340 Comments

Capitalism is probably great for sneakers and widgets. How a person finances their medical bills is not a sneaker or widget. A true free market needs empowered and informed consumers. A patient is not easy to fully empower or inform. In the end Health Insurance Companies seem lot like government anyway with their premiums being analogous to taxes, their in-networks serving as borders. So can't we get some of that instinctual hatred for the bureaucracy of government the ideological right as pointed at the bureaucracy of the health insurance companies?

On a somewhat related note, if one was curious about the history of efforts to nationalize an industry that was balanced, both the good and bad, where would one start?

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Aug 31, 2023·edited Aug 31, 2023

Having lived in and worked on six continents, the best system is in Switzerland. Hayek talks about Gemeinschaft and Gessellschaft in discussing the difference between household economics and market economics. In Switzerland, they combine the socialism with the free market to provide the best health care system. The ACA initially had a mandate to mirror that system.....everyone is required to have basic/catastrophic insurance at an affordable rate negotiated between government and private insurers. Those basic policies are the ante insurance companies pay to provide market-based supplemental insurance policies for those interested in different packages & services.

The worst are the single payer systems that are rationed to the point of being obsolete....hey you have insurance, but there are no doctors or hospitals to treat you. US healthcare is expensive because of the free riders, the link to employment (a direct result of the income tax implementation of the Progressive Era), a progressive tax system that underfunds health care....but mostly because the American Utopia Therapy Cult has medicalized ordinary life stress into a mental illness and our vapid culture's overindulgence in "spa" treatments like acupuncture, massage and other pseudo-therapies under the guise of health care.

Just wait until gender affirmation becomes a medical right and we can add the expense to the list too.....and of course the reversal surgery when 90% of these cases change their mind later.

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Aug 31, 2023·edited Aug 31, 2023

There are more psychologists (2x as many) and psychiatrists (4x as many) per capita in Switzerland. Acupuncture and massage therapy work for pain management. Your reversal claim is a bigoted lie.

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Of course, a massage feels great.....but soft tissue pain management is also known as Advil. Much cheaper and more effective for most. If Acupuncture worked for most people, humankind wouldn't have invented more effective therapies and treatments.

Psychiatry is a Veblen good and Switzerland is a rich country....so I will accept your stats at face value, but the WHO stats I quickly googled show 0 mental health workers per 100,000 in Switzerland, so my guess is that people are paying out of pocket for their postmodern Priest. I have to pay more at work for health insurance because we now have to provide tele-therapy for all of the employees who find work and life in the most comfortable society ever created just too much to bear.

See the studies out of Scandinavia and the UK where the "bigots" who were once the trans Vanguard are rolling back conversion procedures and closing clinics faster than the wind because of what they have learned about timing, cost, liability and patient satisfaction with these procedures.

It would be cheaper to pay people to go on 2 week vacations to 3rd world countries to get their heads straight for the rest of their lives

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I hope no one you care about ends up with a serious mental illness.

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citations pls?

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Aug 30, 2023·edited Aug 30, 2023

Simply put, the American people want Scandinavian healthcare benefits without their taxes. Too bad politicians can't make a coherent argument for raising taxes that the American people will accept. I think both are to blame.

Related to that, Obamacare was spot on to make the healthy subsidize the sick (that's how insurance works, right?), but when that fell apart, we still are struggling.

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Yet we pay more for healthcare than Scandinavian countries do.

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No. Not at all when you consider the taxation taken out of their paychecks to pay for that "free" healthcare. Finland, for example, has the 6th highest income wedge tax rate. And that is applied to all workers... a much less progressive system than the US where over 50% of the population pays zero income tax.

France's public healthcare system requires almost everyone to purchase supplemental healthcare insurance. The expense trajectory for all of these countries with government healthcare are unsustainable.

The US has a more efficient system in many respects even with the insurance middleman because of the insurance middleman.

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The higher taxes go to other things besides healthcare. The per capita health expenditure is the only thing being compared here.

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Nobody said that Scandinavian healthcare was "free".

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It is a crazy supposition to claim that turning over a large and complex service industry that serves 350 million people to the US government is going to result in lower costs. It is frankly a really silly claim given the mounds of evidence that the US government cannot even prevent billions of dollars in fraud from unemployment benefits and disaster loans.

I work directly with federal and state agencies. Although there are many bright and hard working government employees, the general ability for those agencies to operate complex business models that also require constant improvement and adjustment are FAR below even the average private sector organization.

