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> I wonder how Americans can tolerate this situation. Several reasons this terrible system continues to exist but it essentially boils down to entrenchment. -

> I wonder how Americans can tolerate this situation. Several reasons this terrible system continues to exist but it essentially boils down to entrenchment. - The private healthcare industry pays politicians to maintain the status quo. The alternative government run solution does not. - The private healthcare industry creates propaganda and pays the media to spread it. An improved government run solution does not. - Many Americans have decent coverage from their employer. For them, it’s not worth upending the system for what might be moderate gains. More over, propaganda has made them expect worse coverage from any alternatives. - ACA gave many without employer coverage a good enough solution. It’s still expensive as fuck but it subdued enough voters. So, after considering voters who are happy enough with the devil they know, you don’t have enough votes left to overturn the system.

G3rn0ti 5y ago
Isn’t the biggest problem in the US health insurers operating on state level only? This is due to some regulation preventing formation of federal insurers. I never understood why there are no independent national health insurers (read Allianz for example) providing health care for self employed people like in Europe. Edit: A classic by John Mackey (Whole Foods Inc.) but still valid: https://www.wsj.com/articles/SB10001424052970204251404574342170072865070 https://www.wsj.com/articles/SB10001424052970204251404574342... Quote: „Repeal government mandates regarding what insurance companies must cover.“
- ageitgey 5y ago
  The US has states that are larger than countries in Europe. This may or may not contribute to the problem, but it is tiny in the big picture of US healthcare issues. The issue in the US is that the system is hugely inefficient compared to the models in Europe. There is an absolutely massive administrative layer between care providers and payers, price negotiations aren't transparent or efficient, the whole system is hugely complex, and the vested interests are incentivized to keep it that way.
- toast0 5y ago
  Most of the big insurers operate in multiple states. But operation in each state is regulated by that state, and I've heard, but not verified, that most ACA plans offer in-state coverage only, with some exceptions for communities at state borders (if you live near Lake Tahoe, an ACA plan probably covers doctors in the area in NV and CA) Shopping for plans on the marketplace is already terrible when they all cover the same stuff. It'll be way worse if I have to decide between terrible options for what's covered. Especially since we all know none of that is going to be clear or easily comparable, and certainly not pick the things you want covered.... It'll be like broken bones are in the package that excludes cysts, and brain cancer coverage is not available with any other cancers, and to get coverage for any sort of dermatology, you also need coverage for skiing and parachuting incidents. As-is, I can take my list of prefered facilities, look and see who has them in network, and then add the premiums to the out of pocket max to find my rough worst case cost and pick the one with the least worst case cost and call it a day. This is usually also the one with the least premiums, so it's also the least cost if I don't visit the doctor at all.
Kalium 5y ago
It's also worth bearing in mind that the socialized healthcare system the US does have - the VA - does not have a uniformly good track record. This does a poor job of making the case for a larger socialized system all on its own. Which is to say it's not just propaganda.
- ageitgey 5y ago
  The US has a massive socialized healthcare system much larger than the VA - Medicare. Roughly 18% of Americans are covered by Medicare, a socialized system.
  - DanTheManPR 5y ago
    One difference is that the VA is a complete system, with it's own hospitals and staff. Medicare is that half-way solution, a public insurance system which buys medical services for the members from the private sector. As for the VA system's woes, I would say: yeah, it's definitely possible to build a system that doesn't work well. But that doesn't mean we shouldn't be trying.
  - nradov 5y ago
    Medicare isn't really a socialized healthcare system. Most of the providers aren't government employees, and some providers don't accept Medicare patients because the reimbursement rates are low. Many beneficiaries actually obtain their plans through private insurers with the Medicare Advantage program.
- CogitoCogito 5y ago
  > It's also worth bearing in mind that the socialized healthcare system the US does have - the VA - does not have a uniformly good track record. This does a poor job of making the case for a larger socialized system all on its own. > Which is to say it's not just propaganda. No public or private system anywhere in the world has a uniformly good track record.
  - soco 5y ago
rafale 5y ago
> Many Americans have decent coverage from their employer. For them, it’s not worth upending the system for what might be moderate gains. Negative gains I may say. In my experience of the Canadian healthcare and US healthcare systems, the latter, IF you are well insured, feels like a Rolls-Royce whIle the former is like driving a Lada in Pothole City. I remember the first time I called my provider in the US to book an appointment with a dermatologist. She said "Wednesday", I said "What month?" I couldn't believe it was that same week. I used to wait 2-3 months in Canada. And I had to first get a reference from a ER/generalist doctor. Also don't forget the US spends on medicare/medicaid/VA about the same % Canada spends on healthcare.
- shakezula 5y ago
  This is still a pipe dream for some. It’s still very very common to wait months to see a doctor in the states, especially after the pandemic. I routinely wait months to get into my dermatologist, too. YMMV but this is absolutely not the norm.
- brianwawok 5y ago
  Right, this is the point that is missed in every hacker news / reddit post that spends hours making fun of how bad the US is and how some people get stuck with $50,000 hospital bills. If you have good work based coverage, our care is excellent. Fast access, and low out of pocket costs. I do want to improve it for everyone, but I have 0 complaints about my personal access to health care. I cannot imagine living in Canada and being put on a 8 month wait for something important but not urgent...
  - DanBC 5y ago
    > our care is excellent Where "excellent" includes shorter length of life, and over-testing, over-diagnosis, and over-treatment (each of which causes harm) because you've got to have something to show for all that insurance spending.
  - wing-_-nuts 5y ago
    >I cannot imagine living in Canada and being put on a 8 month wait for something important but not urgent... We have pretty long wait times in the US for elective surgeries as well. Not as bad as canada, but it can take a bit to get you scheduled for a hip or knee replacement.
JamesBarney 5y ago
Also the FDA makes it incredibly expensive to compete even on off patent drugs.
moron4hire 5y ago
> More over, propaganda has made them expect worse coverage from any alternatives. Is it propoganda or lived experience? Everytime someone has come around saying they're going to fix my health insurance for me, it's ended up costing me more for the same service as before. Come to think of it, I've yet to have an increase in positive experiences concerning my health insurance. Every doctor's visit feels like a new surprise lurking in the dark.
- pessimizer 5y ago
  It's propaganda. People who have lived experience of the VA system may have complaints, but they're mosquito bites compared to the lived experience of even people with reasonably good insurance who have gotten sick.
- kuraudo 5y ago
  That's because, in a democracy, the incentives aren't to fix problems, but to create more so that you can continue to 'solve' them forever. This is exasperated by the obvious bribes that get flung around in the form of speech fees, employment after political career, and so on which give politicians, even ones ostensibly out to 'fix' your problem, perverse incentives to do the opposite in favor of a massive corporation. I have heard that European Healthcare, especially in places like Denmark, is top notch and somehow free of this evil: I would love to know how they achieved this.
mysterydip 5y ago
One other possibly related point is "free healthcare" (as well as free tuition) are "perks" of enlisting in the military. Take away those and I wonder what the recruitment rate would look like.
- pessimizer 5y ago
  They make less than minimum wage otherwise, so I imagine bad.
xhrpost 5y ago
I've also been thinking, the population segment in the US most likely to have medical expenses and thus see a problem in the system to be fixed are the older generations. But, these generations are on Medicare and Medicaid and thus don't see the same problem as those with expenses who are younger. This is also a large portion of the population that, "doesn't want socialized medical care". So, they in effect, have socialized medical care and it's benefits but don't want anyone else to have it. Is this kind of accurate or am I being too cynical?
silexia 5y ago
The #1 reason we have these crazy expensive drugs is because of our patent system. Ideas are worthless, execution is everything. The free market cannot function when monopolies are arbitrarily granted. End the patent system, and you will end Big Pharma. And we will have more innovation.
joshspankit 5y ago
As well, employers maintain the status quo because an employee who is literally terrified of losing health care is less likely to even consider quitting.

