads that hold society together are broken, and then it rapidly unravels.
See, this is the problem with US politics. Your experts and your press are absolutely convinced that those US Covid-19 deaths are the fault of Trump and that if the idiot population had voted for someone they liked more those people wouldn't have died, even though this has no basis in actual reality. The US Covid-19 deaths are completely and utterly average for a Western country. (The worst death toll currently is the Czech Republic, which everyone was pointing to as the European success story that showed everyone else should be able to do better less than a year ago. This could well change again, of course, just like it did before. A lot of this seems to be luck. Though the current US vaccination rates make it much less likely to rise up the list again.)
Also, all the information about what supposedly worked was distorted by politics too. For example, all of the countries like Taiwan which managed to keep it out relied heavily on imposing border restrictions early, but borders and travel restrictions were seen as evil, Trumpian things - a "prophetic" piece of fiction where President Trump responded to a pandemic by imposing increasingly futile border closures did the rounds on social media early on - so they were completely omitted from US media narratives about how those countries had succeed. Instead they focused on stuff like Covid testing, because of another equally bogus narrative that Trump had sabotaged that. (The US actually had a really ambitious testing program... right up until the tests arrived at labs and were defective. Apparently it turned out some career CDC employee hid the fact they were contaminated and let them roll out to labs, but this was missed by almost all the media coverage, probably because it had nothing to do with Trump.)
A healthy mix of finding new people to blame with the occasional spending of resources to make the unbearable bearable for a little while longer while the min-maxers find a new way to reduce spending to keep the cycle going.
The existing political "solutions" stagger on like walking corpses until they completely collapse, and are replaced by something that may or may not be any better based on the luck of who ends up making the decisions.
Fixed in place is rare unless something, usually external, overwhelms entrenched interests.
The government is on the hook for the majority of the sickest (most expensive) people in our system. Private insurance companies take your money for the majority of your healthy life and hand you off to the government as you move into your most expensive days. It's absolutely insane.
Plus, they try their best to deny any expensive care which your doctor prescribes. It’s really a perverse system. There wouldn’t be nearly so many people advocating for public healthcare if the private system had any hint of respectability. Every provider is terrible value, has poor customer service, and goes their best to screw your over.
The incentives are totally wrong. The incentive for an insurance company is “let me extract as much money as possible from my clients”. That’s completely at odds with providing quality care.
Privatize gains, nationalize losses. One of the oldest plays in the book. It has been applied to resource extraction, service providers, psychoactive substances, and more. Somehow the public always ends up holding the bag.
I wonder what kind of circular logic this could create. Clearly we don't need to lower the age of Medicare eligibility, because 64-year-olds never get sick. 65 is the perfect cut-off based on the numbers! /s
Alternatively, clearly we can afford to lower the age of Medicare eligibility to 64, because 64-year-olds never get sick, it won't cost very much at all.
Actually, I think we should decrease the age of eligibility over time to gradually get towards Medicare for all; I would lower the eligibility age by 6 months every year for 10 years to get to age 60, then 1 year per year for 5 to get down to age 55, then 2 years per year until you're done; maybe speed up again later. That would give Medicare time to increase capacity, and everyone else time to plan accordingly.
At some point you need to also deal with eligibility for people without work history and whatnot.
There would almost surely be a censoring effect no matter what age cutoff you pick, and even allowing for typical government incompetence, surely at some level health econometricians are involved in this type of policy and are aware and facilitate whatever trade-offs are being sought.
I love roasting poor government policy decision making as much as the next person, but that would be a bridge too far.
> There would almost surely be a censoring effect no matter what age cutoff you pick
This seems to be an ethical argument to make the age cutoff 0: in other words, medicare for all.
> surely at some level health econometricians are involved in this type of policy and are aware and facilitate whatever trade-offs are being sought.
I feel like this article would not be massive news if this was true. The other case I recall that would be like this is when oil execs held back info that they were causing climate change. That seems to me to be completely different, however, because that was a private company and we're talking about government employees here.
I don’t see any reason your comment would be accurate. It all depends on trade-offs. If the goal is to reduce cost, then you could equally argue to get rid of medicare entirely.
Clearly the goal (no matter what anyone’s separate normative opinion is) is to balance some complex tradeoff between costs borne by tax payers, costs borne by corporations (through taxes and through employer based healthcare for working age adults and their dependents), and a high level of access for all people.
Nothing about this censored data effect can say anything about the morality of different regions of that trade off space.
As to your second comment, this article is not massive news and it seems laughable to say it is. It’s just a blip in the news cycle, using some data artifact to drum up attention to something that is already well-known for any econometrician or health policy analyst.
Full disclosure: I personally favor nationalized medicine and welcome higher taxes across the board. Nonetheless I don’t find your comment to be accurate or valuable.
Seriously. Infrastructure is falling apart everywhere. The angry homeowner with the median occupancy of just 13 years is able to halt progress on virtually anything from a train to a homeless shelter. We've locked entire cities into a stasis in terms of development for decades and constrained our housing supply by handing untold power to local, often corrupt city governments, who generally have no interests in listening to the needs of those on the bottom of the local economy who have no money to donate nor time with which to vote. We've allowed wages to stagnate and inequality to surge, all while cost of living has been rising. We've done virtually nothing meaningful on climate change in the past two decades. We've defunded our public schools and closed down our mental hospitals in the country with the worlds largest economy. Yet the stock market is at all time highs in a global pandemic. Could you imagine anything more backwards and bizzare?
> Yet the stock market is at all time highs in a global pandemic. Could you imagine anything more backwards and bizzare?
I'm not sure if you're implying this but the stock market never was an indicator of the economic health of the country. Its an indicator of the economic health of the wealthy (tautologically, since its where most wealthy individuals park their wealth) , and for that its been pretty accurate.
That doesn’t work for medical treatments. If tooth extractions or colonoscopies were free people wouldn’t get more of them unless they were necessary. The current state of health care in the US causes people to not seek necessary care which results in much more expensive treatment later.
True, but it’s especially worth paying attention to here because the cost to us goes up when they switch over to Medicare and the actual cost goes up because they now have a more difficult condition.
I’m going to be out of healthcare for a month because I’m transitioning jobs. It’s a bit scary I have to admit. If I have an emergency I’ll refuse to pay the bill.
When incentives are created in a specific way, the underlying data and what it tells you can be significantly altered. Cool to see people questioning the reasoning behind this data rather than accepting it at face value!
Timing analysis in health care is amazing. There is plenty of documentation that hour and day of week affects physician intervention in births. Women who are in labor during normal work hours are much more likely to have medical interventions like cesarean section. On a weekend, the rate of these is far less. Basically it depends a lot on whether your attending doctors need to leave at 5pm on a Friday because they have theater tickets.
Of course they do, and this is why medicare for all is a great idea. It strikes me as rather perverse that health care is largely a for-profit business and that even non-profits (like systems associated with religions) are all about cutting corners and maximizing revenues. It seems logicl to me that health care be a right.
I don't think the language of "rights" makes sense here. It conflates things like free speech or religion, which are self-serve rights, with something someone else must provide.
Rights as in the Bill of Rights can be sued over endlessly in the courts. But the courts aren't a good place to sort out resource allocations, like doctor with patient.
Imagine one person suing to be a pateint of a particular doctor (perhaps a specialist with uncommonly-good outcomes). Or someone suing for frequent helicopter ambulence rides from their remote cabin in the woods.
These may be interesting questions to settle, but the language of "rights" is unhelpful.
A right to vote has to be provided. Right to an attorney is something that might haveto to be provided. Right to a jury by one's peers has to be provided. Right to appeal has to be provided. Even protests generally require permits, which have to be provided. You have the right to be treated equally based on your gender or race, which, if it is provided to one, has to be provided to all.
There are many rights which create the burden of work not only for the government but also for things like public businesses.
All of the things you mentioned are in the spirit of "if this thing is available, everyone must have fair access to it".
If there is to be a vote, everyone (of age) must be able to participate. If you are to be tried, you must have representation, a jury of peers, and possibility of appeals (alternative being that case against you is dropped). If protest permitting is instituted, they must be provided fairly and expeditiously.
Equal treatment is another type of right and even more different than a hypothetical "right to health care".
The issue with health care is that it might not be available (depending on if you are in a remote area, public health circumstances e.g. strains due to a pandemic, limited specialized equipment, etc.). So a "right" to utilize it is unrealistic. At best you can posit a "right to non-discrimination of access to health care on the basis of X,Y,Z" where X,Y,Z can be such things as "gender, race, age, etc." or more politically contentiously "preexisting conditions, enrollment in insurance, ability to pay, etc".
To be clear I also favor public universal health insurance of some kind. But I also think that considering that health care is or could be a "right" is kind of ridiculous.
> "if this thing is available, everyone must have fair access to it"
Ok sounds. Good. Medical treatment is an available service. Everyone should have fair access, no?
> The issue with health care is that it might not be available (depending on if you are in a remote area, public health circumstances e.g. strains due to a pandemic, limited specialized equipment, etc.). So a "right" to utilize it is unrealistic. At best you can posit a "right to non-discrimination of access to health care on the basis of X,Y,Z" where X,Y,Z can be such things as "gender, race, age, etc." or more politically contentiously "preexisting conditions, enrollment in insurance, ability to pay, etc".
To me this reads like pretty creative mental gymnastics to try to exclude universal health care from the original premise. If you're in a remote area, your access to treatment may be of a different quality/difficulty to obtain but everyone in your area will have the same difficulty.
> At best you can posit a "right to non-discrimination of access to health care on the basis of X,Y,Z" where X,Y,Z can be such things as "gender, race, age, etc." or more politically contentiously "preexisting conditions, enrollment in insurance, ability to pay, etc".
That's kind of how voting rights are today but they certainly weren't always. We don't argue as much about the poll tax or various "poll exams" anymore, but banning them at the time was "politically contentious". Something being "politically contentious" is not a good argument for or against doing something as it's really easy to generate controversy (look at the modern news landscape).
> Ok sounds. Good. Medical treatment is an available service.
Which treatment? When? How often? Does "the right to healthcare" include yearly check-ups, for instance? People died from COVID in many different countries, not because they can't afford treatment, but because they need care urgently when we don't have hospital capacity. An emergency room being full is not a situation unique to pandemics, it happens more often than you think.
The comparison with the right to an attorney, while interesting, may not be completely accurate. This right is more about preventing you from being punished without a chance to defend yourself.
> To me this reads like pretty creative mental gymnastics
On the contrary, comparing healthcare to other rights is actually more of a mental gymnastics exercise. As far as I'm aware, no country defined healthcare as a right in their constitution.
Universal healthcare and Medicare for All are already popular ideas in the US. "Healthcare as a right" is not a winning message in my opinion, since it can be attacked from a philosophical and legal standpoint.
To be clear I'm not saying I think it's a bad idea to have universal health coverage because it's politically contentious. In fact I'm not saying it's a bad idea at all; I think it's a good idea. I just think framing it as a "right" is bad. In my opinion, doing so diminishes things that are actual (and hard-fought) rights, such as non-discrimination and freedom of speech, religion, etc.
> If you're in a remote area, your access to treatment may be of a different quality/difficulty to obtain but everyone in your area will have the same difficulty.
It might be almost or entirely nonexistent (e.g. you live in an extremely remote area, you've hiked on foot into uninhabited terrain, you might have a rare difficult-to-treat disease that would require so many specialists as to deprive others of care, etc.). If there are situations where one might not realistically be able to get health care, why would we frame health care as a "right"? In my opinion it's a fantasy and diminishes the meaning of the word. That's why I was trying to more narrowly pin it down to "non-discrimination of access to health care" in my comment.
It's not infinitely available and not all service is equal.
> Everyone should have fair access, no?
If people want to spend their money to buy more of it, what they perceive to be higher quality of it, or to get it sooner, they should be allowed to do so.
Universal health care means everyone gets health care, it doesn't need to mean everyone gets the same health care.
Personally I’m with you- generally speaking “positive rights” do not carry the same weight as negative rights and need a different term (I propose “really good ideas”) but people with our viewpoint have been losing that battle for a long time.
My conception of fundamental human rights is based upon “what would I agree justifies a forceful intervention/war.” Without spilling far more ink then I have time for here, I’ll just say that is a very short list and guaranteed health care doesn’t meet the criteria.
Doesn’t mean I don’t society should try to provide that service, but I’m not going to support intervention in another state if they don’t.
The way I look at it is some rights are good ideas, some are bad ideas, and some are nonsensical and unworkable ideas (regardless of whether they would be good or bad in an idealized world). Health care as a right is the last of those.
You can’t guarantee access to a limited resource so it isn’t a reality anywhere. At best they redefined the meaning of the word “right” which I am also strongly against.
Rights aren't made up is a founding principle of America, every immigrant who naturalizes has to agree and uphold this principle of rights being natural.
That can be seen as just part of the burden of charging you with a crime: the state needs to provide you with a judge, jury, and counsel.
Amd it's not the greatest example of rights-in-action if you ask me. Often such counsel is overloaded and just tries to negotiate a plea deal rather than provide a robust defense.
The solution to that is acting positively to create a system that we think is strong enough to withstand challenges in the courts.
You don't have to wait until the courts strike down your public-defender system for being wholly inadequate, for example, you can properly fund the system in the first place and then the courts won't be legislating it.
"standard of care" is the term that comes to mind. And yes, like all human systems there will be disagreements about what that standard should be, and some system for resolving those, and in a handful of cases people will receive unfavorable outcomes. The point is to act to minimize those outcomes and provide high-quality care to as many people as possible.
The alternative is having those arguments with your insurance company, and you will lose. The death panels exist, they always have, and they are held in a building with "Aetna" on the side.
If "acting positively" means "work it out in the legislature", then we agree. But the language of rights starts to push this responsibility into the courts (at least in the US).
I am not saying there will be no arguments. I'm just saying we shouldn't hammer out the details of a medical system in the courts.
If you are trying to convince people to have the government gatekeep their healthcare, then I don't thinkt he attorney's provided by the "right to an attorney" are something you should mention.
every human has a right to be healthy. However it is provided is fine. We, as a society, have the means to provide this.
Just because we've set up a system that profits off of people being sick should not invalidate people's right to be healthy. That's our doing.
I also find claiming some things are "self-serve rights," to be hilarious. People going to court over constituional violations. Is that self serve? Rights, especially the ones you mention are only "free," or "self-serve," as long as all parties agree to provide them for free. If someone decides that they want to discriminate against your religion, they can do so, and it is up to you to seek remedy.
So how is that self-serve? It isn't. No right is. Things are being provided for you which we, as a society, have agreed are essential. How health is not apart of that is beyond me.
This is the really insidious part: They don't have to cut corners. The government covers the majority of the sickest people. The average US citizen pays into the private pool for the majority of their healthy life and then gets handed off to the government to cover them when they get expensive. It's literally a ripoff.
If something is a “right”, it doesn’t imply the government should just take care of everything and it should be totally socialized. One might consider “clothing” a right, but I don’t think we’d want the government to control what we wear.
I agree that government should ensure universal healthcare, and maybe a single payer system would be the correct model (though other countries have had better results with partially market driven approaches). But my belief there is based on the fact that humans aren’t currently able to make good decisions about their own health care, and government panels probably would be able to make better decisions regarding public health.
> One might consider “clothing” a right, but I don’t think we’d want the government to control what we wear.
I think it would be _pretty awesome_ if freely available durable (and warm) clothing were made available to people that needed it (homeless, foster kids, etc), much the way my taxes help subsidize peoples' food costs.
There's a big difference between saying, "You have to wear this", and "We'll all pay so that people who need it can get shoes/socks/pants/jacket X times per year if needed".
I don’t think that would be awesome at all. Could you imagine a committee trying do decide what clothes are acceptable. All sorts of “buy American” clauses thrown in. Each Congressional district would have to have its own factory to produce one part of the outfit.
How about we have the Gov set up a negative income tax so that if you can afford clothes, you can go buy some. Or if you don’t need new clothes, you can spend that money somewhere else.
Healthcare isn’t driven by want or choice. Government committees can look at data to figure out how to distribute resources. And we don’t want more healthcare like we want more clothes.
Can you imagine? A box full of useful clothes and supplies, decided by government committee, being handed out at the hospital, free of charge, so mother can relax and care for baby! What a nightmare!
I don’t think is right to analogise between clothing and healthcare. Everyone needs clothes; specific needs are highly correlated with climate. While this is also true of some basic functions of healthcare (dental care being the most obvious example) most of the very expensive parts of healthcare (surgery, cancer, etc) are not similarly predictable and therefore fit the insurance model better.
And the way to make insurance model work best is to make it universal, mandatory and governed by cost efficiency rather than shareholder profit. Better still, a universal system becomes a monopsony buyer, able to assess value with domain expertise then demand and receive lower prices for drugs and medical equipment.
Clothing as a "right" is as ridiculous as health care as a "right", in my opinion. Though I also believe that governments should make efforts to provide both to those lacking them.
In the US, its more like a mafia racket; Your money or your life.
One of my favorite things about Thailand was that the hospital lobby had these pamphlets with actual prices for procedures.
The US healthcare industry is filled with criminals. They have blood on their hands and are raking in cash at a massive cost to US society.
Resource allocation is hard. Profit isn’t the problem. Access is. We should be spending more on healthcare as a country, not less. Guaranteed health care for everyone regardless of income level can still happen in a regulated for-profit system.
USA federal government is just in general shitty at execution. I didn’t get any stimulus checks. My unemployment I was supposed to get went to some other address I never inputted into the arcane-af website I had to use to register for unemployment. A traffic ticket that should’ve only cost me $29 ended up costing $468 because the government messed up and I didn’t want to risk getting covid going to court to protest and there was no way to appeal online. I would dread these same people in charge of my health care without at least the option of switching providers.
All that happened in the past 6 months.
If our government could start getting the basics right I’d trust them with my healthcare. Maybe MfA is a great idea but it should be expanded slowly, the way Biden has suggested.
The president od my small local hospital is paid $985,000 per year. I looked it up.
My local hospital also cuts lots of corners to save a buck. I know some nurses who work there. They understaff while they overcharge patients and play absurd games with billing.
I think this is pretty normal in the US. The ratio of hospital beds to population is unusually small for a developed country.