In one gig a couple of decades ago, I contracted with a state agency responsible for hospital outcome reporting. The job was to convert them from a legacy mainframe system to a new relational Oracle client-server platform. I was hired both as a DBA and as a technical project manager. I left after my contract was up in a year (having spent the first month reading a book because somebody forgot to provision me a computer and they would not allow me to plug in my laptop to their systems) and it took them another 2 years to get the system converted. That job in a private company would have been done in a year, and for a lot less money.

The Scandinavian countries are generally the size and population of Wisconsin. They are also culturally homogenous. They also love capitalism and people work instead of getting handouts. All of these things make it easier to expect government will do a good enough job with a complex service like healthcare. However, it would be a fatal mistake to expect the US government to do the same.

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I dunno, we have a state-run military. And Medicare has lower costs than private insurers. Nor is it clear that healthcare costs don't scale.

As far as "cultural homogeneity" goes, say what you really mean.

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I guess you never heard of the $800 hammer or a $1200 toilet seat?

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LOL. The government run military is a constitutional thing and it as FAR from efficient. In fact, under the Biden Administration it is likely no longer capable to defend the country. Medicare uses the private healthcare industry and providers are required to accept it in most cases. It provides inadequate reimbursement for services and thus is funded by the healthcare costs that paying people have to endure.

There is plenty of science to prove that cultural homogeneity serves easier governance because there is less group conflict for needed decisions. Everyone speaks the same language and has similar values and thus public policy is more nimble and timely.

Why don't you say what YOU really mean by challenging that point.

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Right, this is what Elizabeth Warren has been trying to argue for a long time.

Most Americans have their health insurance premiums paid mostly by their employers. If we introduced a universal, single-payer model, those premiums would instead be paid for primarily through taxes. Around 8.5% of Americans are today without health insurance, and some of those people simply choose to go without it, even though they can afford it.

The final 8.5% would now get health insurance, part of which would be paid for by taxes on their own income. Some would come from others' taxes. To a first approximation though, most people would simply pay about the same amount in new taxes as their employers currently pay towards their health insurance. In theory, they will now get a higher wage (since the firm doesn't have to pay for health insurance), alongside higher taxes, ending up basically in the same place.

So going to universal / single-payer doesn't really cost anyone in particular a lot of money, but it's a massive shift in who pays for what, exactly. Warren was frequently questioned about whether her plan required increasing taxes on the middle class (it does). She really, really did not want to say she was raising taxes on the middle class, so she would ignore the question as asked and go on to explain that middle class workers "costs" would go down. As I explained above, Warren is right about the basic accounting. We could go to universal / single-payer without making the typical taxpayer any worse off in net terms. However, you can also observe that she was deeply unwilling to just come out and say, yes, we will raise your taxes, but you'll get something valuable enough in return.

So I think Tallredrider is very much right. "American people want Scandinavian healthcare benefits without their taxes". You are right that Scandis spend less on healthcare, but Americans still seem to be deeply against the new taxes. Even Democrats.

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It's not necessarily that people don't want higher taxes. It's that as bad as insurance companies, are people believe that the government would not be better and would probably be far worse.

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And taxation on the rich is not possible because?

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I never said anything like "taxing the rich is impossible". Nice job trying to pick a fight though.

I referred to Warren's actual plan and her statements about the tax burden. I am talking about real politicians and real policy proposals here.

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Yet your post paraphrasing Warren only refers to raising taxes on the middle class.

I am not trying to pick a fight. Did Warren not mention this?

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Of course, Warren's plans included tax increases on higher-income households as well. That wasn't the unpopular part of the plan she was repeatedly attacked over.

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Because there aren't enough of them. Even totally confiscatory taxes wouldn't raise enough money to not have a broad base tax on the middle class.

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If you look at the percentage of income and assets owned by the top 10%, it dwarfs that available to the middle classes.

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Those assets are extremely difficult to tax because they aren't cash, and the income is often structured to not be income, per se, and is sporadic. Plus, taxing those assets more than once will be extra difficult. It's hard to get it to turn into recurring tax revenue that will continually pay for programs.

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Where are the cites that Finland pays less for healthcare than does the US?

There is one other consideration here. The US market for healthcare motivates most of the healthcare innovation that the rest of the world benefits from. So there is a hidden cost if the profit motive for drug and medical technology development goes away. Finland and other countries are going to have to spend more on R&D contribution because we no longer get to rely on private industry innovation. Collectivist models do not support the level on innovation... why China has to pilfer US inventions.