G3rn0ti 5y ago

Isn’t the biggest problem in the US health insurers operating on state level only? This is due to some regulation preventing formation of federal insurers. I never understood why there are no independent national health insurers (read Allianz for example) providing health care for self employed people like in Europe. Edit: A classic by John Mackey (Whole Foods Inc.) but still valid: https://www.wsj.com/articles/SB10001424052970204251404574342170072865070 https://www.wsj.com/articles/SB10001424052970204251404574342... Quote: „Repeal government mandates regarding what insurance companies must cover.“

ageitgey 5y ago
The US has states that are larger than countries in Europe. This may or may not contribute to the problem, but it is tiny in the big picture of US healthcare issues. The issue in the US is that the system is hugely inefficient compared to the models in Europe. There is an absolutely massive administrative layer between care providers and payers, price negotiations aren't transparent or efficient, the whole system is hugely complex, and the vested interests are incentivized to keep it that way.
toast0 5y ago
Most of the big insurers operate in multiple states. But operation in each state is regulated by that state, and I've heard, but not verified, that most ACA plans offer in-state coverage only, with some exceptions for communities at state borders (if you live near Lake Tahoe, an ACA plan probably covers doctors in the area in NV and CA) Shopping for plans on the marketplace is already terrible when they all cover the same stuff. It'll be way worse if I have to decide between terrible options for what's covered. Especially since we all know none of that is going to be clear or easily comparable, and certainly not pick the things you want covered.... It'll be like broken bones are in the package that excludes cysts, and brain cancer coverage is not available with any other cancers, and to get coverage for any sort of dermatology, you also need coverage for skiing and parachuting incidents. As-is, I can take my list of prefered facilities, look and see who has them in network, and then add the premiums to the out of pocket max to find my rough worst case cost and pick the one with the least worst case cost and call it a day. This is usually also the one with the least premiums, so it's also the least cost if I don't visit the doctor at all.