As soon as my kids are a little older, I am getting out of this country. I am healthy now but as I get older I get more concerned about getting caught in the US healthcare system.
> The president od my small local hospital is paid $985,000 per year. I looked it up.
The CEO of a small local tech company is paid $10m per year. I looked it up.
> “my local hospital doesn’t allocate resources right”
Not surprising. Resource allocation is a difficult problem. Perhaps the hospital would be better off with limits on what they are allowed to pay people like you seem to be suggesting, but I doubt it.
To me this is all fundamentally a sign the USA doesn’t spend enough on health care. I don’t have confidence price controls and nationalization will improve matters.
The unspoken thing is that current Medicare is only sustainable because the hospitals are allowed to recover the costs by charging whatever they can get away with to uncovered people.
If everyone is covered, quite a lot of money will have to come from elsewhere and it's not like seriously raising taxes to source it would get very popular.
US healthcare spending is already far higher than anywhere else in the world. It's not a "quantity" problem, it's an "allocation" problem. Too much is allocated to various middlemen for profit, and generally too much is wasted on care that does not produce good returns in terms of quality-adjusted years-of-life. For example, too much is spent on the elderly and sick, and not enough on maintaining the healthy.
US healthcare is totally overpriced. I don’t believe for a single second that they are losing money on Medicare. Maybe in some areas but not on average.
If only the democrats had had a little courage and ran a candidate that embraced Medicare for All. I think with Biden not embracing it they have lost a great opportunity for many years. It would be the most straightforward way to universal health care. The systems are all there, it has shown that it works and people want it. Now Biden is talking about a nebulous “public option” which won’t go anywhere. What a waste.
Yes, this is more evidence of the failure of the American health care system. If the US healthcare system really cared about outcomes, it would want people to be diagnosed earlier. It is clearly more economically efficient to treat malignant cancers earlier. We (Americans) all end up paying more with the perverse system we have.
I cannot comprehend why anyone would be against health care for all? It seems like such a silly thing to vote against the idea that everyone is healthy.
There are lots of agenda items on the political spectrum but healthcare seems like such a strange thing to not be supportive of. Can someone help explain to me what the oppositions point of view is?
I’m not opposed to a well-functioning healthcare for all, but I can guess at a few possible oppositions: (all of these are phrased as generic first-person statements but by people who are not me)
1. I don’t want my healthcare to be provided by the same people who brought me a lifetime of experiences at the Department of Motor Vehicles.
2. Healthcare is expensive. I’m already paying for healthcare for my family and we’re struggling to get ahead; why would I want to pay for healthcare for others as well?
3. Good healthcare is expensive and I can afford and buy the best health insurance. I don’t want the best to be unavailable to me and my family because we’re all on a “just OK” government system.
4. I’m a medical professional and think that I will make less money under a government-provided system of care.
Edit: I missed the part where this was a list of excuses that had been heard. I was too hasty to reply. Disregard the following.
1) I'd just like to say the DMV in Oregon is an incredible experience. It certainly doesn't have to bad. I've experienced it in Georgia, which was awful. But health care now is a massive problem. I've had to change health care providers six times in the last two years because of it being tied to employment.
2) Because it's actually cheaper to have single payer. It's huge leverage in negotiation. It will catch things quicker in more people, which means better outcomes and less dire (and expensive) treatments.
3) In Germany you can get supplemental medical insurance on top of your national Healthcare which can get you better care. Additionally there are still private practices.
4,5,6) Compared to the rest of the world the US does indeed pay dramatically inflated prices, which has a depressive effecton the finances of the less wealthy. If you're saying you'd rather people (like those waiting for Medicare to get diagnosed) suffer so you can be richer, well... at least you are honest.
Good list of objections I've heard. The people who say #1 will never get on board. The DMV is a state-level agency, and people have plenty of good (maybe not great) experiences with government agencies like Medicare, USPS or SSA. That's more of a talking point for opposition parties who oppose central government altogether.
#2 isn't a serious objection, because the math is pretty clear that almost everyone winds up spending less.
#4-6 are intractable and come down to the population having the will to overcome objections from capital and doctors. I do think that doctors and nurses are gettable if we bring down the costs of malpractice insurance and education so that overall take home doesn't suffer.
In my experience trying to sell the idea, the biggest impediment to real progress is #3, though I am certain I have a local bias. That's the issue that keeps the knowledge working class separate from the labor-working class. I haven't come up with a good answer other than accommodating them by allowing first-class treatment for those with money and second-class treatment for everyone else. Not the most altruistic answer, but probably the most achievable. No one with premium healthcare now is going to risk it, and that's an important political block.
2 is a serious objection because while a government administered program promises to be cheaper in aggregate, it will almost surely not be cheaper for every individual/household, especially if you intend for or expect people to supplement or replace the government insurance with private insurance on top of the public option to get back to the level of the insurance they have today.
You could argue that 4-6 aren’t real objections either because most people aren’t in those fields either.
In the US the cost of healthcare is so ridiculous that underwriting the system and bargaining as a unit for things like equipment, disposables, and pharmacy will save the entire system billions of dollars of overhead/profit/graft (depending on your viewpoint) that currently go mostly to insurance companies and private equity healthcare groups. At some point you will be right that the harm outweighs the good for a sizable group, but we aren't there today.
> You could argue that 4-6 aren’t real objections either because most people aren’t in those fields either.
Bingo. 50 million poor people have less lobbying clout, ie dollars, than the medical or pharma industries.
It’s no coincidence that the ACA provided for money for insurance, without actually increasing the supply of actual medical care. Increasing insurance increases demand, provides a way for the existing industries to get paid, and overall raises the cost of care.
Now had they had a lick of sense and simply spent the same amount of money on setting up clinics (ie supply side), you’d see a drop in prices as existing providers would have to compete with a lower cost option.
regarding #2, the math isn't necessarily clear at all. I actually have no idea how much my health insurance costs. my employer isn't required to fill that box on my W-2, so they don't. I'm mostly convinced that the average cost would be lower, but governments in the US do seem to have an incredible ability to waste money.
In California it's about $500-600/mo for a "Gold" level PPO plan for a 20-30s individual through CalChoice Small Business pool. Bronze level plans are usually in the high 200s to low 400s. HMO plans are usually about $100-150 a month cheaper than PPO. Vision and dental are another $20-50/mo. Spouse roughly doubles the cost, and kids add more to it, but I don't remember the exact amounts.
Keep in mind that even with the Gold level plan you are still subject to network restrictions, paying copays, deductibles, and you have an OOP maximum of several thousand dollars.
Big companies can get better rates than individuals or smaller companies and businesses get to write off the expense, whereas individuals (mostly) can't. It's only the governments' fault insofar as they haven't done something about this already. The rules were written to enable corporate profits, not quality, cheap healthcare. Even as a small business owner, trying to offer healthcare was brutal just from the sheer expense of it. It's almost hard to justify unless you have kids or a chronic condition, but you never know when catastrophe will hit, so the market is fairly price-inelastic.
Well, my insurance for a family of four cost slightly more than 10,000 last year (both employer and employee sides). You could triple the amount I paid into Medicare in exchange for Medicare covering everyone and I and my company would come out ahead. There has never been a year where I have been paying for insurance that it has not grown faster than inflation.
People with good salaries and benefits will presumably see their taxes increase by a couple orders of magnitude more than the peanuts we are currently paying for care. Our employers will save, but not necessarily share that with us. I still think it’s the right thing to do, but it’s obviously going to wreck me personally given my SWE salary.
2. The US federal government already spends about as much on healthcare per capita as countries where it is free at the point of use. You’re currently getting massively ripped off so insurance CEOs can buy another yacht.
3. All civilised countries have private healthcare as well as public. If you really want to pay more to avoid waiting lists and fancier wards, you can do so.
# 2 is what gets me. There seems to be some rather odd idea here that having any portion of ones taxes go to supporting people who can't afford health insurance otherwise, even if it means that people would pay less overall for healthcare, is somehow more unfair than having each person take the personal risk of bankruptcy due to an expensive illness. There also seems to be some thinking along the lines of not having a "choice in the market" if we're all covered by the same system as if the market really provides much of a choice now.
It's important to note that a lot of why people think the federal government isn't good at doing things is because ideologues (from both parties) make it less efficient and more painful for no practical reason. That is sometimes called "starving the beast", or "means testing".
In an insurance pool the other members subsidize you just as much as you subsidize them. Government healthcare could work that way in theory! But making government the administrator of a traditional risk pool is a boring technocratic argument. The substance of universal healthcare is a one way subsidy from higher earners to lower earners.
7. I'm a private medical insurance company. See #4
8. I'm a privately owned hospital. See #4
Overheads in the US are pretty ridiculous, and lobbying gets 5 through 8 incredible ROI.
In addition to all of these reasons, we have tribal affiliation. Health care for all has been spun as socialism for so long that real progress here seems utterly intractable. Even if you could convince politicians that your list of reasons don't add up, they'd still look you dead in the eye and tell you that it won't happen because their constituents would come for their heads.
But have a look at other countries, e.g. Scandinavia, UK. Public healthcare doesn't need to be bad. And it doesn't exclude the possibility of private healthcare.
> Scandinavia, UK. Public healthcare doesn't need to be bad
Here's an article from 2018 (Pre-COVID) claiming the NHS has 4.3 Million people in it's operation backlog with over half waiting for more than one year[1]. That sounds outrageous, and a massive step backwards from what most in the US have today (even with low tier health insurance plans).
I do not know why this is the reality in nations with Universal Healthcare, but the UK is not alone.
I constantly hear anecdotes about people waiting 6+ months for minor operations in the UK (corroborated by this article and others), and how the wealthy/elites of Canada fly into the US for treatments.
Why is it that Universal Healthcare seems to universally turn into massive backlogs and poorer service?
I'm also not convinced we need some new "Universal" system in the US. Everyone in the US already does have access to healthcare (Medicare/Medicaid/Private). The only difference is above a certain income level you're expected to shop for your own. I much rather prefer that instead of it coming out of my paycheck in another mandatory tax without choice of provider.
I live in a country with tax-paid medical (and dental, vision, everything necessary, with some minor exclusions) - they basically take 12.92% of your pretax earnigs for medical + ~30eur extra.
I pay a lot of money for those services, but i get really shitty service for some of those - eg. dental. I see a dark caries spot on my tooth, and basically if I'm good enough to eat (not too much pain), my waiting time is ~6months+ (pre-corona time, probably a lot longer now). I can go to a private dentist and get a filling, but I have to pay for the service. There is no way to either opt-out of eg. dental, or to get a part of the service paid by our national insurance (eg same price as the insurer would pay a government assigned dentist, you just pay a difference). We have a bunch of papers with a bunch of words promising <30 day wait times, but in practice, the wait time are huge.
Yes, if you cut your arm off, they will fix you, but the dental (and many other branches) are pretty bad.
Dental insurance of any kind is pretty rare in the US. Large employers may offer this to their employees, but even then it’s a situation of very high coinsurance for any procedure of substance, and covered procedures are limited. So however bad your national dental system may be, it at least provides some baseline option for everyone — including the poor, the homeless, the jobless, and employees of small businesses alike.
Let me be more frank, it is a scam and nothing more than prepayment for cleanings and X-rays in the vast majority of cases. The only time I have not paid with cash is when I was on Medicaid.
"they basically take 12.92% of your pretax earnings"
Could you clarify this? Is the 12.92% your entire tax burden or the extra amount for medical? If the former, I currently pay $92 a month for health and dental insurance. I made nearly 250K last year. 12.92% of 250K is $2,691 per month. That's .. quite the difference.
Many European countries have a high health insurance tax rate, but capped to a certain income.
Eg. Germany has a 14.6% rate for health insurance[1], but capped at 56,250 EUR of income, thus making it capped at 8,212.50 EUR annually, or 684.38 EUR monthly. Still a lot more than your $92 a month :)
> I constantly hear anecdotes about people waiting 6+ months for minor operations in the UK
Emphasis on the "minor operations". Things are prioritised by need and urgency, so naturally you end up with a long tail of non-urgent, minor operations.
> how the wealthy/elites of Canada fly into the US for treatments
There's a reasonable argument here that the US system has advantages for the wealthy. Generally however this is seen as undesirable.
> Everyone in the US already does have access to healthcare
There's several issues with this statement. The first is that 32.8 million people (12% of the population) were uninsured in 2019[1]. The second is that even if you have health insurance on paper, it's generally prohibitively expensive to use, only kicking in once a deductible is reached that will bankrupt you regardless (40% of Americans can't cover a surprise $400 expense [2] and these deductibles can run into several $1000). The reality for many is that if they're sick, they tough it out because going to a doctor may cause them financial ruin.
> above a certain income level you're expected to shop for your own. I much rather prefer that instead of it coming out of my paycheck in another mandatory tax without choice of provider.
I'm not sure what your experiences have been, but the only context where I've been able to "shop for my own" provider was when an employer happened to offer one of two providers in their available plans, which wasn't always. Functionally I had almost no choice in my health insurance coverage short of specifically finding a job that offered what I wanted, which given my priveliged position as a software engineer would be possible but would be laughable for most professions. Functionally, my health insurance was a mandatory tax without a choice of provider, it just wasn't a tax paid to the government.
I should also note that I now live in Australia, where we have a universal public system where I am still able to choose my doctor and other care providers. In fact, I feel that I have far more choice here than I ever did while living in the US.
I grew up in the US, moved to Canada. Saw a friend wait like 6 months to get an ACL replaced. Poor guy could hardly walk for that time. I've known two people who were told to get an MRI for various reasons... the wait on that is 6-9 months too. One good reason to get an MRI: internal bleeding following a concussion can kill you in days, and a CAT scan won't rule it out. But apparently that isn't a good enough reason to skip the line.
Like the US, about half of Canadians are strongly opposed to taxes. Our health care system is about as good as it can be, with the budget we have for it.
> Emphasis on the "minor operations". Things are prioritised by need and urgency, so naturally you end up with a long tail of non-urgent, minor operations.
How long do you wait for eg. a tooth filling? Or if you notice a dark spot on the skin, to get it checked up by a dermatologist? So the minor things, that can get messy real fast if you dont deal with them fast?
Obviously it would be better to have minor needs met as well. But the point is that when you say “I now have to wait too long for minor things, therefore healthcare for all is bad”, you are implying that you would prefer that you got treatment for a minor condition than someone else got treatment for a major condition.
If the main argument against nationalized healthcare is that so many more people can get healthcare that your minor condition gets bumped down in priority... well yeah, the point is that many more people can get treatment for major problems!
The problem with minor conditions is, that you still have to pay for them. You pay for dental, but don't get the service.
I pay insurance for my car (it's mandatory here - the mandatory part only covers damages on other peoples cars when you're the guilty one). I also pay (extra) for windshield repair, and when a small rock on the highway breaks my windshield, i go to one of the preaproved service centers (or do the paperwork to do it somewhere else), get the glass replaced, and go home after ~30 minutes.
I also pay for dental in my mandatory government insurance (no way to opt-out), and when i see a dark spot on my tooth, i call the government dentist, and they tell me to come in six months, at 11.30am on a tuesday. I could wait that long, but by that time, my tooth could get worse, and a simple drill-drill-fill-fill might end up as an extraction or worse. So basically, I either have to pay for a private dentist to do it (full price, not just the difference in price compared to a government dentist), or wait six months and risk it. Either way, i pay for dental, that I don't get.
Same for eg. dermatologists... find a spreding dark spot on the skin.. wait six months+ (probably more now, due to the plague), or pay 70eur and get it checked out the next day. Wait six months, and a simple burn-off could be cancer.
On the other hand, your nation, state, city, employer, etc are all run by people who were educated in this country. You directly benefit from roads every time you buy goods from any business, etc.
You cannot transmit your tooth rot to anyone else.
> If healthcare was left to free market completely
What evidence of this do you have? Because, in the US, healthcare largely is free market and we do not have the return of any plague or anything similar. In fact, it's free markets that bore out the vaccination the world is using to fight the current pandemic.
They are far more similar than you give them credit for.
Part of the reason healthcare is so expensive in the US is because people cannot afford to get preventative care and so they wait until they are basically dying and then go to the emergency room. If they couldn’t afford $100 to see a doctor before, they can’t afford the $100k the hospital will bill them so they just go bankrupt and the hospital loses it all. The hospital covers these expected delinquent accounts by charging more to people with insurance. The insurance covers these higher costs by charging higher premiums. You are already paying for other people, you’re just doing it the expensive way because there’s so many for-profit organizations in between you and those other people.
I'm definitely for universal healthcare, but one of my worries is the unfairness of an opaque system. Imagine if i'm waiting 3-6 months for an operation as I am for a COVID vaccine (true story!)
Our vaccine deployment differs by state, city, county. 30yos are getting vaccinated in a bordering state while 64yos are not getting vaccinated 20mi away. It depends on who you know, luck, bureaucracy, and how lucky you are with your particular county. I'm in Virginia now and no vaccine opportunity yet. Five miles away in Maryland my friends have received the vaccine.
Imagine this for every dental implant, sprained shoulder, etc.
I'm pretty sure universal healthcare works, but i'm not sure how to get our country to the point where it is at least fair for everyone.
As another has said, these are minor. It's OK to wait.
It isn't like you are going to be out of a job or out of much money: A safety net helps with it. So you are sitting at home or at work on light duty while waiting, depending.
As a counterpoint, I have far from "premium" insurance, and can see my doctor for any reason nearly always within a week, and have had multiple "outpatient" surgeries booked/executed within 3 weeks.
I'm not sure arguing minor surgeries can wait for 6 months-1 year+ is a good thing. If the system cannot handle both minor and major operations within a reasonable amount of time, then something is very wrong.
"Minor" could be that you have a dark spot on your skin that you'd like to get checked out. If it's cancer, waiting 6 months could mean death for you. Sure, minor could also be getting some help for some mild dermatitis. The problem is when those things are lumped together.
Minor, in general, is something that plagues you, yet waiting for surgery isn't going to be an issue. Foot surgery, for example, might fall under this. Waiting won't take complications.
For skin cancer checks, though, you can go to your family doctor. (I have to get skin cancer checks due to a medicine I'm on). If they find anything worrysome, sometimes they can remove it in-office or get you to the correct person in a timely manner. You know, because doctors know that some skin cancers spread quickly (others aren't that serious).