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After Medicare Part D passed in 2003 the pharmaceutical companies rejoiced. They no longer had to fear competition from Canada and Medicare couldn't bargain down costs. They could charge whatever they wanted.

My husband is a pharmaceutical consultant and works R&D. Pharma no longer needed to compete so they made smarter investments by paying for access to favorable legislation... like keeping compounding pharmacies from competing with them. They went into patent wars big time and made insignificant changes to formulations to get a new patent where they could charge five to ten times more. They started buying up generics and shutting them down.

In 2008 the industry shed a lot of workers and jobs became very tight. What used to be a steady set of gigs became erratic.

Pharma likes to say they won't be able to do R&D if they can't charge whatever they want and its a lie. They do have to make a profit to stay in business...but currently their profit margins are out of line for most other industries.

They need to forced to compete again.

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Aug 30, 2023·edited Aug 30, 2023

This type of graph is available pretty much anywhere everywhere. Finland is roughly $5.7k per capita and US is $12.5k. More than double:

https://data.oecd.org/healthres/health-spending.htm

EDIT: terrible copy editing

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The missing understanding here is why healthcare costs are so high in the US. It is basically because of government healthcare regulations that doubles and triples the amount of administrative costs. And so then rewarding the same people that cause this mess of regulations by turning over to them the keys to the entire complex industry is idiocy.

Now, the cost of drugs and medical technology is an area that might require price controls. However, in doing so countries like Finland and Canada are going to see their costs increase because today the US, just like it does for defense, holds the lion share of expense that the rest of the world feeds from.

Lastly is the point about service quality. In the US you can see a specialist in a few weeks in most areas and for most specialties. In Canada you can wait for a year or more.

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You're going to have to provide a citation for regulations doubling and tripling admin costs. Medicare pays 1.3% of its budget to administration. Most of it is moving the money around. Since it's also routinely defrauded I think they need more staff.

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Ordinary Americans don't pay directly though, which is the key point.

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A couple of givens:

1. Doctors will not take a pay cut. In the 1970s, doctors in California went on strike. (They ignored their Hippocratic Oaths; many are more businessmen than healers. Interestingly, during the short strike, the death rate went down, a very hard fact to discover, by the way.)

2. The same drugs cost less in Mexico and Canada. (Sick Americans are being forced to subsidize them.)

3. Despite our seeming obsession with health, exercise, and diet, Americans are the second-fattest people on Earth. (We were #1, but Mexico very recently surpassed us by .3%.) Obese people are unhealthy people; they have more medical problems and thus higher medical bills, a drag on the system, which we all pay for.

4. To increase profits for people and institutions in medicine, expensive tests are run, partly to avoid malpractice suits: "We left no stone unturned, but she died anyway." (You, thus, can't really blame them for running CT scans and MRIs for a patient with a broken leg. What if he slightly hit his head or maybe damaged an organ?) When we're in the emergency room, we want everything available on the menu, or many of us do, anyway; fear is the ultimate motivator.

Unwinding, reorganizing, or eliminating any of these Gordian knots is, to be realistic, beyond anyone's, or any group's, ability, power, or patience.

In a Hail-Mary effort, we could place German health administrators in charge of our healthcare system. They could make it function like theirs, that is, they could make it function like theirs if all Americans would get on-board. Not gonna happen. Some problems cannot be solved. A defeatist attitude? I see this conclusion as undeniable and thus telling it like it must be told.

All Mother Nature expects of you is that you live long enough to reproduce and get your offspring to the point where they can stand on their own two feet. Afterwards, humans are, again according to cold Mother Nature, superfluous. However, we beg to differ and refuse to go gentle in that dark night: We want to live forever, a fact made manifest by many religions offering eternal life. Billions have signed up for such programs. Death is too scary for most of us; it's literally unthinkable for everyone (Some tough guys may try to bluff us with their nonchalance, but I doubt that they would remain calm if experiencing a life-threatening event; for example, remember the complete panic of the people atop the Twin Towers as they looked down at the raging, unavoidable fire below them, trapping them where they were. Many tried to save themselves by jumping off and flapping their arms, screaming at the top of their lungs as they dropped).

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I have often heard it said that in Finland, high school teachers are paid like doctors. This is true, because doctors are paid like well-paid public school teachers.

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Well when you saddle them with $200,000 of college debt to become a doctor, I would expect them to hold out for a decent salary.