Kalium 5y ago

It's also worth bearing in mind that the socialized healthcare system the US does have - the VA - does not have a uniformly good track record. This does a poor job of making the case for a larger socialized system all on its own. Which is to say it's not just propaganda.

ageitgey 5y ago
The US has a massive socialized healthcare system much larger than the VA - Medicare. Roughly 18% of Americans are covered by Medicare, a socialized system.
- DanTheManPR 5y ago
  One difference is that the VA is a complete system, with it's own hospitals and staff. Medicare is that half-way solution, a public insurance system which buys medical services for the members from the private sector. As for the VA system's woes, I would say: yeah, it's definitely possible to build a system that doesn't work well. But that doesn't mean we shouldn't be trying.
- nradov 5y ago
  Medicare isn't really a socialized healthcare system. Most of the providers aren't government employees, and some providers don't accept Medicare patients because the reimbursement rates are low. Many beneficiaries actually obtain their plans through private insurers with the Medicare Advantage program.
CogitoCogito 5y ago
> It's also worth bearing in mind that the socialized healthcare system the US does have - the VA - does not have a uniformly good track record. This does a poor job of making the case for a larger socialized system all on its own. > Which is to say it's not just propaganda. No public or private system anywhere in the world has a uniformly good track record.
- soco 5y ago

rafale 5y ago

> Many Americans have decent coverage from their employer. For them, it’s not worth upending the system for what might be moderate gains. Negative gains I may say. In my experience of the Canadian healthcare and US healthcare systems, the latter, IF you are well insured, feels like a Rolls-Royce whIle the former is like driving a Lada in Pothole City. I remember the first time I called my provider in the US to book an appointment with a dermatologist. She said "Wednesday", I said "What month?" I couldn't believe it was that same week. I used to wait 2-3 months in Canada. And I had to first get a reference from a ER/generalist doctor. Also don't forget the US spends on medicare/medicaid/VA about the same % Canada spends on healthcare.

shakezula 5y ago
This is still a pipe dream for some. It’s still very very common to wait months to see a doctor in the states, especially after the pandemic. I routinely wait months to get into my dermatologist, too. YMMV but this is absolutely not the norm.
brianwawok 5y ago
Right, this is the point that is missed in every hacker news / reddit post that spends hours making fun of how bad the US is and how some people get stuck with $50,000 hospital bills. If you have good work based coverage, our care is excellent. Fast access, and low out of pocket costs. I do want to improve it for everyone, but I have 0 complaints about my personal access to health care. I cannot imagine living in Canada and being put on a 8 month wait for something important but not urgent...
- DanBC 5y ago
  > our care is excellent Where "excellent" includes shorter length of life, and over-testing, over-diagnosis, and over-treatment (each of which causes harm) because you've got to have something to show for all that insurance spending.
- wing-_-nuts 5y ago
  >I cannot imagine living in Canada and being put on a 8 month wait for something important but not urgent... We have pretty long wait times in the US for elective surgeries as well. Not as bad as canada, but it can take a bit to get you scheduled for a hip or knee replacement.

JamesBarney 5y ago

Also the FDA makes it incredibly expensive to compete even on off patent drugs.

moron4hire 5y ago

> More over, propaganda has made them expect worse coverage from any alternatives. Is it propoganda or lived experience? Everytime someone has come around saying they're going to fix my health insurance for me, it's ended up costing me more for the same service as before. Come to think of it, I've yet to have an increase in positive experiences concerning my health insurance. Every doctor's visit feels like a new surprise lurking in the dark.

pessimizer 5y ago
It's propaganda. People who have lived experience of the VA system may have complaints, but they're mosquito bites compared to the lived experience of even people with reasonably good insurance who have gotten sick.
kuraudo 5y ago
That's because, in a democracy, the incentives aren't to fix problems, but to create more so that you can continue to 'solve' them forever. This is exasperated by the obvious bribes that get flung around in the form of speech fees, employment after political career, and so on which give politicians, even ones ostensibly out to 'fix' your problem, perverse incentives to do the opposite in favor of a massive corporation. I have heard that European Healthcare, especially in places like Denmark, is top notch and somehow free of this evil: I would love to know how they achieved this.

mysterydip 5y ago

One other possibly related point is "free healthcare" (as well as free tuition) are "perks" of enlisting in the military. Take away those and I wonder what the recruitment rate would look like.

pessimizer 5y ago
They make less than minimum wage otherwise, so I imagine bad.

xhrpost 5y ago

I've also been thinking, the population segment in the US most likely to have medical expenses and thus see a problem in the system to be fixed are the older generations. But, these generations are on Medicare and Medicaid and thus don't see the same problem as those with expenses who are younger. This is also a large portion of the population that, "doesn't want socialized medical care". So, they in effect, have socialized medical care and it's benefits but don't want anyone else to have it. Is this kind of accurate or am I being too cynical?

silexia 5y ago

The #1 reason we have these crazy expensive drugs is because of our patent system. Ideas are worthless, execution is everything. The free market cannot function when monopolies are arbitrarily granted. End the patent system, and you will end Big Pharma. And we will have more innovation.

joshspankit 5y ago

As well, employers maintain the status quo because an employee who is literally terrified of losing health care is less likely to even consider quitting.