Minor actually means minor. It doesn't mean waiting to see if you die.
Why are you arguing waiting for a year or longer for any procedure is ok?
That doesn't sound ok to me... and objectively is a massive step backwards from what we have in the US today.
In the US today, no matter if you have zero income, little income, or high income - you can see a doctor promptly and have any procedure performed within a month of less.
Scandinavia is OK, not what many people in the US would call great. My uncle had prostate cancer, was basically put in hospice to die. He was kept comfortable and it was a nice place, but he was in his 70s and basically written off. And I'm not even saying that's the wrong approach. His life expectancy was in single-digit years at that point regardless, so why spend a lot of money on low probabilites of success? But a lot of people in the US think that every effort should be made, no matter how hopeless the situation or how much it costs.
People are afraid of government 'death panels' while completely ignoring the fact that such panels definitely exist now, but they are opaque. Try arguing with the insurance company when they've decided to deny your coverage.
A long while back, my brother worked for a local "non-profit" health insurance company. Same part of the building as some of the lawyers. They'd brag amongst themselves in the break room about the various ways they'd managed to avoid responsibility for paying a big claim. He ended up quitting his job because he couldn't stomach working in that environment.
Having seen all four of my grandparents go through their end of life, I came to the conclusion that we treat our pets with more compassion than some of what our elderly (or terminally ill) fellow human beings must endure.
I don’t think every effort should be made, at least not in every case. I don’t think every effort should even be offered in many cases.
I don’t know the exact line for me, but if there’s no reasonable prospect for 3 months of out-of-hospital life, maybe palliative care is the most humane thing. In some cases, active intervention should be able to be requested by the patient (with reasonable oversight).
It’s not primarily for money reasons, but a shocking percentage of healthcare dollars are spent in the last 1 month of patients’ lives. Some of that is intensive care for patients after trauma or other acute incident and that care should continue. But a large part of that is spent on futile efforts, what one surgeon friend of mine called “warm autopsies”.
I am an immigrant from a socialist, ex-communist country in the Balkans, where socialized medicine is the norm, as is having really good doctors. The few times I’ve had to go to the doctor there, either to be seen myself or to help my grandmother, was an awful experience. I’ve had to spend 2 weeks going from office to office until I could finally get an appointment (just an appointment!) for my almost-blind grandmother, for a simple cataract procedure.
The procedure was scheduled ONE YEAR from the time of appointment, which meant she was blind in one eye for a whole year.
That’s the absurdity of a socialized system.
Everyone already knows the absurdities of this system here so I’ll skip that part of my rant.
This issue is so polarizing, it occurred to me - why don’t we have a medicare-type system (call it m4a) for those who want it, and not for those who don’t? It’s about a 50-50 split anyway.
The catch is, if you don’t pay tax for m4a, you can’t use it.
This way, those who are concerned about “paying for others and receiving inferior service” don’t have to, and those who can’t or don’t want to deal with a privatized system are free to use it.
- If the waiting times are too long, then ultimately it's a supply issue which can be solved by increasing supply (i.e. more funding). Of course, this is obviously easier said than done but it's not really an inherent problem of the system.
- What would your grandmother do in a situation with a privatized system and she couldn't afford surgery? This isn't theoretical: this happens in the US all the time. While I agree that being blind for a year is not acceptable, it's only in certain positions of privilege in the US in the current system where you would even be treated and again is more inherently about funding than it is about an inherent fault of a socialized system.
- I think that if you don't force everyone to pay in the system and allow for private healthcare, people (and politicians!) don't have incentive to improve the system because they can just take private insurance and ignore a languishing public system. The public system doesn't have to be bad, but creating a two-tier public/private system incentivizes people to not care about public healthcare.
The issue is that of incentive, to put it bluntly.
What is the incentive of a medical provider to provide The Best Care Possible, when they know for sure there is no competition? You end up with a system whose only raison d’etre is to continue working as little as possible with no real progress.
Yes, not being able to afford it is obviously a bigger issue than being blind for a year. In this case, she had the option to go to a private surgeon and get it taken care of for much more money.
As for your last point, in a socialistic type of service, “progress” serves to elect public officials. In a capitalistic service, “progress” serves to make more money. Both of these approaches have their flaws; however, I would argue that progress is faster and service of higher quality when a government is not involved. The gov’t advantage is that it’s “cheaper” and thus more accessible to everyone.
As a commenter posted below, I think we have a critical mass of folks (half the country, basically) who would be willing to go the public route. I really have to think this through, though, bc it would create some interesting incentives to sign people up to one or the other.
Well, that means that poor people will likely have a large incentive to buy in, while the upper 5-10% would opt for private insurance rather than paying additional income tax. Unfortunately, the poor and middle class probably will not be able to fund a well functioning level of health insurance by themselves.
> This issue is so polarizing, it occurred to me - why don’t we have a medicare-type system (call it m4a) for those who want it, and not for those who don’t? It’s about a 50-50 split anyway.
I've been thinking about this a lot myself lately too. It seems like there is critical mass for the people who want universal healthcare, so why can't we make it happen? It doesn't seem that unreasonable to set up a dual system where people who want their taxes to pay for healthcare can get it, and the rest can make their way with the private insurance companies. Win/win.
The difficulty would probably be in keeping the tax pools separate. And deciding at what point someone paying into the single payer system gained permanent eligibility even when unemployed. Things like that.
Probably because people earning less than average will want to be in the shared pool, and people earning more than the average will want individual insurance schemes.
A dual system where we chose to have our tax dollars go where we want... why stop at healthcare? If I don't want my tax dollars to go to... say the military? Can I defund the federal flood insurance because I feel we need to disincentivize living on the coast as sea levels raise (and personably live 900' above sea level)?
Having individual discretion over what tax dollars goes to leads to an unmanageable mess for those trying to actually create a budget. Additionally, sometimes a national priority and the hard choices that goes with that means having taxes spent on things that aren't necessarily popular with the entirety of the electorate.
The control over the budget comes (in theory) with voting on a house member who aligns with your goals for the budget. Yes - in theory.
> A dual system where we chose to have our tax dollars go where we want... why stop at healthcare?
I think a bit of differentiation could be good, but I draw a distinction here. You get to choose among choices available to you. So unless "not paying for the military" was an option written into law by congress, you could not select that option. And it would be unlikely to be offered, for many reasons, not the least of which is that everyone benefits from the military just by virtue of living within the borders of the US.
I don't think it should be a menu where each citizen gets to select from a huge range of options. I think for some things that would work, but there are many things too fundamental to let people opt in and out.
I would contend that everyone/society benefits from having the population, as a whole, being healthy.
More people who are able to be productive members of the workforce, better mental health from improved financial security, and less cost from preventative rather than responsive treatment.
That also gets to the heart of the problem - not everyone recognizes the benefits that I've suggested from a more universal healthcare system.
I would also contend, that I don't see the benefits from the level of military spending that we have.
I see healthcare as a special case, though (the rule about exceptions becoming the rule, notwithstanding).
The healthcare system is interwoven with rules and regulations. For instance, we already have tax rules depending on your yearly FSA/HSA contributions, tax deductions based on how much money is spent, and most importantly the Obamacare rule that one must have insurance or suffer penalties. Would another exception break the system?
My main concern here is: what happens if someone who isn't paying for insurance ends up at the hospital?
First of all, does the hospital delay care until they can verify that the patient has insurance? What if it's an emergency?
If the hospital doesn't delay care, and afterwards the patient is found to not have insurance, they'd be billed right? What if they can't pay it, and they default? How does the hospital make up for that loss?
Under the current system, I believe the hospital eats the cost, and adjusts their rates accordingly, so the insured end up footing the bill Anyways. A socialized system formalize this, and distribute that cost across everyone instead of just the people who pay for insurance/healthcare.
> 1. I don’t want my healthcare to be provided by the same people who brought me a lifetime of experiences at the Department of Motor Vehicles.
The public option still doesn't create that situation because its health insurance. They still aren't going to be healthcare providers.
> 2. Healthcare is expensive. I’m already paying for healthcare for my family; why would I want to pay for healthcare for others as well?
You already are through Medicare, Medicaid, and the Hospital System. In the articles example, you have people waiting until 65 to get more expensive surgical intervention that is less likely to preserve their life due to the wait.
> 3. Good healthcare is expensive and I can afford and buy the best health insurance. I don’t want the best to be unavailable to me and my family because we’re all on a “just OK” government system.
Under a public option system, you'd still be able to buy private insurance. No one is banning this.
I think its misguided because the quality of insurance doesn't guarantee the quality of doctor and frankly, unless you are a specialist in their field, its unlikely you'll be able to accurately gauge the quality of care you receive. I've known plenty of people in the profession of manufacturing dental implants/equipment who thought they could judge the quality of their dentists and failed miserably to the point of needing to switch dentists due to poor workmanship.
> 4. I’m a medical professional and think that I will make less money under a government-provided system of care.
Alright, how do you feel about lowering the federal tax rate for me personally? Not everyone else, just me.
Seems a bit unreasonable when phrased that way doesn't it?
>"if you like your doctor, you can keep your doctor."
Which was always a stupid line because it's not "your" doctor, it was never your doctor. It was your insurance's doctor. If you get a new job and "your" doctor isn't in the insurance network, they're no longer your doctor.
> Under a public option system, you'd still be able to buy private insurance. No one is banning this.
Of course not. A public option obviously implies there is a private option. But a public option isn't the only thing being suggested. This was in the Medicare For All draft bill that Sanders introduced:
> SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. (a) IN GENERAL.—Beginning on the effective date described in section 106(a), it shall be unlawful for— (1) a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act; or (2) an employer to provide benefits for an employee, former employee, or the dependents of an employee or former employee that duplicate the benefits provided under this Act.
You can say "well, he's only one senator and he got toasted by Biden in the primary anyway", but he's a very influential and powerful figure and it's unfair to say that nobody is suggesting banning it.
If the insurance is fixed price (eg. pay $X and get $Y services), then yes. If it's a tax, you pay percentage of what you earn, and if you earn above average, you'll also be paying above average insurance rate but still getting average service.
With health care, average is just what health care is. Being rich shouldn't get you better actual health care. Cancer is cancer. A broken bone is a broken bone.
Everything else is bells and whistles. Want to pay to get that MRI next week instead of in two months? Fine. Want to pay for an fancy room? Fine. You still get the same health care, though. Even if you pay more tax
> Being rich shouldn't get you better actual health care.
Why not? If the healthcare is perfect, then there's no need to pay for better helathcare... but if it's not (eg. long wait times, outdated procedures,...), if someone pays to get a dentist tomorrow (instead of waiting 6monts for a government one), why not?
Being rich shouldn't mean that you get better health care because your net worth doesn't make you a more deserving human than someone poor. Being poor doesnt mean you should suffer or get substandard care.
And to be fair: I have socialized medicine, but I only got that lucky in my 30's after I moved from the US. I don't have long wait times for a doctor's appointment: Non-urgent has more wait time. (And it's OK: It doesn't matter if I have a cervical cancer screening tomorrow or in 2 months). I can get into the dentist urgently if needed.
If I need to wait for 6 months to get a surgery, it means it isn't urgent and there is a safety net to get me through. IF you don't have a safety net, wait times are cruel. All that said, there is a private option here and folks do pay to skip some wait time - I'm generally against this as again, your net worth shouldn't determine whether you get care due to humanity and all - but I'm fine with folks paying for general bells and whistles. Sure, have a fancy room with fancy food if you want.
You have so many replies and they're all so low quality. (EDIT: This was probably hasty of me, there are a number of good replies now. I had quoted some bad ones here, but that seems like it simply prolongs their effective life. I've removed those quotes.)
On the other hand, perhaps you'd get better replies if you started with a better question. Nobody is "against health care for all". Nobody would "vote against the idea that everyone is healthy".
A better question is: Should the US federal government (continue to) ensure that some level of health care is provided for all, and what level is that?
"None" is an extremist answer; would you abolish the Emergency Medical Treatment and Active Labor Act, which requires most hospitals to treat any person in mortal need who shows up?
"All" is the other extreme, although it's unclear whether it's an "extremist" answer if there are real countries that have implemented federally guaranteed "best-effort all health care for all". Which I don't know enough to answer. Do those places exist?
Anyway, I think that's a better starting point for the conversation.
I hate to get involved, as I am already feeling ill from stress today, but I can’t help but notice that the reasons being given as “things they’ve heard” as arguments against universal healthcare have nothing to do with the only reasonable argument I’ve actually heard.
That argument is this: first look at the history - why is it that health care is so expensive?
I (well not I, but scholars of this bent) argue some of the reasons for that are (a) price and wage controls during ww2 leading to employers subsidizing health care as a way to increase real wages while sticking to the letter of the law, so to speak, and this becoming a “sticky” practice leading to a general divorce of payee and payer in the health care system, as more and more people get employee subsidized insurance, and thus allowing prices to get distorted as the signal was hidden behind the subsidy, and meanwhile (b) the AMA, restricting the supply of doctors, bolstering their prestige, and wages. Etc etc
Just talking from the point of view of the price system, meaning nothing against people with other arguments for the existence of the ama.
So, if health insurance removes the direct price signal from health care provider to health care recipient, prices rise for years, and the problem festers and grows worse as politicians punt it down the road...
Finally we come to the universal health care system as the answer. In this light it may be seen as a further divorce of payee and payer, such that cost will rise over the long time horizon, or effectiveness per dollar will drop, etc.
On the other hand the public private quagmire that arose as a result of insurance company protectionist land grabs and back room deals between employers and insurers did no favors for outcomes under the present system. Anybody try a high deductible health plan this decade? What shit. It’s so bad that likely a universal system will be an improvement, even from this vantage.
I’m impressed to see the thoughtfulness of your response; not just correcting but and especially differentiating an “extreme” from “extremist”. I think it’s also helpful to differentiate the sentiment. One is an extremist position, the other is opposite. If you need more emphatic language the other is polar opposite. It can sound extremely far away (true without characterizing), or emphatically so (true without using words like “radically different” which are true but also emotionally misleading).
> I cannot comprehend why anyone would be against health care for all? It seems like such a silly thing to vote against the idea that everyone is healthy.
There is a large number of people who are actively opposed to the "wrong" people receiving anything, even if it means cutting off their own nose.
I don’t think that’s true. I think you’re misunderstanding the way some people perceive fairness.
There are some people who feel very strongly that it’s unfair to give out benefits such that the people who worked hard and took care of themselves are no better off than people who did not work hard.
For example, regarding student loan forgiveness, I have heard people say: “I struggled for years to pay off my student loans, but now the government is going to just cancel everyone else’s debt? That’s like punishing me for being responsible and rewarding people who didn’t sacrifice for putting the problem off.” And I can see how someone would feel that way. It would be more fair to track down everyone who had student loans and refund the full amount for all of them, including people who had already paid them off.
I’ve also heard friends who are legal immigrants oppose amnesty for illegal immigrants because they feel it’s like punishing everyone who went through all the trouble of the legal process.
I don’t think you can actually prove they are right or wrong in their argument. This is exactly like the parable of the prodigal son, so it’s an ancient human dilemma that giving grace and generosity to people who are in need tends to make people who are one notch up the ladder feel bitter that when they needed help they didn’t get it, and that their hard work is somehow invalidated by the fact that others got something for free when they had to work for it.
Finally, there’s always a question of who pays for things, and some people just feel that - while they’d prefer some government benefit in theory - they aren’t willing to pay any more in taxes in order to get it.
Considering the US has a track record of relatively high total taxation (when you add up all the local, state, and federal entities), while receiving generally poor public services, there are plenty of people who feel the answer is to stop “wasting money” on the problem and expect the government to become more efficient or better at providing services before they’d support any more taxes.
A lot of people feel that broad welcome in a policy means fewer resources to share with more people. If you're in an advantaged position, it may make sense to oppose such broad social care measures.
There is some merit to that argument, because we have artificially constrained the supply of doctors in order to sustain their high salaries. Perverse is a polite word for the situation.
Not disagreeing necessarily, but I’m not sure the 1:1 comparison works with “most of those countries”. For example, the US is burdened by a disproportionate amount of R&D which helps to lower costs in other countries. It’s a complex problem and overly simplified comparisons don’t often offer a real fix
To an extent, it does. Particularly when other countries have cost control regulations, the companies are incentivized to make up those R&D costs elsewhere. Today’s drug profits are funding tomorrow’s novel medicine.
Note in not saying this is ethically fair or optimal, just that it’s a consequence of the particular system
Again, drugs are a only a small part of overall health costs. They only make up 14% of healthcare spending[1] in the US. For contrast, they make up ~15% of healthcare spending in Canada, and ~16% of healthcare spending in the UK.
Your theory does not explain why the other 86% is so bloated.
All my comments were deliberately couched to specifically not pretend there is a simple answer to healthcare cost bloat in the US. It is merely a testament to a single factor that increases costs while also inhibiting naive comparisons. The US healthcare system is awfully complex to even scratch the surface about causal factors in a forum post.
Beyond that, you may be conflating prescription costs with drug research, which is not the same. The fact that prescription costs take up roughly the same percentage of total healthcare costs seems to support my point. An equal percentage of a bigger pie would indicate they are inflated.
My personal stance is that the US optimized for access and quality at the expense of cost. As the saying goes, you can only have two. R&D spending is a large part of this. The US contributes over 40% of the worlds medical R&D, effectively subsidizing other nations. It’s not a bad thing and it doesn’t explain away all healthcare costs but it does create systemic ramifications. It’s been awhile since I’ve viewed the numbers, but the US had the highest health access and quality scores for a country of comparable size. Off the top of my head, I think the next closest was Russia. Again, the point being simple comparisons are harder than one may think when dealing with complex systems.
The only countries of comparable size to the United States are in the developing world. That's a horrible bar for the richest country in the world to be trying to meet. If anything, it has the unique advantage of having unprecedented economies of scale among developed nations.
I keep harping on drug prices, because you keep mentioning R&D. R&D is not the reason for why non-drug healthcare is so expensive. There is no mechanism by which high R&D costs lead to high specialist/GP/nursing/administration costs. There's no way for, say, Pfizer to siphon money from any of that into R&D. R&D is not the reason for why these costs are so high.