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In most European countries, state education is free.

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If doctors worked 9-5 and didn’t have 10 years of training, this might make sense. I was raised by a doctor who worked 90 hour weeks. A doctor friend does 24-hour shifts in the neonatology unit three days a week. They cannot be easily replaced. There’s a reason these people are more highly compensated than teachers.

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In some countries, doctors are not paid much more than a well-paid teacher.

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That is because it is as difficult to become a high school teacher in Finland as it is to become a doctor. If you raise the barriers to entry, you reduce the supply, which raises wages.

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It is my understanding that doctors in Finland are not paid that well, relatively speaking.

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Well sure, but that does not change my point that the lower the barriers to entry, the more supply there is of 'qualified' people, so the lower the prevailing wage.

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I didnt think the doctor shortage in such countries is not so much worse than the US.

This is in part because medical education in most of the world is somewhat different than the US, namely, medical education is typically part of undergrad study and not grad school.

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I don't mind the rich getting richer, to a point, say, a billion dollars, but I do mind the poor getting poorer, especially if that poor person works two or three jobs trying to keep his family fed, clothed, housed, and with access to medical and dental care. I want a living wage for all workers. No one can live on $7.50/hour with no benefits. And if we are a decent nation, we will see that no is left behind; yes, that's a tall order, but ethics require it. And if we ignore or skimp on ethics, we all pay a price every minute of every day. Vicious people cannot be happy (cf. Plato).

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founding

I’m always surprised to see people argue for an NHS-style single payer system when there’s evidence that multi-payer universal systems in which the government regulates pricing (such as Germany’s) work better for patients.

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I suspect the relative baseline health of the UK population vs. German is a major confounder here.

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founding

Is the UK population healthier? I don’t think so but I’d love to see stats. I’d bet Brits drink more, exercise less, and eat more poorly.

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Sep 11, 2023·edited Sep 11, 2023

>I’d bet Brits drink more, exercise less, and eat more poorly.

My assumption was the same as yours, but I did a quick Google and I was surprised to find that Germans apparently drink more than Brits (https://worldpopulationreview.com/country-rankings/alcohol-consumption-by-country) and get less exercise (https://www.euronews.com/next/2023/03/05/exercise-in-europe-which-countries-do-the-most-and-least-physical-activity). However, they do have a marginally lower obesity rate (https://data.worldobesity.org/rankings/).

Not at all what I would have assumed based on the few weeks I've spent in Berlin.

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founding

yeah, I'm surprised. I'd really like to see the survey that's based on, as well as the age stats for both countries (I believe Germany has a larger elderly population, but I could be wrong). Then again, Germany is a big country so even though this doesn't remotely reflect my experience here (everyone is super sportlich over here) it could very well be true.

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According to these population pyramids, it looks like Germany's 70+ population represents about 16% of the total, versus about 14% in the UK.

https://www.populationpyramid.net/germany/2021/

https://www.populationpyramid.net/united-kingdom/2021/

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This lack of planning at a higher administrative levels results in numerous morbid symptoms. Rural hospitals are closing in favor of highly centralized complexes. Hospitals charge monopoly rents, despite being operated on non-profit bases. Hospitals also routinely defraud Medicare. Pharmaceutical companies use public research create super profitable non-essential medicines, whilst neglecting antibiotics. Essential medicines like insulin have price increases for no reason besides profit. We've been making it for decades!

A not-so-much discussed problem is the guild nature of medical doctors. The AMA has lobbied for reducing medical schools, capping federal funding, and cutting residency positions for the sake of protecting their compensation and status. This is why we have seen the enormous growth of NPs and PAs.

Kudos for bringing up EMTALA. I didn't realize it was so recent.

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As far as I know, modern insulin is really good, and more expensive, but you can get Insulin Classic (TM) very cheaply, and it works, just not quite as well. It's not the same product, but more expensive, it's a more expensive product.

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Aug 30, 2023·edited Aug 30, 2023

"A not-so-much discussed problem is the guild nature of medical doctors. The AMA has lobbied for reducing medical schools, capping federal funding, and cutting residency positions for the sake of protecting their compensation and status. "

This take is from the late 1970s, early 1980s. The AMA has been asking for increased residencies and med schools since at least the 1990s.

"Pharmaceutical companies use public research create super profitable non-essential medicines, whilst neglecting antibiotics."