I’m only reiterating this because your responses make me think I’m not stating my central claim clearly enough: there is not “a reason” healthcare in the US is expensive. There are multiple, sometimes covariant reasons. Only one of those is drug prices. And if you don’t think pharmaceutical companies impact those other healthcare costs, you may not have a sound understanding of the healthcare system.
Related to your comment about the difficulties in comparison, you underscored my other point. People flippantly say “but look at country X’s costs” without understanding the nuances that make such comparisons worthless.
Well, if it comes to making a choice between better health outcomes, weighed against doctors only making six figures a year (and medical schools only charging five figures per year), I think the choice for most of us would be pretty simple.
This only "makes sense" if such a person believes that their personal advantage is more important than other people. It makes no sense whatsoever from a Rawlsian perspective.
One voter quote I'll never forget sums this up: “I voted for him, and he’s the one who’s doing this,” she said of Mr. Trump. “I thought he was going to do good things. He’s not hurting the people he needs to be hurting.”
Well, if you are not from around here :-), the calculus is simple. The healthcare "industry" manages to levy anywhere from 4 to 6% tax on the GDP of the wealthiest nation on Earth, and instead of giving that tax to the Government it goes to a handful of individual corporations.
That wealth sucking monster has its tendrils deep into every PAC and politician it can find. And like a giant organism that wants to survive. It employs hundreds of thousands of people who insure that the status quo, remains.
Even people who aren't employed by the beast but are wealthy hold large quantities of "stocks" in the beast so that they, like small trigger fish on a shark, might benefit the wealth that spills over as the beast munches at the trough of human despair and disease.
Yeah, it's a bit cynical, but I swear every bit of it is true.
That same beast produced a vaccine to Covid-19 in merely two days. I believe all but one of the major vaccines to the virus come from the USA. The machine is all-consuming but it surely doesn't all go to waste.
Which vaccine would that be? The Pfizer one was developed by BioNTech in Germany (it's also produced by Fosun Pharma for China), the Johnson & Johnson one was developed by their Belgian subsidiary Janssen. I think only the Moderna (NIAID) and Novavax are truly "US-developed" vaccines. The AstraZeneca one was developed in the UK, Sputnik V by Russia, and CureVac is German.
Besides, I don't think patient-healthcare spending (where the US is spending an additional 5-8% of GDP) affects that or where they were developed.
That’s not remotely true. Even of the two RNA vaccines, Pfizer-BioNTech was developed in Germany.
The Johnson & Johnson vaccine was developed in the Netherlands.
Oxford-AstraZeneca is a UK product. And China, India and Russia each have multiple vaccines approved.
The best faith argument against health care for all is that it creates a strong incentive to limit freedom.
If the government were responsible for everyone's healthcare, then it would want to reduce healthcare costs. If it were to reduce healthcare costs, it would have to understand and regulate or tax things that hurt health. Things that hurt health are things like sugar, tobacco, alcohol, advertising unhealthy stuff to children, sports, especially adventure sports, driving, etc.
If the government can draw a direct correlation between sugar consumption and health costs, there is now a strong incentive to tax and regulate sugar.
If people go skiing and that becomes a significant health cost (broken bones) you now have a strong incentive to tax skiing.
For adventure sports, it's easy to imagine what is currently the balance between safety and excitement could end up being regulated past a point you would personally be happy with.
This increases government size, increases government intervention, and limits both business "freedom" and individual freedom. The catch phrase for this line of thinking is "nanny state."
Personally, I don't like being obese, and I don't like looking at obese people and "just don't eat sugar" is harder than it sounds. I am quite in favor of government intervention for the benefit of society as a whole in the form of things like sugar tax or sugar regulation, but I find the argument that this kind of intervention harms freedom compelling (just not more compelling than the benefits of giving up that freedom).
This is the exact argument that was used in some states regarding mandatory motorcycle helmet laws. It’s also possible to hold both views at the same time (paternalistic laws should be avoided and also society would be better off if everyone did exactly what the law intends)
I am also in favor of health care for all, but I'm not necessarily in favor of subsidizing all kinds of reckless behaviors by having the public pick up the hospital bills either.
Like, if you want to go, say, base jumping (just picking a risky recreational activity here), I'd be OK with saying "you need a separate insurance for that, if you hurt yourself the government isn't picking up your tab." That seems like a more straightforward way of handling the problem than to try to somehow tax base jumping.
The trouble is, of course, where to draw the line. It's possible that the cost of these voluntary risks is just negligible compared to general health care.
Why is a passion for base jumping more/less of a condition/affliction than doing heroin or getting cancer? What about people who take dangerous jobs, what if the job isn't so much dangerous, but the person did something stupid/against regulation on the job? What about teenagers doing reckless shit because they are too inexperienced to know better? What about STD's, those are more or less a choice to get. Kids are elective, why don't we tax pregnancy? Should we have drug insurance you need for doing illegal drugs?
How would you feel if you had kids and one of your kids took up base jumping? What if they took up high school football?
Once you've carved out exceptions, you've now changed the frame to something horrible. Systemic problems (obesity, drug use, mental health) probably deserve government meddling, but your first sentence is exactly the problem with conservative points of view. Conservatives can't put themselves in the position of doing something reckless and therefore feel they deserve to be better off (more money in their pocket) than the other person, until something bad happens to them. "Fuck you I got mine" is the liberal characterization of this attitude.
"cost of these voluntary risks is just negligible"
I was hospitalised for a few days because my cat bit me - is keeping a cat reckless behaviour?
I think it would be supremely silly, and more importantly hugely expensive, to try and monitor behaviour and track down what people were doing that caused an injury in order to decide whether their health care costs should be covered.
The solution in the case of risky activities (sport) in New Zealand is the compulsory ACC system which is insurance against accidental injury.
Every business has to pay ACC premiums depending on how risky their business is (in terms of health outcomes). If you are injured, everyone involved is indemnified (you can't sue them) but ACC pays for all your healthcare.
Eh, I don't find this argument compelling. Insurance companies already have significant influence in the government, and the line from sugar consumption to health care costs has already been established. So if this is the concern, well... guess what... it's already the case.
Also, while there are examples of behavioral engineering taxes (tobacco, etc.), this can't really be applied so easily to a basic food item like sugar, which is in practically everything in varying degrees. People have revolted over taxes on tea, mind you. A coffee tax, sugar tax, etc. is nearly unthinkable.
Furthermore, this type of taxation is not correlated with already existing examples of socialized medical systems, and this concern over pleasure taxes is not typically expressed by opponents to socialized medicine. Rather, the issue I hear expressed is that people who have good insurance already are scared they will wind up with something worse, and will have no other options at that point. This belief seems to be related and magnified by the xenophobic tendencies of the American political right (the more vocal opponents of socialized medicine; though so-called moderate liberals don't really entertain it either). They believe that if we let marginalized groups have equal access to good medical care, it will dilute their own access, creating scarcity and resulting in longer wait times to get treatment. These people also generally fear 'big government', and characterize anything run by the government as inefficient and costly. Therefore, they essentially believe they will pay more in taxes than the cost of their existing insurance; that they will be subsidizing the cost of care for peoples they generally contempt (HIV meds for homosexuals; abortions for women); and will have worse care for themselves. That's pretty much the argument in a nutshell. It's extremely petty and self-serving.
But, it's not so much that their belief is fully incorrect. While it is likely that health care would cost much much less overall for everyone, it could reduce their presently-VIP access to essential medical treatment in some instances. They believe their money entitles them to better access to medical treatment.
In conclusion, the more realistic (and actual) good faith argument is that insurance companies already do lobby the government to prevent any legislation that would pose an existential threat to their industry, which has vast wealth and power. Socializing medicine is good for medicine, and bad for medical insurers. So, they pay politicians who perpetuate the beliefs I described above and resist meaningful regulation and reform of the medical industry.
This is simply a fact. No need to construct unrealistically contrived stories about pleasure taxes. Ask these people in private what they believe. They will certainly tell you!
Canadian here. We have an extreme version of this, which includes a ban on private pay for anything covered by the public system.
It's a bad system, and what's worse is that it has become politically impossible to even talk of reform. Every politician just promises "more money for hospitals", "more money to reduce wait times", etc. and yet little progress is made on addressing these issues because nobody is willing to tackle the root causes, primarily misaligned incentives.
Our wait times for elective surgeries are terrible. Our use of electronic health records is still patchy at best. Innovation is extremely difficult - health tech startups simply cannot sell into the giant health insurance bureaucracy without going under.
Co-pays for "medically necessary services" are illegal, meaning there's rampant overuse that drives up costs. The patient experience is often brutal, because nobody is incentivized to provide a good one. If you have a chronic condition the odds are good that you will have poorly coordinated care. Specialist appointments can take months or sometimes over a year to get.
We have far fewer imaging machines per capita than almost any other Western country. Getting an MRI or CT can take a long, long time.
Instead of money, influence buys you faster access. Hockey players get primo access to imaging and specialists, as do politicians. If you know someone they can help you skip the line.
So if you mean "Medicare for all" a la Canada, this is a disaster in the making. If you mean "it would be nice if we found a way to provide basic coverage for everyone", this is a laudable goal that is eminently achievable with a mixed public/private system, where public insurance should really focus on the basics.
Healthcare is not as magically different from other industries as people think. Doctors still care about how much they get paid, how many hours they have to work, and how much time they get to spend with their families. Skill and efficiency varies widely across practitioners. Egos are involved. All of the human elements don't simply vanish because you declare that healthcare must be available to everyone for free.
Markets do a lot of things well. America does not have truly free-market healthcare, unfortunately, but you do not want the Kafkaesque, bureaucratic disaster we have up north.
If everybody in Canada has realistic access to essential healthcare (including dental and vision), you’re already doing better than we are in America. A lot of your complaints apply to our system, too—in the sense that I’ve experienced them firsthand—but I honestly consider myself lucky just in that I can afford care (cushy tech job) and I’ve never caught a hospital bill large enough to clean me out (at least, not since I was a kid without a lot of money).
Seriously. There are people in America who literally have to choose between fixing the constant pain of mouths full of rotten teeth and caring for their children. It’s not like there are no bright spots, but our outcomes are some of the worst (if not the worst) out of (ostensibly) first-world countries by most (if not all) attempts at objective measurement I’ve seen, and that’s generally not even including non-health outcomes like medical bankruptcy.
I wouldn’t say extant socialized systems couldn’t be improved upon, but I tend to think people complaining about those systems are either a) in a position where they could afford care in America, which absolutely isn’t everyone, or b) just don’t know how good they have it.
Nope, vision and dental aren’t part of our system - and thank god because they’re much more pleasant to deal with.
I’ve experienced our healthcare system both as a patient and as an entrepreneur trying to innovate. On both counts it has been brutal - the best experience I’ve had by far was when I had orthognathic surgery, which falls under dentistry and is therefore private pay and subject to market conditions.
It was night and day. I could email my orthognathic surgeon when I had questions, where my family doctor is an inaccessible black box that can barely be assed to fax (yes, fax) a prescription renewal to the pharmacy after a week of hounding his secretary.
I started a telemedicine company that was treated with downright hostility by government bureaucrats who had their own vested interests in competing with the private sector.
If you think what Canada has is great and I’m just a complainer it’s because you haven’t looked at how the rest of the world organizes care. A competently regulated private insurance market can deliver the same broad coverage at a lower cost and with better patient experience than our incompetently-run crapfest of a system.
> If you think what Canada has is great and I’m just a complainer it’s because you haven’t looked at how the rest of the world organizes care.
I think a system where everybody has access to healthcare is better than one where they don't, assuming the outcomes are comparable. For Canada vs. America, the data I've seen do not bear out a claim that Canada has worse outcomes in aggregate. Furthermore, from what I understand of it, Canada's system guarantees everybody healthcare. On that basis I'm claiming that it has a significant advantage over the American system. If you'd like to argue that it's not important that everybody has access to healthcare, do that. Otherwise, I'm glad you have the money to pay, and I'm certainly glad I have the money to pay (up to a point), but I don't see that as a good reason to ignore those who don't.
I'm not married to any particular way of setting it up. I just care about outcomes, and it's obvious to anybody who's paying attention that healthcare in America is fundamentally broken with respect to outcomes. Vague claims that the free market will fix everything if we just let it work its magic (as seen in other replies to my comment) are not convincing to me, because why should they be? Saying something doesn't make it true. People say a lot of crazy things, and a lot of it doesn't even pretend to try to make sense.
Related to that, I would be for starting off with a state by state or federal Dental coverage for all. Overall health starts in the mouth. A lot of people don't know that. If we start treating people for simple things (before they get bad) in the mouth we will save a lot of money when trying to do Medical coverage for all.
> There are people in America who literally have to choose between fixing the constant pain of mouths full of rotten teeth and caring for their children
And if government got out of the business of healthcare --other than ensuring a fair and safe market-- these people would not have to make that choice.
Take corrective eye surgery as a very simple single-variable example. It used to cost tens of thousands of dollars to have your eyesight corrected with laser surgery. I think we are down to $500 or $1,000 these days.
Imagine that, with different scales, applied across the entirety of healthcare. Let entrepreneurs do what they do best. It has proven to lift more lives than anything else in our history.
> And if government got out of the business of healthcare --other than ensuring a fair and safe market-- these people would not have to make that choice.
I don't follow. As far as the people I'm talking about are concerned, the government is not in the dentistry business, so what business are you imagining them getting out of? And how would said getting-out make dental treatment affordable for these people?
In fact, dentistry seems to be managed more or less on the same basis as vision in this country, i.e. the ceiling on cost is relatively constrained and either you pay for it yourself or you have insurance that's separate from any standard health insurance you may or may not have. With regard to your LASIK example, as far as I can tell, lots of things in dentistry—e.g. orthodontic treatment—have gotten easier and cheaper and more effective, but they haven't invented an automated dentist-bot yet, and I am very skeptical of your (apparent) implicit claim that government meddling in the dentistry industry is to blame for that. It seems a lot more likely that different problems are different, and some are less amenable to technological breakthroughs and automation than others.
I have already said the variables, or points of influence, are significantly greater and deeper than just one item.
Government has its paws in dentistry and eye care just as much as it does everywhere else in the medical field. Let's take three of those layers.
First: By guaranteeing exorbitant student loans it causes people to graduate with $300K+ in hard costs for their degrees. Medical education is not a free market in that sense. Universities can charge whatever they want because they have guarantees from the federal government. It's easy for an 18 year old to enter into a $300K+ commitment without having a clue what that means in the long term.
Second: Government has known that our tort laws are in real need of modification. The cost of malpractice insurance varies from specialty to specialty, yet it can be in the tens of thousands of dollars per year. It is important to note that, when you walk into a hospital, the entire medical staff has to be on malpractice insurance and the hospital itself has a set of umbrella policies.
Third: If you are going to face attorneys, you need attorneys of your own. Hospitals have expensive law firms, attorneys on staff or more.
Fourth. Medical device and drug regulatory costs are insane. I tried to develop a simple hearing assist device years ago. The FDA costs to get this super-simple device (that would have potentially helped tons of people) was easily in the tens of millions of dollars. Massive. It also required years of pounding your head into the FDA wall to push it through. This is one of the reasons for which we have lots of bright engineers working on how to get people to click on ads rather than on developing medical solutions.
Fifth: The tort reform issue extends into the medical device and pharmaceutical industries. Let's say I did make that simple hearing assist device. Well, I would have had to have a sizable amount of cash devoted to both liability insurance and simply paying attorneys a ton of cash to defend from lawsuits. This is a sad reality of any industry in the US and it is particularly worse in the medical domain. Our companies get sued all the time, and it cost a ton of money to defend yourself and your company. This is why most of them try to settle and avoid courts. It's expensive, yet cheaper. In fact, this could be a sixth point, how the government has fucked-up courts, but I'll leave that one out.
There's more, a lot more. I haven't just had a casual look at this. I've been running businesses my entire life. I am very much used to deep analysis of the cost structure of things before reaching conclusions. Most people don't do this. They look at something like "raise minimum wage" and think of it as a single variable problem rather than the complex multivariate system of equations it represents.
The medical industry is governed by financial equations as well. And just like in any other industry, the cost of goods sold (COGS) drives the cost of products and services end-users pay. Just like nobody is going to sell you a laptop or an iPhone at a loss, nobody is going to perform surgery or see a patient at a loss. Each layer in the chain has costs, families, loans, responsibilities to look after.
At the most basic level the problem is simple: If you increase COGS, prices go up.
And then there's the need for profit. Yes, I did say "need". I know some think profit is evil. Well, get over it. It is a necessity.
Have you ever had to keep people employed, leases and rents paid, mortgages paid, student loans paid, for, say, six months or a year because of some event that led to an economic downturn?
Most people only think of this pandemic as such an event. Not so. This kind of thing happens every so often in business due to a range of reasons. I had to take a second mortgage on my home and fill-up a bunch of credit cards to keep people at my company employed back in 2008~2010. We had a bunch of money (from profits) saved-up, yes. It wasn't enough. We were coming out of a couple of years of capital intensive R&D and were not ready for what happened with the economy. Profit --business and personal-- leads to savings which leads to stability.
In a nutshell, a person graduating with hundreds of thousands of dollars in student loans, needing tens of thousands of dollars per year in malpractice insurance, with hundreds of thousands of dollars (or more) in additional debt (home, cars), etc., will demand a high salary. Not because they are greedy, because they could not live without it. When your base burn is $15K to $20K per month, you can't work for minimum wage.
This leads to healthcare costs being high. You have millions of medical professionals and millions of medical clinics of all kinds who's financial equations are driven by exorbitant costs that are a direct result of government action or inaction for decades.
These are not new problems. They've been talking about them every election for as long as I can remember. It's just talk. Nobody does a thing about it. Just like gun control. Talk, talk, talk. People vote for you and then you do nothing about it. I don't understand why millions of people don't rise up and protest the abject incompetence and dishonesty of our elected officials. They have been talking about fixing this and fixing that for over fifty years and do nothing. Our political system is badly broken. And we pay for it in more ways than one.