Why would a pharma company spend billions developing a new antibiotic when the first thing anyone is going to do with it is never use it unless thry really, really have to? New antibiotics will have to be made through public research or a huge public prize of some kind.

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Ah, I wasn't aware of them reversing course, thanks for that. Glad they're doing it. There's been legislation to correct this that's been stalled in Congress for years. I have no idea why, it seems like a win for all parties involved. The most recent cap went into effect in 1997 in the Balanced Budget Act.

Yeah exactly, the profit incentives are not there for essential tools like these. A chilling thought if we suffer a bacterial epidemic. They'd have to manufacture them and if that's not profitable they're not going to do it. They would never accept direct government production.

There's also perverse incentives for doctors to overprescribe very profitable drugs which creates things like the opioid epidemic.

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US healthcare actuary here. As far as I can tell, the biggest problem really is about health care itself rather than health insurance.

A large portion of private health insurance in the US is financed on a non-profit basis, and the costs are still quite high. Many of the largest insurers (the Blues) are mutual companies that return premiums to members in the event that their claims experience is better than expected. On top of that, most large employers do not really "buy" health insurance for their employees. They just piggyback on the negotiated prices and administrative systems of a major insurer and finance the claims themselves on a non-profit basis.

The obvious problem, and one that I have no idea how to "solve" is just that the care itself costs a ridiculously huge amount in the US compared to other countries. If providing care in the US cost the same as it does in Germany, nobody would care that much how we financed it. Germany spends something like 40% less per capita on healthcare than the US, adjusted for purchasing power. But that seems like it would involve doctors and nurses and such getting paid way less than they do now.

Maybe in a single payer setup the government could declare that all healthcare providers in the US get their revenue cut by 40% and just tell them to deal with it, but I would expect there to be some major disruptions if that happened. A more realistic scenario might be freezing reimbursements at current levels and waiting for inflation to cut out the 40%. Even so, we're definitely talking about a major restructuring of a major segment of the economy, not just moving some dollars around, in order to achieve anything like affordable care.

Seems like a genuinely difficult problem.

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Removed (Banned)Aug 30, 2023·edited Aug 30, 2023
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I've been reading about hedge funds, private equity getting in to medical specialties and tightening their monopoly power. If we have private wealth needing a cut in profits on top of the existing players, it seems as if that would add a lot to the costs.

Not sure about the accuracy of what I'm saying.

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A culture of highly entrepreneurial medical professionals might deserve some consideration.

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Provider salaries are 8% of overall health care costs, which includes nursing. So cutting everyone's salaries in half will save you 4%.

And to be frank, no one is going to spend all the time and money to go into medicine to make less and be treated worse than a plumber.

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I was surprised at how much an orthopedic surgeon made per operation, considering the total cost. He said the hospitals took most of it.

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founding

It’s absolutely the earnings of doctors and hospitals. German doctors don’t get rich. I can’t say overall whether Germans are healthier (they certainly smoke more), but most do see doctors regularly and are therefore receiving preventive care far more often than Americans.

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The last time I read up on this--which was granted like 10+ years ago--the answer was "the providers are making out like bandits."

By providers I mean: medical device manufacturers, pharmaceutical firms, hospitals, and doctors.

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I don't have a detailed breakdown of where the money goes, but off the top of my head:

- According to one of Freddie's links administrative costs are quite a bit higher in the US

- Salaries for doctors are something like 2x as high in the US

- Drug prices are higher in the US, and drug companies are definitely able to make higher profit margins than insurers, but even so drug spending is a relatively small fraction of overall healthcare costs (like 12% according to this https://www.cdc.gov/nchs/hus/topics/health-care-expenditures.htm ).

The money is definitely going somewhere, but I don't know if it is that useful to characterize the difference in expenditures as "profits". Total gross profits in the US are something like 15% of GDP, and healthcare spending is like 18% of GDP. Healthcare industry profits are located somewhere in the 25% or so of profits attributed to the rather broad category of "other non-financial" in this table https://apps.bea.gov/iTable/?reqid=19&step=3&isuri=1&1921=survey&1903=239 .

So "profits" on their own are definitely not enough to explain the difference in healthcare costs between the US and the rest of the world even if we assume that there is no profit in the healthcare industry anywhere else.

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There's also capital expenditure on facilities and medical devices. Hospitals are only getting bigger and this applies to non-profit hospitals as well since they have to spend the money. There's also the labor costs of the insurance and hospital staff struggling with one another. These two items show up as expenditures, not profits, and they are at loggerheads with delivering care.

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The German government sets prices.

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Germany doesn’t have single payer, The Netherlands, doesn’t have single payer. When people talk about single payer I assume they have no idea what they are taking about.

There is no reason to expect single payer to work better than a system of highly regulated non-profit insurers. Why do people keep bringing it up?

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Single-payer is often just used as a synonym for Universal in American discourse on healthcare. It's unfortunate, but I wouldn't assume people that mention single-payer don't know what they're talking about. They mean that the government should pay for healthcare for whoever wants it, funded by taxes. The system would still be multi-payer if e.g. we don't ban people from buying their own private insurance. I don't think many people are caught up on that detail..

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This is true for most people speaking casually, but Sanders advocated abolishing private insurance. I had to explain to many friends that Canadians and Germans can (and do) get private insurance.

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The general consensus seems to be that the Swiss, German and Dutch system where people buy their own insurance from highly regulated private non-profits insurers and those that can’t afford it get a subsidy from the government works better.

So why ignorantly pontificate about such a minor detail that paints one into a rhetorical corner?

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founding

Lack of imagination. I’d rather have German healthcare than the NHS any day.

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People bring it up because it works. For example, it works in these countries: Norway, Japan, and Canada.

As for the German and Dutch systems, fewer administrative bodies result in less labor expended shuffling paper.

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Norway doesn’t have single payer.

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Uh, what? The government guarantees healthcare and manages the hospital system.

Even if we do throw it out there's still two others.

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Aug 30, 2023·edited Aug 30, 2023

You’re on the hook for everything until you hit your (admittedly low) out of pocket max. Then you get a card that covers everything for the rest of the year.

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I'm frankly stunned by this. Are you arguing that the patient is a payer? That this is in fact a million payer system?

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I’m arguing the patient is the payer because the patient has to pay up to the out of pocket max. Yes.

That was one of the Obamacare Republican proposals as I recall. The government would offer “catastrophic” coverage by paying for anything that was above x% of AGI. Would you call that single payer? No, you would not.

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Removed (Banned)Aug 30, 2023
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See Larry’s comment above.

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I think that two instances where the free market is naturally unbalanced is in medicine and criminal defense for the reasons you describe. I’ve long wondered if we would be able to provide some baseline healthcare akin to the public defenders/right to an attorney, leaving room for a private pay “more attention for your money” tier akin to privately funded defense attorneys. Never been able to figure that out.

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Something along those lines is the default model in many European countries

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Aug 31, 2023·edited Aug 31, 2023

With Medicare/Medicaid/ACA we aren't so far off of that. Only 8.5% uninsured in the US, which includes those that could afford to buy insurance but don't. I'm personally in favor of something like RyanY describes. Universal coverage funded with taxes, but pretty no-frills. If you want better you go get it on the market. I just don't see the political will to do that. It's a major new program with major new taxes. You could keep most people basically in the same place financially, but not everyone. There would be a lot of winners and losers and so it's a *big* to do. About 5% of the country would be the obvious beneficiaries- the people that can't afford any insurance right now.

I just don't see the Democrats being willing to spend much political capital on this 5%, whom aren't even nearly all likely Democrat voters. Rhetorically, of course this is the Dems plan, but when budget constraints bite, they'll find some crisis affecting college grads and spend on that instead.

Nonetheless, it still feels like universal healthcare is such an animating issue for so many on the left. It seems to me it wouldn't matter if the uninsured rate was 0.1%. It's a matter of principle.

Again, my preference is universal, but I am also seeing why there isn't much momentum on this issue today. The good news is that a stronger, fairer economy will also help whittle down that uninsured rate, and that might be the faster way to make progress on the issue.

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Hmm, isn’t another alternative to single payer that we require the purchase of private health insurance, similar to what we do with auto? That would still accomplish the goal of the young subsidizing the old.

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ACA

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What do you do to the people that can’t, or refuse to, pay?

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I would imagine something similar to what we do with auto insurance: nothing. As long as enough people pay to affect the costs in the system, it’s probably still a win.

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But I think my comment is pretty silly compared to the one above comparing this to Obamacare pre-repeal of the individual mandate

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Man, spoken like someone who’s never been hit by someone without insurance haha. They isn’t enforced at all in my experience.

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If people don’t pay for car insurance and get caught, they will get tickets and in most states eventually get their license suspended. That doesn’t work for health insurance (and fining people for not being able to afford health insurance is basically a poor tax).