You might disagree with me because, perhaps, you like government to run everything. Yes, government is necessary, and yet it has to be controlled and in moderation. Reality doesn't change because you don't like what you just read. And our reality is that our healthcare system has the government's fingerprint all the way to the starting point, when a well-intentioned 18 year old decides they want to become a medical professional. We have friends who have literally sent their children to other countries to study medicine (they can because they have dual citizenship) because they can graduate with a good medical degree at a small fraction of the cost of what the equivalent education would be here in the US. That, to me, says it all.
You’re complaining about our government’s systemic dysfunction, which is not something I’ll argue with. I think we are circling the drain and already totally fucked, honestly. So when I talk about making some aspect of our society work better (e.g. healthcare) I’m presupposing that we’ve managed to sort out a government that’s halfway interested in making things work.
Put another way: it’s a false dilemma to say we can either accept the non-attempts of our non-functional government to fix issue X, or throw Americans to the capitalist wolves and trust them to build us a libertarian utopia where the free market solves all ills. The latter is extremely naive.
Despite what you seem to assume about me, I do believe in capitalism up to a point, actually. I think it’s the best way to bubble up drive and vision to a place where the individuals so endowed can move us forward as a civilization. But, when we’re talking about administration of a broad application of settled technology (in the broadest sense), the advantages of capitalism tend to be subsumed by blind profit motive; this gets us monopolies, it gets us rent-seeking and racketeering, it gets us abuse of consumer “rights” and outright human rights in many cases. I really don’t buy that all of this is the government’s fault; corporations with unchecked power have done some pretty horrible things.
Your claim that profit is necessary isn’t true, either, except in the broadest reference frame. One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth.
Now, do we need to do a better job at the interface between public and social services (e.g. the people who run the trains) and private enterprise (e.g. the people who manufacture the trains)? Yes, we do. The same would go for an expanded socialized medicine program, or just an attempt to stop the bleeding with our current system. But this brings us back to the same place: everything is broken, and the outlook is bleak. And the proposed solution of a “well regulated” (imagine I’m waving my hands around) free market does not convince me, simply because profit motive does not necessarily align with human happiness and well-being. History is full of examples of just how incompatible those two things are, and the present has some good ones too.
> One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth.
As I said before, and I'll add a little bit: Please, grab a spreadsheet, start to develop the financial equation for anything you care to look into and think it through.
Public transportation probably has a much larger profit motive than any private enterprise. You have to look at the financial equation that drives the thing. They don't call it "profit", and yet it is exactly the same thing.
What form that it take?
Go research benefit and pensions. People in these government organizations get life-long pensions that they did not pay for. They also get life-long health coverage...they did not pay for. These pensions are unsustainable without the "profit" in the form of ever-increasing taxation, bonds and other methods.
It's money in excess of the cost of goods sold. Same thing. Different name.
I think you misunderstood my perspective on this. I am not proposing some crazy scenario where capitalism runs rampant doing as everyone might wish and make an even bigger mess out of healthcare. Not at all.
My point of view is very simple:
Government is bad at executing on just about everything.
Their role should be to engage in creating the legal and regulatory framework within which entrepreneurs have to function in order to deliver goods and services.
They should not be in the business of implementing any of it. They fuck it up more often than not. Look at the mess the Trump administration made out of the vaccine deployment as a recent and painful example. This isn't a Republican or Democrat thing, they all suck at getting things done correctly, effectively and efficiently.
They should have grand debates (in public) exploring how to engineer a legal and regulatory framework for healthcare that allows our entrepreneurs to deliver excellent products to everyone. No monopolies. No exclusions. Etc.
Of course, they also need to make sure their rule-making deals with all relevant elements of the financial equation.
Simple example: You cannot, positively cannot, lower the cost of healthcare in the US if a medical education costs hundreds of thousands of dollars, malpractice insurance tens of thousands, and a hospital has more lawyers than doctors. It's crazy. So, again, for example, get out of the student loan business and education costs will come down.
There's a lot of "structural" work that needs to be done before any insurance entity, public or private, can reduce costs. I've been saying this all along. This isn't magic. It's math. There's a financial equation for everything and you can't force lower end-user costs if the cost of goods sold is high.
It's the no-free-lunch principle. Probably the fundamental law of the universe, right up there with gravitation.
> Go research benefit and pensions. People in these government organizations get life-long pensions that they did not pay for. They also get life-long health coverage...they did not pay for. These pensions are unsustainable without the "profit" in the form of ever-increasing taxation, bonds and other methods.
Yes. Public money subsidizes public transit, and that money comes from taxes etcetera. I'm not sure how any of this is supposed to contradict what I said, which explicitly acknowledged that public transit examined in a context-free vacuum is often a money loser—do you think I imagined that the funding for it pops out of thin air? The point is that mass transit is necessary for cities to function beyond a certain density, so the economic dividends of a growing city must in part be credited to it.
You could probably make a reasonable argument that if workers kept more of the wealth they create then public transit could more easily operate in the black. Instead, the people least likely to use it keep most of the money the people most likely to use it might have spent on it. Holding our current (extreme) wealth inequality equal, the solution to this is to disproportionately tax the wealthy to fund it. They may make a fuss, but they (or at least we) should remember that they made their money on the back of a functioning society.
Most of the very large cities in the Western world do appear to have relied to some degree on public transit to attain that status, so if you want to argue that it was actually an economic drag they'd have been better off without, the onus is on you to put together the spreadsheet (or whatever) proving that.
(We also have a problem of it being extremely expensive to build public transit in our cities, much moreso than in e.g. European countries with heavily socialist policies. To me, that suggests that there's a lot more going on here than big government bad, big corporation good.)
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> Government is bad at executing on just about everything.
> Their role should be to engage in creating the legal and regulatory framework within which entrepreneurs have to function in order to deliver goods and services.
There's a problem here, which is that the latter is something they will have to execute on, and I bet neither of us believes our current government is up to it. So that begs the question: if we did have a government actually capable of executing well on hard problems, why should they not directly solve the public problems that private enterprise is not well suited for, i.e. the ones that do not produce tangible local profits in the short to medium term?
Our government put men on the fucking moon, and IG Farben made Zyklon B for the Nazi gas chambers and bought slaves from the SS to use in lethal medical experiments. The right answer isn't easy; it may not exist at all, in the sense of having a destination and a workable route thereto through the intermediate configuration space. It's certainly not going to be as simple as people on Twitter want to imagine it is. Unfortunately, your vision of government stepping back to let private enterprise (with a gentle guiding hand) create a utopia where all people are provided for in their every need seems just as hopelessly idealistic as anything else.
> There's a problem here, which is that the latter is something they will have to execute on
That could be slicing it too thin. Either we trust them to work on legislation and regulatory matters or we don't. In which case we have an even larger problem. When I say "execute" I mean the act of creating, administering and running organizations. Yes, there are examples of what I will call corner cases where they do OK.
> Our government put men on the fucking moon
I'm going to pull the "that was a different era" card on that one (and a bunch of others).
One thing that seems to be painfully clear of our era is that we can't seem to get anything of note or scale done. Here in California they sold everyone on high speed rail. Ten billion dollars they said. LA to San Francisco or some such thing. Well, we are up to, I think, $100 billion and, as far as I know, we haven't even built ten miles. Even worse, what we built doesn't even qualify for "high speed" by any stretch of the imagination (and you can't even ride it because it isn't finished). If I remember correctly, the project started in 2008. Twelve years later and we spent ten times what it was supposed to cost and have absolutely nothing to show for it. At this rate we are going to end up spending a trillion dollars on this disaster.
That's what I mean by "government is bad at executing on just about everything". There are so many examples of this its a tragedy.
Here's another one that drives me insane. The postal treaty of 1879. This is the treaty that makes it so parcels from China travel across the US for free. Yes, taxpayers subsidize transit of Chinese shipments through the US. The intent, back then, was good: Help developing nations gain access to markets and grow. China is the second economy in the world. This treaty is beyond ridiculous. I, as a US-based manufacturer, cannot compete with Chinese counterparts along a number of vectors. And yet, if my cost structure was exactly the same and my COGS was exactly the same as theirs, I could not ship across the US for free...and they can.
How incompetent do politicians have to be not to understand something like this and rescind it 25 to 30 years ago, if not earlier? The only politician in memory who even spoke about this and wanted to rescind it was Trump. And, of course, because our politicians are far more interested in party warfare than actually delivering results for the nation, nobody supported him. And here we are, subsidizing China's businesses.
This is a failure of execution in the sense that, when a problem is identified you move to resolve it. Ignoring something like this handicaps every single US business and it is objectively wrong.
> The right answer isn't easy; it may not exist at all
I could not agree more. While I believe my analysis of the various scenarios we discussed has merit, I have completely failed at even imagining what a real executable solution could look like. The reason, I think, is that the system has so many moving parts, so many variables, and such history, that it is now nearly impossible to alter the course we are on. Well, until we crash into a bank and they have to dig us out of the mud. Sorry, didn't mean to be defeatist...I just haven't come across anyone who can conclusively demonstrate that we have path out of this mess.
> Unfortunately, your vision of government stepping back to let private enterprise (with a gentle guiding hand) create a utopia where all people are provided for in their every need seems just as hopelessly idealistic as anything else.
Likely so.
This is where we can start to get into a philosophical discussion, the start of which is a simple question that is likely almost impossible to answer completely:
Are human beings free; or are we meant to be controlled by a ruling class?
These are two extremes. At the "I am free, man" end of things you have a complete mess. All you have to do is look at what happens at a Walmart when people get desperate. And, of course, at the "submit to our rule" extreme you have pain and misery...because men are evil to each other and we do evil things to each other...that's why my grandparents had to face a genocide and the death of so many members of their family...just because they existed.
I don't believe we do well in a 100% free state. What I mean by that is that humanity has shown this framework doesn't deliver a better life for the community, much less a large nation. In fact, this has never reached the scale of an entire nation for a reason; it doesn't work.
We do have examples of the opposite extreme, and as I said, it ends badly. I think reading The Gulag Archipelago should be required reading (perhaps in abridged form) in order for our young adults to understand what some of these systems can turn into.
I can't tell you what the right balance between those extremes might be. The US seems to oscillate around a centroid that has, so far, delivered decent standards of living and a sense of future that does not exist in other parts of the world. And yet I shudder to think about what could happen here if and when unemployment doubles or triples due to the almost impossible-to-stop domination of business markets by China.
What then? How will we behave? How are our politics going to change?
I have my predictions --based on having lived in multiple cultures, including under military rule. I'll spare readers the gory details at this point. It's too depressing to write about.
Here's a painful and personal example of the dysfunction one can experience in our broken medical system.
My mother is dealing with stage four pancreatic cancer. She has done OK but, of course, there is no stage five for a reason.
She is currently in the hospital (I was with her yesterday; I typed my prior comment from the hospital) with some complications. Doing OK, we think.
Here's the bullshit: Her oncologist can't go see her at the hospital because he is not in the system. The best they can do is consult with him over the phone for his opinion and then make their own decisions. Yes, she is on the ACA.
The sheer lunacy of this scenario is hard to describe with words. Screaming is more in line with a proper description.
I am not going to blame government for this. I have no clue how this situation is so other than to understand that it is about money, about who gets paid for what. And yet, our government makes the laws and rules that govern such industries. They have fucked up healthcare beyond what any objective observer would, I suspect, think is a good system that serves patients as first class citizens in a healthcare system.
Even in third world countries your doctor can come see you at any hospital. Here, in the US. Not so.
If you were wondering why I am so down on what our politicians have done (or not done) over decades, it comes from far more than an academic thought exercise.
Really sorry to hear about your mom. I wish her the best.
I'd been meaning to write a more substantial reply to your last comment, but I've been underwater at work and haven't had the time; maybe this weekend. But I do think we have a lot of common ground, and you certainly won't hear me defending our current healthcare system or many of our current politicians.
No problem. Part of life. She is doing fine and out of the hospital for now. Thanks.
One of the issues I have with trying to have longer discussions on HN is that there are a lot of non-participants who have nothing better to do than to downvote rather than participate. I don't care about the little karma counter, could not care less. What I do care about is being able to have reasonably intelligent discussions where people might not necessarily agree without using karma violence to silence one or more participants by eventually having posts flagged, etc.
HN, for the most part, is a decent community and they have done a great job of maintaining order. As someone who has been participating on discussion communities since the days of USNET I am equipped to fully appreciate the effort that has gone into HN.
That said --and I know this is hard-- I wish they could figure out a way to eliminate what I perceive as sophomoric punitive down-voting that is generally devoid of any substance and has, from my perspective, no value at all.
The only way we learn anything is to engage in substantive conversations where we openly explore ideas we might necessarily agree with. Canceling those we might not align with serves nobody, does not lead to anyone learning and all sides of an argument lose.
Yes, I know this is a hard problem.
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My general view of what government can accomplish and how tends to be very negative because I have seen them muck-up just about everything they touch. People will demand more from a fast food restaurant than the politicians they elected. It's crazy.
For example: Why is it that politicians suffer absolutely no consequences for lying to us? None. In fact, as a matter of law, if you or I lie to the federal government we go to jail. They can lie to us on a daily basis without consequences. How is that possible. You lie to a police officer and, same thing, the consequences to you are severe. The opposite is not true.
This asymmetry is very, very wrong. And yet, as I mentioned, we demand more of a fast food eatery than the politicians we elect. How does that happen? Lack of education? Lack of information? Indifference?
Same with the freedom of the press. Do we really think the bill of rights created this protection to include lies, fabrication and manipulation? I know this isn't an easy problem to solve. Sure. Well, how many centuries do we need to sort it out?
Oh, wait, these are things that require politicians to do their jobs. Never mind.
Yeah, the idea of having these people have full control of healthcare terrifies me.
Interesting example: you are arguing government is the problem. In what way is eye surgery is regulated less than dentistry?
On the other hand laser technology has hugely improved in the past couple of decades. Much of it thanks to publically funded research.
Science and technology has lifted lives out of dirt and poverty, not abstract 'enterpreneurship'.
Our Nobel prise winners do not become businesmen, and do not die billionairs. They give away fruits of their labour in public reports, they keep no IP or patents.
When market is saturated enough and there are 2.5 big companies serving it suddenly there is no room for entrepreneurs. The companies would rape their customers when not enough competition.
> Our wait times for elective surgeries are terrible. Our use of electronic health records is still patchy at best. Innovation is extremely difficult - health tech startups simply cannot sell into the giant health insurance bureaucracy without going under.
Americans who propose such systems have no awareness of this reality. While "healthcare for all" sounds great and makes for a good political campaign slogan and bumper-sticker, none of these people would tolerate living under that system for a microsecond.
Some of us have had the experience of living in countries where you have "healthcare for all". And, I have to tell, you, it isn't "healthcare" and it sure as hell isn't "for all". Wait times in the hours, days and months are not uncommon.
I have to believe entrepreneurs could do far better than government ever could. This has been the case for nearly every human pursuit in history. Not sure why we don't give it a shot. Setup a competition. Let the best system win. Let people choose.
I am Canadian, live in Toronto. Lots of what you say is true. But generally there are good sides as well. I've had either experience. One has to be smart though. I know it is nigh to impossible to get to walk-in clinic where I live. Multi hour wait guaranteed. What I do in this case - buy bottle of vodka and go visit my friend in Vaughan and show up in their clinic. Most of the time there is no wait there at all.
But then the best facilities and the best doctors would all be in private practice where they could earn more money, and the public care would be done by whoever was left over.
I think that’s a bit of an exaggeration. Most healthcare workers got into the field for reasons other than money. And with a well-funded public healthcare system, I think the US could still support pretty good wages. For example, the VA and military can attract a pretty good standard of doctor, partially through the offer of paying for medical school and with excellent benefits. I don’t think that every top specialist will opt to serve the rich in private hospitals, or that there would even be adequate demand from those rich to require the supply of every top doctor.
That actually depends on implementation: there are countries where private practices practically don't exists besides people in the 1% who pay for the convenience and attention; and countries like Poland where a lot of people have work-provided healthcare benefits which mostly decrease wait time for specialists - very limited subset of healthcare overall, there are no common private cancer treatments etc.
I don't think there is country where people buy very broad private coverage after having mandatory public one, so the scenario you're trying to present wouldn't happen: there would not be enough jobs for "all the best doctors" in private sector.
>I cannot comprehend why anyone would be against health care for all?
Nobody is against health care for all. Everyone wants that, people disagree on the optimal way to achieve that goal.
It's like saying "I don't understand why anyone would be against housing for all?" while you're advocating for confiscating all private property and having everyone live in state-run housing. Which is fine, and maybe a good way to achieve that goal. But isn't the only way to do that.
I'd like to believe this actually true, but I don't think so. Otherwise we would be able to have actually healthy debate about it. I think the reality is there is a very vocal group that wants state run healthcare and the other side thinks things are fine the way they are. If there's another way to do it, let's hear about it.
Few will say that explicitly in mixed company, but the gravitational pull seems pretty clear to me in the wider debate. Nobody is against health care for all who deserve it, but it's considered very gauche in most circles to directly argue that some people don't deserve health care, so I think it sublimates into complaints about stuff like the constitutionality of the ACA mandate or wait times for hip replacements in Canada or whatever.
>I cannot comprehend why anyone would be against health care for all?
Because people keep coming up with schemes that involve things that are deal-breakers to various groups of people.
Then you add up all the various groups and suddenly there's a significant majority/minority that will vote against universal healthcare.
It doesn't help that voting for a politician is basically a blank check to do whatever for the course of the term. Many people are for universal healthcare but vote against it because they expect the politicians to botch it.
But this isn't a full explanation, is it? There are schemes such as Medicare for All that a large majority of Americans accept, yet they aren't implemented.
And even amongst the republican party almost the majority support Medicare for All, yet democrats don't support it, why?
There are plenty of people that would support an imagined Medicare for All with the same cost that the UK's NHS has and the same level of care of the best US insurance plans, minus the bureaucracy and struggle to get treatment approved. Unfortunately, whilst this sells well to voters, any actual concrete implementation runs up against the fact that you can't actually have both - the NHS gets those low, low costs by not offering expensive treatments at all and having long waiting lists for most other things. Also, any major changes to US healthcare run into the issue that it involves a lot of well-paid jobs, and so a lot of the promises made by politicians along the lines of Medicare for All would involve making a lot of voters much less well-off by cutting their pay. That's not popular either.
People accept “Medicare for all” just like they accept the most recent “covid relief bill” with $1,400 checks per person. If you get into specifics and start including costs (taxes) into the equation, the popularity falls off a cliff.
This is also exactly how Canada passed its Single Payer healthcare, Province-by-Province. Saskatchewan was the first Province to offer single payer in 1947, followed by Alberta in 1951, etc. By 1961, all Provinces had some form of a single payer healthcare system. To this day, Canada's single-payer system is Provincial, not Federal.
Yes, it started within each province, but the Federal Govt passed laws in 1981 defining what each province had to offer. If you don't adhere to the rules, say bye-bye to federal funds.
It would be fairer to say that the Canadian system is national with provincial implementation within that framework.
Yes, that’s a great point, but it’s important to understand how the status quo system came about. There’s a path dependency. It didn’t start as a top-down system, it happened from the bottom-up, and the Federal government only supplemented funds once the political will for the healthcare system was broad enough that literally every province was bought into it.
None of that is the case in the US yet. There have been attempts (by the Rs) to provide block grants to States which have received pushback by the Ds.
Also even today, the Canadian Federal government does not supply the majority of the funds for each Province’s insurance system, it’s still a minority relative to the Provinces. It’s an extraordinarily stable system because the power over whether the system continues to function is largely decentralized.
The federal transfer payments for healthcare are significant. I cant find exact numbers (no doubt they are out there), but I vaguely recall hearing it’s close to 50%.
But yes, each province developed their own program and the federal government agreed to throw in funds as long as certain requirements were met.
Not that different from federal highways funds in the US actually. That’s how the federal government maintains minimums for drinking age, DUIs, speed limits, etc.
Maybe another potentially surprising fact: Canada’s Federal income tax is more or less identical to the US’s; and in fact the US imposes a slightly higher tax on ultra high earners than Canada. This works in Canada because Provinces levy high taxes as well, and 80% of government spending in Canada happens at the Provincial level. In other words, if Americans want to make the US more like Canada, there’s a really easy way to make the US more like Canada: the States.
Both sides would say that they are the ones supporting the nation's health and supporting people having access to healthcare. The reasons why typically have to do with the average quality of care and the cost--the same things you want to improve--however, while you advocate for removing the private market to improve health, they advocate for removing the government skew on the market to improve it.
A lot of ink has been spilled over it, on both sides.
There's a third side and it's the one that's been winning: use regulatory capture to increase health industry profits. This is the side that brought you the ACA and individual mandate. The only reason the mandate existed was to protect insurance company profits. If you look at the cost of healthcare, it's skyrocketed post-ACA.
While I'm a proponent of socialized medicine and M4A, without a doubt even the free market would be better than what we have.
I don't think that majority of people are opposed to the idea that people who need healthcare should not get if they can't afford it. It's more that there are different ways of achieving that and there are different degrees of service you can deliver that satisfies that requirement. That's where people disagree I would think, and it creates a deadlock of sorts.
"I cannot comprehend why anyone would be against health care for all?"
I think it's because we imagine how it would pan out based on current costs. When I was running my own company, the premium for really good health insurance was $2400/month for one employee and their family.
So, if you assume everyone will be given good insurance and do the math, there are some REALLY BIG new taxes coming your way to do that.
Of course, it doesn't have to be that way, but we US citizens can't imagine the government doing it well without taxing us to death. At least some of that worry is well founded.
I don't think people imagine good insurance for everyone will be $1500/month. Maybe it would be, but it's hard to fathom given our terrible track record thus far.
>> I cannot comprehend why anyone would be against health care for all
A lot of people feel slighted that they work, or worked to pay for things and other people that don’t get those things for free. Health insurance is provided by your employer so it is one of those things.
"Healthcare for all" and "single payer healthcare" are two very different things. Most countries still have private health insurance companies, but the government subsidizes healthcare.
The main blocker of doing this in the US is that the focus tends to be on building a single payer state. ~80% of the population already has insurance through private companies, and they're mostly pleased with it.
What percentage represents “mostly” here? We’re solidly upper middle class and I can’t think of many people who are. The only time I was when I worked for a California startup and that was like magic compared to insurance in New Hampshire.
I'm actually for universal coverage in the US, but rationing de facto exists in all systems and it's kind of a question of how, not if. So some people feel they are better off if that rationing is done some other way (like money).
I'm for universal coverage because we know health costs go up when people can't get certain basics and we know this actually puts people at risk of homelessness.
I worked in insurance for a few years. I worked for Aflac. They mostly do supplemental insurance and they made most of their money in Japan, a country with universal coverage.
So some countries provide universal coverage and allow for supplemental coverage. My best understanding is this works fairly well and fixes some of the problems I've heard Canadians complain of in their system, though I could be misinformed. I don't have first-hand experience with either.
One last argument that I think isn't entirely crazy talk:
People who can get free care may neglect their health because they figure "it's free." This can end up being a big burden on not just the healthcare system but society in general for various reasons.
> People who can get free care may neglect their health because they figure "it's free."
Surely more people neglect their health (as in, they may worry about it, but they don't do anything) because it costs money they don't have to go see a doctor?
I was a military wife when I was diagnosed with a serious, incurable condition that is very expensive. Most of my medical care was free. I had the occasional small copay for drugs not carried by the military hospital.
I began getting better by spending $300/month on supplements and making dietary changes.
I was a homemaker, so it "wasn't my money" and my husband wasn't an ass about it, but money was always a sore point and I always felt very aware of some of the psychosocial stuff where everyone not only thought I was kind of a loon for pursuing "alternative" remedies, but I was also "being financially irresponsible" to do so.
I got better. I feel justified. The world continues to call me a loon to my face.
I can't win for losing, but it's made me very aware that if you give free drugs to people, some people will take drugs instead of doing things like eating healthy and exercising.
I think in general people only care about what is going to impact them directly. If they already have healthcare, they assume those that don't are doing something wrong or simply just don't care. I have mine, you're on your own.
The reality is quite different and there's so much money to be saved on healthcare long term if we do this.
While I think this isn't stated very well, from a Canadian perspective I think there must be some truth to it.
Of course, the Republican party will always oppose universal Healthcare. But why does the Democratic party oppose it when the majority of Americans can agree on the specific plan of Medicare for All and much more than the majority of Democrats too?
There must be some reason for the Democrats not to back a generally popular and overwhelmingly popular amongst their base policy that also is generally good for the country and economy, both to reduce inequality and increase economic output, but I just don't see it plainly.
The vast majority of Democrats do support a public option, which is universal healthcare, and that's currently part of the party's platform. Whether to limit or abolish private insurance is where it gets contentious, and where support isn't as strong. While I'm sure the insurance industry is also a factor, the Democrats are more or less following the poll numbers on this.
Why abolish private? I'm reading from HN about being more like EU regarding Healthcare but private here can do what they want and even get paid for treating with public money if they accept the shittier government mandated prices.
Oh, no one means abolishing private healthcare suppliers.
The question is whether you should be able to completely opt out of the public healthcare system and go 100% private. Which IMO you shouldn't be able to - otherwise you get yet more fragmentation and higher costs.
But certainly, most healthcare providers would still be private at least for a good while.
Afaik, American parties are much more about winning elections than ideology. It is not certain that supporting Medicare for All would have increased Joe Biden's chances of winning. Especially since their strategy was to get Republican and right-leaning voters to switch parties. Also, Biden handily defeated Bernie Sanders in the primaries so it is not certain that more progressive policies would have benefited the Democrats in the general election.
It seems to be a version of the sunk cost fallacy.
Democrats spent a lot of political capital to pass the ACA, and the thanks they got from voters was being kicked out of the majority for almost a decade. The law was unpopular at first, but now that people have gotten used to it, the ACA finally has majority approval. Today, Democrats are back in the majority and one of the major figures in passing the ACA is serving as POTUS, so he sets the agenda, and the agenda is to fortify the bill which is essentially his legacy.
Meanwhile M4A is championed by an Independent senator who isn't even a Democrat. No way Democrats are going to go with his plan, even if it's supported by a majority of their base.
I await the excuses about how Republicans obstructed their way through a utopian healthcare law while Democrats held the House, Senate, and Vice Presidential powers.
It's the same position the Republicans were in a few years back when they controlled all the same and vowed to repeal ACA, which never happened either.
Both parties thoroughly enjoy the talking points and fundraising opportunities.
Certainly they wouldn't support M4A, but it's definitely the Democrats that work to pass laws that increase the cost of healthcare. Prices have been spiraling out of control since the ACA.
As someone who has been purchasing individual insurance since 2003, prices were spiraling out of control long before the ACA. My premium went up every single year outside the first couple years the ACA was in effect where they went down a little bit.
While it was certainly going up pre-ACA, if your costs went down due to the ACA then your case was extremely unusual. Costs are way up since it was enacted:
The graph of "how much does healthcare cost over time" on the link that you provided yourself to prove that costs have been "spiraling out of control" has had the same steepness since 1990. If it's spiraling out of control because of the ACA, then it's also spiraling out of control because of the Gulf War. At least now people with pre-existing conditions can be covered. We're not even done dealing with a pandemic that has infected 31 million people. Imagine a world where none of those people could ever get healthcare in the future because Covid-19 is a pre-existing condition.
The ACA forced people into this system with the individual mandate. I gave the insurance industry zero dollars until the ACA forced me to send them almost a thousand dollars a month. Before the ACA you could go to the doctor and just pay out of pocket. If you’re healthy this was a much more cost effective solution.
So not only did the ACA continue the increase in healthcare costs, it forced more people to pay for something they didn’t even need.
It is very easy to win an argument if you change what it is you're arguing in the middle of a discussion. You said that "Prices have been spiraling out of control". I said that the rate of price increases in healthcare in the United States have been relatively constant. Now, your response is that you, the commenter, used to pay nothing, and now you pay a lot more. Did you know that you are not the entire United States? Did you know that your experience is not a representative sample of all citizens of the United States? Did you decide to selectively ignore data that you provided, on your own, to prove a point that is only true for a fraction of people?
I posted data that shows that price is indeed spiraling out of control so it’s not just my personal experience. My situation isn’t that unique. Why do you think they created the individual mandate? To force people who didn’t want or need insurance to pay for it. Zero to non-zero is a huge jump. If I was alone, they wouldn't have needed to create this legislation to artificially capture the market.
The price has been "spiraling out of control" for the past 30 years, at the same rate almost the entire time. Saying that it's the ACA's fault is to lie by omission, because you're blaming the past 10 years on something that's been a trend for 20 years before that.
The fact that you now have to buy insurance is a separate issue from whether the costs have been spiraling out of control, because even if the prices had remained flat since 2009 your personal experience would be that you're spending more than you used to. That's not "cost". If I walk to work, then start driving a car, and then replace that for a truck, I don't say that "gas costs are spiraling out of control." You're conflating two things and think you made a slam dunk case. You didn't. It's embarrassing.
There's a huge difference between $100->$200 and $500->$1,000. People's earnings make it that there's a threshold that gets crossed where insurance becomes unaffordable. It's debatable if that happened before or after the ACA but the raw amount changed post-ACA is much larger than prior periods. People aren't measuring this by rate of change, their measuring it with their bank account.
> If I walk to work, then start driving a car, and then replace that for a truck, I don't say that "gas costs are spiraling out of control." You're conflating two things and think you made a slam dunk case. You didn't. It's embarrassing.
The correct analogy is that you live a block from work so you walk. Then one day the government introduces legislation that makes driving a car mandatory, so you have to buy one to drive the block to work. Your commute costs are definitely spiraling out of control at that point.
> You're conflating two things and think you made a slam dunk case. You didn't. It's embarrassing.
If you have a point to make, make it. You don't need to attack me as well.
You said that "health care costs are spiraling out of control". Your justification for that is that you spend more money on health insurance than you used to back when you used to spend nothing because you got nothing. Making a blanket statement of "healthcare costs" and "out of control" needs to come with the following caveats:
1. They're spiraling out of control for you -
2. Because you used to pay nothing
3. Because you used to get nothing
4. Because you didn't worry about it.
Say all that. The price, for the average consumer, that buys health insurance has been rising for decades. It has not slowed down because of the ACA but it hasn't sped up because of the ACA.
You're making a blanket statement based on your atypical experience of not having health insurance and then making it seem like it affects everyone.
People fear that we won't be able to afford the demand of everyone expecting to get what they get now with luxury plans plus everybody else under or uninsured getting more than before. Also, a lot of people's livelihoods directly come from the healthcare for profit system, and there haven't been serious proposals for how to transition that workforce, and a lot of pension and private retirement equity is also bound up in the profits of these companies.
When everyone has something, we don't feel as special for having that thing.
This should be reserved for expensive sneakers, cars, and luxuries, but some apply this perspective to health-care, and are disturbed that someone of less means should have access to the same hospitals and doctors as them.
That's not the only reason of course, but it's often the unstated motivation behind the stated reasons for opposition to universal healthcare, like government rationing of care.
I don't think it's that people are "disturbed that someone of less means should have access to the same hospitals and doctors as them" but rather that that they don't want to have their own access to those doctors delayed, rationed, or removed. (It's not "I don't want others to have what I have" but rather "I don't want to lose what I have".)
If I'm honest, I basically fall into that boat. When my son shattered his arm, we went straight to Boston Children's and got the best imaginable care. When my wife had a scary situation, I called several MD friends and found who were the best specialists to consult and we went down that road and got a good outcome thankfully.
I sure hope to hell everyone has those same experiences at emotionally and mentally trying times. We've had generally very good experiences with our medical system and I'm reluctant to risk blowing all that up, trying to re-jigger the entire financial foundation of the industry, and hope that what comes out the other end is every bit as good but a lot cheaper.
That sounds simultaneously fantastic and fantastical.
It's basically just profit. There's more money to be made by a system of price discrimination than there is by a system of universal healthcare.
If you want to look at the root political cause the blame here lies squarely with the Democrats and Obama Administration. Prior to the passage of the ACA the prevailing consensus was for the Healthy Americans act. Look it up. Look at the Co-Sponsors, very much bipartisan, and very much universal healthcare. If not for the ACA americans would have had Universal Healthcare 10 years ago.
The #1 thing that must be done is the decoupling of insurance from employment. The HAA does this and provides universal basic coverage, while still maintaining a private market for certain levels. It also still allows employers to contribute towards healthcare but in a much more transparent way.
Right now, employers have a massive advantage in regards to healthcare as a benefit because they can offer you a plan that may cost them only $100 a month, but if you, on your own outside of your employers group policy attempt to purchase a similar plan it would likely cost $1000+ a month.
Enacting universal healthcare in the US is not some impossible dream. It's a fairly straightforward process laid out decades ago and very nearly implemented in 2009.
Detach insurance from employment, eliminate coverage groups entirely, all private insurance companies have to pool all customers into the same group. The government also underwrites certain types of coverage for these companies, mainly preventive and catastrophic. The government then offers a competing product to consumers. It is defaultly given to every citizen, paid for via taxes. If you choose to go to a private company you can get a tax credit for a certain portion of premium paid.
There is no billing of customers, providers bill the government, the government can then in turn bill private insurers if a person is covered. Certain services may be a la carte per the private insurance. For example if you want expanded services not covered by the government policy, like more days in skilled nursing, physical therapy appointments, cosmetic, etc.
I have question.
Wouldn't everyone want to go to the best hospital in the city if they have something serious like cancer. For example, wouldn't everyone want to northwestern in chicago?
These top hospitals are always in well off areas of the the city. Wouldn't this be inequitable? Would govt interfere and make sure that these top hospitals are distributed equitably ?
Because "for all" is generally taken to mean provided by the government, and history has shown that without functioning markets government guarantees are ultimately worth the paper they're printed on. And if we actually had a functioning market, then why does everybody need to go through the government, as opposed to only the people who actually need the financial assistance?
We don't take "food for all" to mean that supermarkets are paid by the government. Rather there is a functioning market for most people, and subsidies to help those who cannot afford it. The competitive market keeps the overhead from getting out of hand and makes it so most people have the autonomy of paying for themselves on the spot, while the government provides a safety net for those who cannot.
Now having said that, the entire healthcare system is presently a dumpster fire. The other side of the aisle has done very little to address this dumpster fire with market based solutions - eg make providers publish full price schedules that are uniform for all payers, issue estimates for all non-emergency care, prohibit providers billing arbitrary amounts post-facto, and strongly punish any fraudulent billing. Such reforms could certainly exist alongside increased access to health "insurance", but that political team has been mostly spreading FUD to keep the status quo rather than proposing solutions. Meanwhile Medicare is actually pretty good, it seems that Medicare For All is the only train leaving our current situation, and it therefore makes sense to get on it.
>I cannot comprehend why anyone would be against health care for all?
Because that's not a policy. The debate is over which policy implementation is would be best or if the government should be involved at all. I personally like the idea of public option health insurance.
Bernie sanders put out a good piece on why it needs to be all in and can't be optional. Can't find it now but it delved into game theory. Maybe someone else happens to know where to find it and can link it.
An argument that I find compelling is that the government is obviously corrupted by corporate influence. If you can find a talk on healthcare.gov by Mikey Dickerson, it's pretty alarming. Basically, the government attempted to run a website, they sent out to contractors for help, 100 contractors returned, and 100 contractors were glued together to create a non functioning website.
Obama, embarrassed by this, came to silicon valley to ask top engineers at Facebook and Google to come fix the site. These engineers heeded the country's call for help, came in, and unfucked the website, largely by telling 90% of the contractors to fuck off.
Now do you really want a government that can't run a basic website because they can't hire industry professionals at competitive pay to build it, but instead contracts out to businesses in a corrupt an ineffective way, to be running this?
Corporate influence is so strong in America, and institutions have gotten so weak, it's hard to argue that OUR government can run this type of program. Especially considering half the country doesn't want it and won't hold the government accountable for it.
Our situation is vastly more complex because of the American attitude on tax. "Taxes is theft" is a pretty common sentiment. The instant tax is involved 90% of Americans will hate the administration in power.