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This is what Obamacare is. People are levied fines if they don't pay for plans. Lower income people who don't qualify for Medicaid are means-tested for tax rebates. State level financing plays a determinative role here, a plan in California is miles better than in Mississippi.

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That’s no longer the case for Obamacare (well, technically there’s a fine, but it’s $0). When it did exist I think it was terrible, basically a poor tax.

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Ah OK the fines were repealed under Trump. I was out of the loop because thankfully I don't have to get a marketplace plan.

Yeah I agree, it was absolutely awful. Pay for this shitty plan or else.

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The Australian health care system addresses many of these issues while retaining private and public aspects:

Everyone pays a Medicare levy of 2% of their taxable income. Medicare and the public hospital system provide free or low-cost access for all Australians to most of the out-patient health health care services. Private health insurance gives patients choice outside the public system, particularly for hospital I.e. hospital services. For private health care both in and out of hospital, patients pay monthly fees in order to contribute towards the cost of their health care.

An additional tax is payable by those that do not take out private health insurance to incentivize participation so that private health care companies remain financially viable. All medications are highly subsidized by Medicare which, by buying in bulk, has the power to negotiate low prices.

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"provide free or low-cost access for all Australians to most of the out-patient health health care services"

Who is paying the salary of these outpatient health care providers? Doesn't sound like they're going to be making much money.

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Doctors (both specialists and general practitioners) and allied health practitioners are all paid by Medicare. They levy a top-up payment on patients directly - about 20%. They do very nicely. Doctors make good money and have great lifestyles.

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Australia's systems seems very sensible and would probably work well here IF we could just get it set up. We just have to find away around the roadblocks (mostly put up by the GOP).

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The other ways that health insurance is not like car insurance is that:

1. If you repeatedly put the wrong fuel in the car (as I do), then behave recklessly while driving, causing yourself to be involved in repeated similar accidents, the insurer is allowed to either say "no thanks" or make the premium so high that you are essentially uninsurable. When comparing ourselves to e.g. Singapore, it helps to also compare lifestyles.

2. If the car becomes severely damaged enough, they scrap it and give you money for a new one. How do you scrap a person's body and give them a new one?

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Back in university I did a moral philosophy class and had to read an article about "rationing by responsibility", the idea of restricting access to scarce medical resources to those who got sick for reasons outside of their control. If you ended up in the hospital from a heroin overdose or a motorcycle accident, you're on your own.

The article was against this position, and made the persuasive argument that nobody goes around maximizing their healthfulness at all times, so where do you draw the line? Nobody gets a full eight hours' sleep every night, nobody gets 10,000 steps in every single day, nobody goes a whole year without a glass of wine or a bowl of ice cream. A functioning society in fact depends upon people willing to sacrifice their personal health for the greater good (working long hours in a stressful job is not ideal for maximizing health and longevity, and yet we still need doctors to do exactly that).

On the one hand, yes. Nobody, least of all me, maximizes their health at all times - when most people get sick, it's probably at least partly indirectly due to their own behaviour.

On the other hand, some people are more responsible than others, and one can't help but bristle at the idea of the taxpayer paying for some junkie to be resuscitated after his fifth OD of the year, or a gay man who refuses to use condoms when having sex with strange men in bathrooms and then - surprise! - contracts HIV.

The idea periodically resurfaces in different guises. During Covid I saw lots of petty tyrants on Reddit demanding that unvaccinated people be refused admission to hospitals if they contract Covid. I'm sure these people would be outraged if I suggested that the same restrictions be applied to the obese, even though exactly the same arguments apply (in fact, I believe the data shows that obese vaccinated people are more likely to be hospitalized because of Covid than unvaccinated people of a healthy BMI).

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There are plans that adjust premiums based on lifestyle. I used to have one that provided a lower premium in exchange for lifestyle monitoring. I had mandatory bloodwork, and if my numbers were bad I would have to talk to these incredibly annoying "lifestyle coaches" who told me to walk more. I didn't realize I had to fast before the bloodwork (was also young and dumb) so I was flagged as pre-diabetic despite my protestations.

I also met a guy who had a pedometer that required a minimum number of steps per day for lowered premiums.

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>I also met a guy who had a pedometer that required a minimum number of steps per day for lowered premiums.

Ted_Kaczynski_mugshot.jpg

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Try checking the "Yes I smoke" box on your next insurance application and see what happens to your premium.

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I just re-did the health insurance for our company, and they did not even ask the question.

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Adding, I don't literally put the wrong fuel in my car, but do have a less than optimal diet.

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Any moral argument for universal healthcare will fail its first encounter with a republican. And since there are many republicans in congress and in the wild….

Obama tried this and barely got halfway with ACA. It’s like a religious thing for the right…much like…well…religion, so it’s just not going to get very far.

I’m surprised Medicare and Medicaid have lasted this long. I think the argument for kids is the most tenable. Maybe you might have some luck with some version of Medicare for under age 18. But btw 18 and 65….that’s going to be a tough road to hoe.

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I don't think it's the moral argument that fails with Republicans, it's the refusal to state where the outside limits are. What treatments will not be covered, no matter how sympathetic the case? Without that discussion up front, you are asking to run the A/C with all the windows and doors open. Even the person who is sympathetic to the discomfort of the building occupants just won't agree.

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For five years I worked customer service for a major US health insurer. It is an administrative labyrinth that requires much time, patience and skill to navigate. I’m

Not a fan of big government, yet I know the government could hardly do it worse. Also, with so many options available, insured people do not know details of their coverage that they pay for. They only find out when the bills are actually processed.

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Physicians lose an estimated 17.4 percent of Medicaid claims to billing problems, compared with losses of 4.9 percent for Medicare claims and 2.8 percent for commercial insurance claims.

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People like to use the DMV as an example of big government inefficiency. But at the DMV you at least eventually get your license.

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That’s cause handing out drivers licenses is extremely simple. There are only two types, and only about 4 requirements for each. DMV still manages to make a hash of it. Health care is vastly more complex.

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Oh no it was just a glib joke about how insurance can end up denying your claim despite all your efforts. I don't think they're comparable at all.

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People in "single payer" UK die of cancer at rates far far higher than people in the US. deBoer tries to go around the problem that there's infinite need for resources but only limited resources. But you can't. Let's give out everyone a government backed insurance card is stupid for the same reason giving everyone a million dollars is stupid. The sorting mechanisms reassert themselves, this time in waiting times. If you have good insurance, your cancer gets detected early. If you have single payer insurance, you have to wait until it's stage 4 and you are sent away to die. That's how it works in places like UK and Canada. I know definitely about latter from my uncle's experience.

I got so say, when Freddie starts staning for Omnipotent Omnipresent State, he seems like such a tool. Please note that when he had to get surgery, Freddie was a-OK with the system as it was. Now imagine having that injury for more than a year, awaiting surgery. I wish that has happened, because for some people nothing short of an extremely painful personal lesson will ever penetrate.

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I definitely know from my own experience that that's not true. Different single-payer systems may or may not be better at preventative care and testing, and triaging, but they definitely do those things.

I've had cancer, detected early, treated as soon as detected. I've had relatives detected at various stages, and they all get treated.

Do you always get seen by a specialist in time in a single payer system? No. I've had that happen with non-life-threatening consequences, and it was enraging, although fortunately not permanent. That's a genuine problem, but it is very much addressable, and addressed on an ongoing basis.

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founding

People in Germany’s price-regulated multi payer system don’t though.

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Aug 30, 2023·edited Aug 30, 2023

I think the US can deliver its high standard of cancer care with a single-payer system. The billing clerks aren't creating the treatments.

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No, for-profit companies are creating them, and if they can't make money, they will stop creating them.

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The profit motive would still exist. They would be bargaining with a larger buyer. Pharmaceutical companies sell at a profit in non-US markets.

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I've waited a year for a specialist in the US though so how does this argument hold up?

We get the same shitty waiting list plus high deductible insurance.

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"If you have good insurance, your cancer gets detected early. If you have single payer insurance, you have to wait until it's stage 4 and you are sent away to die. "

It's actually quite controversial whether the supposed benefits of screening for all kinds of cancers actually make a difference now that drugs are getting better, if screening actually ever did much, which was also surprisingly unstudied.

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The comment is a bit harsh, but I think the insight that need is infinite and resources are limited is spot on. It’s also rarely addressed in these discussions.

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I couldn’t finish the article after you dropped that bombshell about the inevitability of death.

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founding

`I intend to live forever. So far, so good.'

- Steven Wright

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Freddie is obviously completely clueless on this matter. Just ignore him and keep on trucking.

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"death is inevitable, you are human, nobody lives forever" - typical Marxist bullshit. I am a golden god

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