So if you laid out a road map:
1. Convince the public you can do it
2. Convince the public they should pay for it
3. Actually implement it
4. Keep doctors and patients both happy
How confident do you feel about any one of those points? I honestly don't feel confident about any of them. The only compelling argument against this line of thought is that most of the western world has done it successfully.
What I am confident about is that we have to solve the American corruption problem before we can solve the healthcare problem.
I am very pro healthcare for all and single payer.
Watching California screw up vaccination in pretty much every way possible, and then on top of that prefer wasting doses by preferentially shipping vaccines to the central valley and other areas in order to satisfy non-health-related "vaccine equity" has really started to change my mind.
Once my bad health-related decisions are costing others money, society has a much stronger case to stop me from making those decisions. And I don't want to leave the determination of what constitutes a bad health-related decision to the vote. Especially with how expansively the scope of public health and mental health has grown.
Your objection appears to me to be without merit. You are essentially engaged in the fallacy of the slippery slope. There are quite a few countries that provide universal health care without oppressing people by policing their bad health care decisions.
You wish to deny universal health care access in the United States because there is a potential that society will enact laws to prevent you from making bad health-related decisions. It's quite hard for me to grasp how this is a legitimate concern of yours. Besides, your bad health-related decisions already cost others money.
Haha, I hear this phrasing more and more, almost always coming from the left, as we continue to slide faster and faster down the slopes you pretend don't exist.
I think the top trending Twitter threads this week are about how the government will soon be rolling out vaccine passports. Six months ago, anyone claiming these were coming would have been chastised for their fallacious slippery slope arguments.
The fallacy of the slippery slope is not a fallacy because the slope can't ever come to fruition. It's a fallacy because the scary scenario is always a possibility even if the status quo remains. The slippery slope is a fallacy because the fear mongering it uses can be applied to every situation.
The essence of the argument I responded to was:
I don't want government run healthcare for everyone because some scary scenario might possibly come to fruition. Therefore it's OK that millions don't have adequate access to healthcare.
The reasoning is sloppy and this fact has nothing to do with politics.
Well as a fellow techy who respects logical arguments, I understand what you're saying and don't disagree with your main point.
OTOH, outside in the real world i.e. Twitter and Reddit (haha), this rationale is not what was being used to attack dissenters and anyone who dared question the official standard line. Anyone who pointed out a very relevant example of a "colloquial" slippery slope- especially if it was something that was labeled as a conspiracy that we'd never allow happen or to get that far - e.g. vaccine passports, full time remote learning, restricted travel and forced government quarantines at inflated costs, fining small businesses for having one customer while Costco and Walmart are packed to capacity, etc. 6 months ago and was now occuring or being openly considered - was attacked by the mob who maliciously or mistakenly were peddling the "slippery slope argument has been debunked, just like the Earth is not flat - you are banned for 48 hours" to shut down debate.
I think how arguments are framed matter. It’s one thing to say, “If A happens then this means scary scenario B will happen.” And another to say, “If A happens then we need to be vigilant that B doesn’t result as a consequence.”
The problem as I see it is that debate on policy does not revolve on how best to achieve an outcome. It typically revolves on the mistaken belief that if change comes then either it will be glorious or have dire consequences. In the healthcare debate rational people should want everyone to have access to the healthcare system. So how best to go about achieving that? That should be the focus.
>I don't want to leave the determination of what constitutes a bad health-related decision to the vote.
The answer is to maintain both private and public insurance systems. As is already the case with Medicare. I don't think anyone is stopping you from buying your own private insurance if you are 65+.
And that's the thing I find strange about the healthcare debate in the US. There is already a huge public insurance system in place - Medicare. Yet people pretend that a public system like that is some sort of ideological novelty in the US. It's not.
Damned right. At the beginning of the pandemic, people were arguing that you shouldn't drive because you might risk an accident and use a hospital bed that could be used for a COVID patient. This is a degree of behavioural policing that I am not willing to accept.
So I'm sure you smoke, though most insurance policies charge through the roof if you do? And do you drive as fast as you want since hey, don't police my behavior?
Our society polices behavior all the time. And we accept that as part of a smoothly functioning society that tries to be fair and equitable.
Right, but right now, you lack the ability to push me to the back of the line for healthcare because of my love for extreme sports and motorcycling. You may want to do that because you believe it is "fair and equitable" but you can't, because you're just another third party in this relationship between me, my provider, and my insurer.
You may want everyone to only ride the lowest risk means of public transit, only eat the right food, only perform the right activities because you arrogate to yourself the right to police behaviour in pursuit of equity.
You are welcome to want this, of course, and I do celebrate your openness in stating your objectives. But that's why we're opposed. I don't share your objectives. I am willing to accept some degree of inequity in the pursuit of some degree of individual freedom.
For the record, I don't smoke. I do speed, like so many other people in California. But fortunately, my auto insurer adjusts me up for that.
EDIT: I cannot reply to you, jay_kyburz, but I do not anticipate mere societal pressure. I anticipate legal rules placing me in a different line that only gets treatment after 'conventional risk' people. i.e. at some point I believe someone will say "Rich software engineers get treated for pulling their shoulder jumping off bridges while this brave firefighter had to wait (unstated that he had to wait to have a wart removed or something)" and then the outrage will roll up until anyone jumping off bridges for fun is now placed permanently behind everyone else.
I have no objective to control your activities. I just think that a society inherently restricts freedom. That's the covenant we make for having a "civil" society. Isn't your insurer impinging on your freedom by charging you more for what they deem reckless or risky behavior? We require people to wear seatbelts, to drive sober, to have a license when operating most vehicles. We restrict people from a large amount of BASE jumping. We prohibit many drugs for recreational use. Society is full of restrictions.
And if you don't have insurance? You sure are pushed to the back of the line for healthcare. Get laid off? COBRA only covers you so long, so you'll have to get on the ACA. That's why maintaining the existing healthcare system is a non-starter. It's why traditional Medicare is so popular. Once my generation dies off, it's a no-brainer that the younger generation will do away with the nonsensical system we have.
Right, society does restrict my freedom. It doesn't seem particularly outlandish that I already chafe at the fetters and object to any further expansion of that control.
Essentially, you seem to be arguing that since society already controls me it should have further power to control me. Well, I think the control it already exercises on me is too much, and I desire a reduction in said control, or at worst a stalling at where it stands right now.
There's nothing strange about this disagreement. It's fairly garden variety, except for the argument in favour of the slippery slope, which I must confess to never having heard before.
EDIT: I cannot reply to you, jay_kyburz, but I am content to retain the status quo, which would seem acceptable to both so we have no quarrel.
I'm more concerned about the slippery slop sliding the other way, people thinking they can do what they want with no regard to how it might impact their community.
Where’s the evidence that that kind of pressure ever makes a difference to anyone's behaviour?
Surely the pressure to avoid debilitating illness/injury or slow/painful premature death is far more profound, and for anyone who doesn't care about that, there are much bigger issues at play than the cost of healthcare.
> I cannot comprehend why anyone would be against health care for all
I think context is important here. Everyone, absolutely everyone, wants healthcare for all. Ask anyone if they'd like to live in a country where you simply don't have to worry about health insurance and have everyone covered and everyone will say "yes". The devil, however, is in the details.
The first problem is that the US public has no trust at all in their government's ability to do anything right. Let's not even talk about political parties. In general terms, our government seems to be filled with incompetent, partisan, power-hungry and petty individuals who would have trouble selling used cars in the real world. They are actually an insult to used car sales people, who have to work hard to earn a living.
Examples of this abound. From the high-speed train to nowhere in California (and now we are talking about building trains again?), to half billion dollar websites that don't work, to, well, the DMV --everywhere--, pandemic response, etc., etc., ad nauseum, etc.
Try to call a government organization for help and see what that feels like. IRS, DMV, your representatives. Yeah. I don't want these people anywhere close to my healthcare and quite a few people feel exactly the same way. They've gone too far already.
Here's personal context: Before the ACA my family's health insurance cost $650 per month. We had excellent coverage, great doctors, good service, low costs, and all was well. We were forced into the ACA. The minute that happened our cost went up to $1,800 per month. Yes, that's over $20K per year for health insurance. Oh, but it doesn't end there. Our deductible went up to $5,000 per person per year. In other words, each of us has to spend $5,000 before any insurance coverage kicks in. There are five of us. Which means we would have to spend $25,000 in a year if all of us need medical attention before the wonderful ACA provides any coverage at all.
And the doctors and clinics we now have to go to? I gave one of the clinics in the list a name: The place you go to if you want to die.
Yes, we have mucked up health insurance in the US beyond recognition. Adding more government is the absolute worse thing we could do in the US. They are incompetent and will cause all kinds of pain. And the costs will be staggering.
The ONLY way we can have government do the right thing is if every single politician had to, by law, use healthcare at, say, the median of what they create. They would have to live with what they create. Today that's not so. They have gold-plated healthcare for life. At no cost. We do not. Make them live by what they create and things could be different. You would have to ensure no loopholes at all. They would have to have nothing better than what the average person in the US has access to and they would have to pay for it themselves.
I have always been a firm believer in the power of the entrepreneurial spirit. Yes, there are horror stories in every industry. And yet, by an overwhelming majority, it is hard to ignore the fact that entrepreneurship has lifted billions of people out of poverty and made billions of lives better everywhere.
With proper oversight and careful regulation, the private sector would do a massively better job than government ever could in the US. That's just a fact. The comparison along one vector is as simple as what SpaceX has accomplished in such a short time vs. the massive aerospace contractors. Before anyone says "yeah, they got government money and were able to start from the foundation laid by NASA, etc.". First, don't diminish the amazing work they have done. Second, the traditional rocket/space companies have had DECADES of a running start, with even more government backing, contracts, exclusivity and support than SpaceX ever got. And yet the difference in results could not be starker.
We need an Elon Musk to take on healthcare. If government thinks they can do better, fine. Allow private enterprise to give it a try in parallel with a government effort. Same rules. Let people choose.
IMPORTANT: Sorry for the caps. It's better than the only emphasis available on HN.
It is vital to also understand that Medicare has serious issues. In a nutshell, it isn't insurance. Yes, it covers a bunch of things up to age 50 (or 55, don't remember). After that it becomes a loan you have to repay. In other words, at the age when people start to need more and more medical care the system will provide you with care but it is a loan. What's worse is that the government, by law, has to collect on that loan and can --and does-- attach your estate.
What does this mean? It means that placing people into Medicare by the millions (as the ACA did) is likely the largest private property grab by a government in the history of humanity. OK, maybe a bit dramatic. However, this is factual in that the US governments (federal + state) have the right to your estate as a means to pay for what you owe for healthcare after the threshold age. In the US it is easy to amass a million dollars or more in healthcare cost as you get older. Not difficult at all. Which means your home and everything you own is on the line because you got placed into Medicare through the ACA. Under certain circumstances your children can be liable for your medical debt. The millions of people who got placed into these programs have no idea what they agreed to when they signed on the dotted line. No idea.
And that, among other things, is why nobody in the US should ever trust government with their healthcare. There's more, but I don't have the time to get into it. My wife is a doctor. She and he colleagues should write a book on the horrors of government-driven medicine in the US. Things like doctors having to order piles of unnecessary tests because they fear career-ending malpractice lawsuits.
Like I said, this post is but the tip of the iceberg. We can't say "but they do X in country Y". No two nations are the same, culturally, economically, politically, etc. Which means such a statement is invalid and irrelevant. What matters is what we do here. And our history, with regards to government competency, leaves much to be desired.
My thoughts, as a healthcare professional, who has lived in Scotland, Australia and now the US, and has worked for software companies who develop line of business apps for healthcare companies, and health insurance companies:
> Here's personal context: Before the ACA my family's health insurance cost $650 per month. We had excellent coverage, great doctors, good service, low costs, and all was well. We were forced into the ACA. The minute that happened our cost went up to $1,800 per month. Yes, that's over $20K per year for health insurance. Oh, but it doesn't end there. Our deductible went up to $5,000 per person per year. In other words, each of us has to spend $5,000 before any insurance coverage kicks in. There are five of us. Which means we would have to spend $25,000 in a year if all of us need medical attention before the wonderful ACA provides any coverage at all.
Because up until that point, insurers had diligently been kicking people with any pre-existing conditions off insurance, and sharing that information with other insurers so you couldn't get coverage anywhere.
Blame the insurer, not the ACA.
> It is vital to also understand that Medicare has serious issues. In a nutshell, it isn't insurance.
It's as vital to realize that healthcare insurance in the US isn't insurance either. It's amortized and bulk buying discounts for your healthcare. Hence not just deductibles, but copays, coinsurance, maximums, etc. All of these things are in place to ensure that you never become an unrecoupable weight to the insurer. That we have health "insurance", in the US, is one of the biggest cons.
> My wife is a doctor. She and he colleagues should write a book on the horrors of government-driven medicine in the US. Things like doctors having to order piles of unnecessary tests because they fear career-ending malpractice lawsuits.
Doctors contribute to this. They also order piles of unnecessary tests when they, entirely coincidentally, happen to own DI (diagnostic imaging) equipment, facilities. In fact it's such a profitable way to "invest" for medical professionals that DI companies will help you find likeminded doctors to pool up with, will offer you guaranteed ROI, and will finance the purchase of the equipment, walk you through Certificate of Need processes where applicable. And then we wonder why doctors who own such stakes order in the order of two standard deviations more DI for their patients...
> Because up until that point, insurers had diligently been kicking people with any pre-existing conditions off insurance, and sharing that information with other insurers so you couldn't get coverage anywhere.
Yes, and that's an opportunity for sensible regulation. For example, when you buy auto insurance there's a small amount added-on for "uninsured motorists". That's fine. That works. And that does not triple your insurance costs.
In addition to this, no, the ACA did not fix this at all. All they did was throw people into Medicaid/Medicare. It is a false equivalency. Medicare/Medicaid isn't insurance and it does not provide the same level of care that real insurance does. There are doctors who flat-out refuse to see Medicare patients because they would have to provide that care at a loss.
There's a fairness element here that I guess I don't understand why you might have trouble with. Let's extrapolate my family's health insurance costs out to ten years so we get a sense of the scale of the damage done by the ACA. In round numbers, it means over $200K. Yes, over $200K in costs from the ACA. Prior to ACA, about a third of that, less actually, because right now the ACA is doing shit for us due to the high deductibles. We are paying over $200K NOT to use something.
This is insanity. And what it means, among other things, is that my wife's office will not see Medicare patients if they can help it. Every single employee's insurance has doubled or tripled. Their costs have gone up tremendously just on that front. I think their health insurance costs are in the half million dollars per year range.
Over $200K in ten years for something we don't use because the deductibles are so high we have to pay cash. That is punitive. That is far from "healthcare for all". That is deeply discriminative. This kind of money represents a number of things, such as a secure retirement, paying for kids college, and just being able to save for rainy days (or pandemics).
> That we have health "insurance", in the US, is one of the biggest cons.
Agreed! And who sets the rules? Government. And who fucked it up? Government. And now we want to trust them with the entire system?
C'mon.
What we need is for a deep review of the equations that govern this industry, from student loan guarantees to tort reform, FDA costs and more. I am not delusional enough to think this will ever happen. Politicians don't tend to fix things unless they have to. Happy people are far less motivated to vote for someone than people who remain angry at a situation that can be blamed on the person they are running against. That's why nothing is ever fixed. From a political perspective it is far better to have a bunch of angry poor people than to truly work towards fixing the problem. Votes are king. Our political system is broken. It exists for our politicians, not the people or the nation.
Yes, we need government, but what we have has devolved into a beast that works for itself and not us.
> I cannot comprehend why anyone would be against health care for all?
Then you probably shouldn't voice an opinion on the issue. If a lot of people disagree with you can't come up with a coherent explanation for why, then you almost certainly don't understand the problem space.
> Can someone help explain to me what the oppositions point of view is?
Government-run healthcare is not socially optimal.
Edit: The people downvoting me are salty because they realize that they can't form a coherent argument for an opposing opinion. Guess what - I already know all of your talking points. I would engage with you on them, but this shitty website won't let me post more than like 5 times an hour.
More people are in favor of universal healthcare than against it.
No one fully understands the problem space, those that do only understand the parts they care about. However, the current system just doesn’t make economic sense for 90% of current and future Americans.
Therefore, we should change the system, and given the success of universal healthcare schemes throughout the developed world, we ought to try it ourselves.
Perhaps some of our richest, urban, and politically left states could show us the way. It's not like they don't have enough money or political support.
Maybe unchecked immigration and a vast welfare state will work out just great. I'd just rather California prove it out first before we roll it out to the rest of us.
> More people are in favor of universal healthcare than against it.
In the US, you can get an answer in either direction depending on how you phrase the question. When you bring in the fact that this will cost money, people tend to flip. Most people in the US already have healthcare through the government or through their employer, so they don't actually really care enough for anyone to pull this off politically.
> Therefore, we should change the system
I agree, the current system is sub-optimal.
> given the success of universal healthcare schemes throughout the developed world
What success? Most countries with "universal healthcare" A) are poor relative to their demographic-imputed economic capacity B) have low-quality care compared to market-based healthcare systems, and even compared to the worst-of-both-worlds American healthcare system often have horrendous metrics on quality of doctors, procedure wait times, etc.
US healthcare isn't good. I never said it was. But the correct direction of reform is towards market-based healthcare, not to make it even more DMV-like.
> universal healthcare does not imply government-run healthcare
There is no practical way to implement one without the other in the US.
> But the correct direction of reform is towards market-based healthcare
I suppose if you subscribe to, say, the normative-over-empirical approaches of the Austrian school of economics. If you are concerned with universality and cost-effectiveness, instead of the doctrines of the free market cult, reform toward the shape of systems which empirically do those things better than the US, which there are plenty of examples of in other advanced economies, would make sense.
My evidence is that I've lived in countries with market-based healthcare (Thailand, Mexico) and countries with socialized healthcare (Canada, UK), and the market-based healthcare is always infinitely better. My wife had to wait months to see a psychiatrist in Canada, before we moved away. WTF? In Thailand it's like $50 and you get in right away.
> empirically do those things better than the US
Why are you bringing up the US? It's not market-based healthcare.
Both the source article and every comment in this thread except for one on the middle explicitly references the US; I didn’t bring it up, it was the established subject of the discussion.
I can't comprehend how someone can believe in a flat Earth or that vaccines cause autism but I'm knowledgeable enough about those issues to emphatically state that such people are stupid or willfully ignorant.
With regard to government run healthcare not being socially optimal. The United States spends far more money per capita on healthcare than any universal health care system in the world. There are lots of examples which show that universal healthcare systems can be much more optimal than the American system.
The factors that cause America to spend a lot of money on healthcare don't go away when you switch to a single payer. If anything, they get worse.
Reform needs to happen elsewhere; for example, we need to stop using taxpayer money for extremely cost-ineffective treatment of very old people (which is where most of our money goes).
The factors might not go away. It depends on how the reform is done. To say that they won't go away is incorrect. You don't know this. As with all reforms, they can be done well or poorly.
Sure, in a magical world where we suddenly switch to a perfect utopian medical system, the problems will go away. But none of the concrete proposals in this thread will make the problems go away.
It's hard to claim that this can only happen in a magical world when there are numerous examples of universal healthcare that provide better outcomes with lower costs.
There is also heritage of the territories system like the homesteading act as very bottom up for various reasons. The approach specifically wasn't even to establish a state with an appointed governor or to send out survey corps and use them to establish "seed settlements", or even to start auctions in lands covered by existing forts but to do it from the bottom up with land allocations. Instead it was essentially a petition to join once a sufficient population was achieved and unified.
They had a "national memory" of getting screwed over by the old world and having Pointy Haired Boss mercantalists telling them to travel for months across the atlantic for trade rather than trade with other colonies - and many of the founding fathers were smugglers for their scoffing laws not in their interest.
Now the national memory is clearly memetic like well nations - their ancestors were likely actually still farmers or tradesworkers before emmigrating from their origin or immigrating to the states. Essentially the mentality is they /were/ the resources and didn't (while ignoring those they used as resources). Thus top-down anything is viewed with suspicion and "cutting a slice for yourself" as good. Corruption involving vote buying and extortiong likely also didn't help the trustworthiness to government institutions. Given those alone even if assuming ahistorical tolerance I wouldn't be surprised at publically funded X being looked at with a jaundiced eye as a "Okay how you are setting yourself up like a political boss - how are you trying to shove funds into your pocket this time?"
Combine that with the longstanding elite education having a Greeco-Roman obsession's influnce and seeing the ironic effect of what seems like common sense "supply your own military with equipment so their means don't limit your defense" as effectively establishing a generalismo to gain personal armies.
All of those point to ample reasons to view publically provided X with suspicion. The only reason public education did as well as it did was fear of catholic influence and them being better organized. The red scare had an internecine ancestor. "If they didn't provide education to the masses the Catholic church would and upset the general very peaceful in comparison to Europe balance of power." That notion of retaining that peace and not having "all of the bloody European wars for absolutley no gain" was very agreeable to all, especially emmigrants from said wars so Catholics wouldn't be too put out by "redundant funding" of what the church effecfively going to protestants as the church already gave it to their parishoners.
The more I think about the more I can see both sympathetic and bigotted reasons for them to have been suspicious of "free X" as a trap. Either way the roots existed well before Jim Crow a specifically post civil war system. Even if the centuries of suffering of Jim Crow could be retconned away it would probably "just" leave the South looking more like the North sooner as opposed to public healthcare approaching its 1st centurty anniversary.
Insureance has choice in it. I am buying what I please. Young healthy person is not in need for same coverage of middle age person: it is also use risk pools so that I am not group in with sickly persons. Data are showing that 5% of patients have create 50% of health costs; I am not wanting to pay these. https://www.forbes.com/sites/michaelbell/2013/01/10/why-5-of...
i dont want to pay for the treatment for people who made terrible decisions. people wont be healthy. they will succumb to the billion dollar advertising and garbage fastfood/snack business.
the past month the media has been shilling the vaccine instead of telling people how important diet and exercise is.
i havent been to the doctor in years. last time i went to the dentist he said i had the best gums he had ever seen. take care of your body. i only have health insurance in case something extreme happens. deepthroating fast food everyday and tryign to make me pay for your treament is bad.
I was going to ask why Americans don't privatize their military but looking at the proliferation of mercenary company like Blackwater taking over military operations in Afghanistan/Syria/Yemen, maybe Americans are slowly starting to put money where their mouth is.
Sure, considering I was a frantic proponent of universal healthcare before I observed the US Gov's handling of the COVID crisis and the responses of Americans to it, I changed my mind. Here are some of my reasons:
* I want to be able to be an informed participant in my healthcare. When the US Gov lied about mask efficacy so that there would be enough masks for healthcare professionals and when many Americans considered this acceptable, I lost faith in the government's ability to meet this need of mine. Either they were incompetent or malicious and neither trait is one I desire in someone treating me.
* My life involves a wide variety of risk taking: I use drugs, motorcycle, bicycle, jump off bridges, etc. During the COVID crisis, many Americans stated a desire to allocate healthcare according to behaviour. I would prefer to pay to offset my risk rather than alter my behaviour. I fear the puritan streak in American politics will push me to the back of the line in healthcare despite my ability to offset any risk with money.
* I am a software engineer. I am high income, relatively wealthy, and overall fairly comfortable. I am also in a profession that does not provide me a social cachet. During the COVID crisis, many Americans stated a desire to allocate healthcare according to a notion of value to society that elevates those with high social cachet. These are generally people who can be argued for: teachers ("they are taking care of our next generation"), medical professionals ("you don't think we should treat our healthcare heroes first?"), soldiers, firefighters, police, god knows what. I fear that people's dislike of my profession will push me to the back of the line.
So now, no universal healthcare, thank you. And yes, I am quite familiar with the NHS. I've paid enough into it and have many family members who work for it. The existence of other successful systems does not mean that the US can replicate them. There is a path problem, a second system effect, and differing social norms.
Well, there you have it, an actual statement of reasons from someone who actually opposes UHC.
We had the same thing here where basketball teams and politicians were getting covid tests every week while the rest of us couldn't get one when we had symptoms. I don't think that's a private vs. public healthcare issue necessarily.
> During the COVID crisis, many Americans stated a desire to allocate healthcare according to a notion of value to society that elevates those with high social cachet.
All of the professions you mentioned (except, perhaps, “god knows what”) involve interacting with other people as part of their primary function.
I’m sure you can see the wisdom of allocating the initial tranche of vaccines to “people who do valuable work and are at higher risk of causing community spread while doing so” over “people who do valuable work but can do that valuable work while isolated, thus reducing the risk of community spread”?
The outcome doesn't bother me. The reasoning for high social value professions vs. low social value does, since it works for non-contagious situations as well.
The teachers continue to be the ones "taking care of our beloved children, the next generation"; The nurses continue to be "healthcare heroes"; the firefighters continue to be "brave and courageous"; all this continues to be true when I'm getting in line to have pancreatic cancer treated. I don't want to die because some pretty primary school teacher showed up at the last moment for that kidney transplant and society has decided that it wants her more than it wants me.
And obviously I have no objection to vaccinating high-degree nodes before low-degree nodes subject to the usual arguments.
It really is about status, though. For example, here in the UK there was a huge amount of pressure to vaccinate policemen early but no such pressure for private security guards, even though security guards were at much higher risk of dying from Covid but the police weren't. Same with, say, teachers and bus drivers. The recurring pattern was that it was the professions with high status that got to push for priority, not the ones with high risk. Our government managed to push back against this in large part because the vaccination roll-out was going well and they managed to argue that prioritizing on things other than age would slow it down, but if it had been slower or some of the unions stronger they might have ended up having to give in.
Not quite. There are private hospitals in Canada but very few.
The reason is because physicians are banned from treating patients in the public system and private system. If they choose to treat private patients, they can't work in the public system. With such a small private system, that's not sustainable.
In addition, private hospitals/clinics can't offer certain procedures. MRIs are allowed in some provinces, but the list isn't very long.
Basically Canada is not interested in having any private healthcare system because then it would be "2 tier". They prefer everyone go to the same system.
Any idea why Canada decided to be so extreme - even the UK (which has the overtly socialist NHS) happily has a smaller parallel private healthcare system and a lot of doctors work in both.
"But it was only with the 1984 passage of the Canada Health Act, drafted in the final months of Pierre Trudeau’s premiership, that Canada codified its de facto ban on private healthcare.
The reason was a wave of “extra billing” that had swept Canadian healthcare in the 1970s. Canadian patients were increasingly being hit with user fees and copays that were gradually chipping away at the supposed universality of Canadian healthcare."
Basically, private doctors wanted to be able to also bill the public system and any additional cost the patient is required to pay. That went against the idea that "healthcare should not be purchased".
Thank you. As it so happens, I am aware that when a HNer requests an answer like this they are fully aware of two things:
* They can stay righteous knowing that the mob that they are the vanguard of will apply suppressive pressure on their behalf
* They can disclaim responsibility of knowledge of the mob
* The fellow members of the mob will post answers "on behalf of" the side they oppose which will strawman those positions
Interestingly, many HNers will disingenuously ask "for feedback" or "an honest discussion" knowing full well about this phenomenon.
Therefore, I'm not upset by their reaction because I was braced for it. My position is logically sound. Objections come from different moral foundations and different circumstances, not from logical failure. And I can accept that you can also have an opposing logically sound conclusion rising from different axioms since our axioms are beyond our Aumann Agreement Horizon.
> It is clearly more economically efficient to treat malignant cancers earlier. We (Americans) all end up paying more with the perverse system we have.
Maybe it turns out that we're all actually saving money by having undiagnosed people die off early instead of paying for preventative care for everyone.
> It is clearly more economically efficient to treat malignant cancers earlier.
This is not necessarily the case, because additional screening has costs - both direct costs of running the screening, but also hidden costs like costs associated with false positives (which represent the vast majority of cancer diagnoses). For example, we realized recently that for many years we had been too aggressively encouraging women to get breast cancer screenings, and it ended up not being socially optimal due to the high cost and false positive rate.
> The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.
> . For women who are at average risk for breast cancer, most of the benefit of mammography results from biennial screening during ages 50 to 74 years. Of all of the age groups, women aged 60 to 69 years are most likely to avoid breast cancer death through mammography screening. While screening mammography in women aged 40 to 49 years may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger. The balance of benefits and harms is likely to improve as women move from their early to late 40s.
> . In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime (known as "overdiagnosis"). Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment.
> . Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s.
> Go to the Clinical Considerations section for information on implementation of the C recommendation.
Here's a page that details the false negative rates for this type of screening:
> Data based on results from a single screening round for women regularly receiving digital mammography indicated that false-positive results were common in all age groups (Table 1). The rate was highest among women aged 40 to 49 years (121.2 per 1000 women [95% CI, 105.6 to 138.7]) and decreased across age groups (P < 0.001). Rates of false-negative mammography results tended to increase with age, ranging from 1.0 to 1.5 per 1000 women, but did not statistically significantly differ across age groups.
> For women with initially positive mammography results, rates of recommendations for additional imaging were highest among those aged 40 to 49 years (124.9 per 1000 women [CI, 109.3 to 142.3]) and decreased with increasing age (P < 0.001). Rates of recommendations for biopsy did not statistically significantly differ across age groups and ranged from 15.6 to 17.5 per 1000 women.
> Rates of invasive breast cancer were lowest among women aged 40 to 49 years (2.2 per 1000 women [CI, 1.8 to 2.6]) and increased across age groups (P < 0.001). Rates of ductal carcinoma in situ also were lowest among women aged 40 to 49 years (1.6 per 1000 women [CI, 1.3 to 1.9]) and increased with age (P = 0.055). Women aged 70 to 79 years had the highest rates of invasive cancer (7.2 per 1000 women [CI, 6.4 to 8.1]) and ductal carcinoma in situ (2.3 per 1000 women [CI, 1.7 to 3.0]). Consequently, the yield of screening was more favorable for older women. For every case of invasive breast cancer detected by mammography screening in women aged 40 to 49 years, 464 women had mammography, 58 were recommended for additional imaging, and 10 were recommended for biopsy. In contrast, for women aged 70 to 79 years, for every case of invasive breast cancer detected by screening, 139 women had mammography, 11 were recommended for additional imaging, and 3 were recommended for biopsy.
> Overdiagnosis is the diagnosis of a cancer that wouldn’t have gone on to cause harm in a person’s lifetime, in other words, if the person hadn’t been tested (whether that’s screening or some other type of test), the person might never have known they had cancer, and would not have died from the disease.
This website is full of overconfident midwits - nothing new. I appreciate that you're still willing to put in the effort to show them the evidence. Unfortunately, I'm at the point where I don't think it's worth it; it's not like they developed their current opinion by looking at any evidence, so they're not going to change it on account of evidence.
A big part of it, for a lot of older people, is they will not go to the doctor, for various reasons. Religion, fear, stubbornness, ignorance...
Even if they have Medicare.
Try to get your old cranky uncle to go for yearly physical, much less a prostate exam. Some people refuse to take their heart medication, or insulin, etc.
My father in law had a mild stroke and refused to go back for his checkups after.
It’s tough to reason with them. Plenty of them can put off going in until they’re either forced to by relatives, or have an emergency. And a lot of times it’s too late by then.
In case you're wondering why you got downvoted, my guess is that people have the following trivial counterargument. Even if all of that is true, that wouldn't explain the specific jump at 65. That's clear evidence that people want the medical treatment but it's not available to them without Medicare.
The jump at 65 is likely in part because it's the official definition of old for basically everything in the US and it's a lot harder to justify being in denial about needing to see the doctor from that point forward.
What's the point of a prostate exam? Prostate screening doesn't save life, and it causes harm. People may want to do it if they know they have risk factors, but otherwise it's not recommended.
> For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening.
The advice for people 70 or older is stronger: The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.
> The problem of overdiagnosis has received an increasing amount of attention in the field of cancer screening. It is a particularly large issue for prostate cancer because prostate cancer can have a long period when it is detectable but asymptomatic. As early as the 1980’s, before the use of prostate-specific antigen (PSA) for early detection of prostate cancer, overdiagnosis was recognized as an important issue for prostate cancer screening that used digital rectal examinations.1
> Individuals with cancer that is overdiagnosed do not benefit from having their cancer detected by screening but they suffer from the harms of evaluations done to establish that cancer exists and the harms of treatment for the cancer. The harms of treating prostate cancer can be both serious and common.2, 3 Even if individuals with screen-detected prostate cancer do not undergo treatment, they may suffer from anxiety and diminished well-being because of the cancer diagnosis and they may be burdened by the testing and interventions used to monitor the cancer. Uncertainties regarding the benefit of PSA screening in reducing prostate cancer mortality in randomized trials2 and evidence that the incidence of prostate cancer increased dramatically with the adoption of PSA screening,4- 6 have moved overdiagnosis to the forefront of discussions about whether and how to screen for prostate cancer.
A 65yo still has on average 10 to 20 years to live. Further they are often grandparents and today's "two working parents" economy is built on thinga like unpaid childcare from many grandparents.
That’s a good question. I think the brits have these numbers. But keep in mind: the US is spending way more per GDP than any other country including the ones with universal health care. So you get less coverage for way more money. And life expectancy isn’t better either. Basically the current US system is way overpriced for the results it delivers.
As a young, educated, skilled person, why would I want to stick around in a country that won't take care of me when I finally retire and can actually have some free time? Take care of your seniors if you want people to stay.
The point is that preventative screenings and procedures are being underutilized because health insurance plans discourage their use. That we can measure the effect of these policies should galvanize government regulators to rethink their incentive structures that lead to this travesty. If you read the article, 3 of the 4 cancers that had the largest disparities (Colon, Breast, and Prostate cancers) all have preventative screenings, and two of them have minimally-invasive preventative procedures if discovered early enough. It is incredibly sad to see that when the prognosis is very positive if found early[1][2][3]. I personally feel that these screenings should be covered for every health plan, even when people have had cancer in the past. My mother was charged 20 times the normal copay for a procedure because as a breast cancer survivor, her insurance re-classified yearly screening from preventative medicine to an elective procedure.
Which in the US means waiting for Medicare. Doesn't it? For most Americans there is no part of retirement and growing old that doesn't revolve around access to Medicare.
Also, relatedly, speaking as someone who worked in National Cancer Institute-designated center, I can say that the reason why cancer has absolutely kicked our ass, that no one talks about, is actually because of paywall stuff like this.
If you want to solve cancer, we need to abolish patents and copyrights. The combinatorics are still far outside our capabilities. At least 90% of the efforts of all cancer researchers are wasted, and we have less than 10% of the brainpower we need to solve it.
Cancer is a political problem.
Let's hope someone can get the truth to Biden. I have hope that he would have the courage to do what is right.
To those who are in favor of a national healthcare system which is payed for using tax revenue:
Can you give an example of an existing state or federal government agency which is consumer facing and well functioning?
I am personally a big fan of the FAA, which I believe fits those criteria, but the FAA requires a substantial filter you have to pass (generally: getting a pilot's license) before you begin interacting with them.
Is there some government program that works well that you could point to and say: it will work like this?
Because the unfortunate experience I have had is that some of these national-level projects do work passably-well for micro-countries like Canada, but don't seem like they would scale at all for the 3rd largest (by population) country in the world.
> Can you give an example of an existing state or federal government agency which is consumer facing and well functioning?
National Parks Service. All of my interactions with its employees and facilities have been pleasant and efficient.
Furthermore, there's no need to have a healthcare system administered at the national level. Even a "micro-country" like Canada has provincial level systems. The population of Ontario, the largest province, is between Pennsylvania and New York. The population of Newfoundland and Labrador, the 2nd smallest province, is similar to that of Wyoming. The federal government only specifies standards and inter-operability. That model is probably a better fit for the US than a literal "Medicare for all".
Once again, hogwash. You are making a non-sequitur argument as there is no developed country with similar population size to compare.
What population got to do with delivering universal healthcare? It is actually opposite of what you are trying to imply. Larger the population better universal healthcare can be provided as cost and services shared across larger number of people. If smaller country like Japan can provide more effective healthcare than US, then US should be able to do 3X better not 1/3rd.
Why hasn’t the EU demanded that member countries abolish the healthcare systems and create unified system? By your logic, everybody would win here, and the win is obvious. So what is holding it back?
