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I wrote Hacking Healthcare for O'Reilly, I've managed hospital systems and group practices, I've been a patient with a life threatening illness. This is a reall

I wrote Hacking Healthcare for O'Reilly, I've managed hospital systems and group practices, I've been a patient with a life threatening illness. This is a really low effort article, it doesn't even really define what it considers "healthcare". In the US healthcare is 1/5 or more of the entire economy, so who profits from 1/5 of all US economic activity is a silly premise. The US doesn't have one healthcare system, it has 50+ (or 51, ...59, is healthcare in Puerto Rico part of the US healthcare system?, how about American Samoa?). Contrary to many peoples opinions the "healthcare system" is not operated or overseen primarily at a federal level. The federal government is one of the largest buyers of healthcare as an insurance provider, that is true. Comparisons to other countries that are much much smaller than the US are sort of silly to me. Europe does not have one healthcare system. Subsidized education and price controls in foreign systems also make comparisons excruciating. I think it is usually a canard. OECD data is, in a word, "garbage", as it relates to healthcare. Just one example: In the US, eyewear for seeing purposes is healthcare. In almost no other countries do you need a prescription for eyeglasses. Prescription eyewear in the US is a 20-30 billion dollar market, depending on how you want to count it. I think the mechanisms for paying for healthcare in the US are really inefficient and involve too many intermediaries. This is a result of a lot of accidents of history. America is a very physically large country with a lot of people all over it, we expect very high standards of care, we consume a tremendous amount of pharmaceuticals, we have wildy abundant and relatively inexpensive food that seems to be correlated to our being much more overweight than a lot of other peoples, we engage in a lot of dangerous activities at a rate that far exceeds what a lot of other peoples do that seems to correlated with our culture, on and on. Instead of hand wringing about differences between ourselves and other cultures we would be better served looking at boring things like medicares 3 million pages of medical claim guidelines, clearing house operations and conflicts of interest, better incentives for state level responsibility, antitrust litigation, lots of practical things that don't make click bait headlines.

rozenmd 3y ago
> In almost no other countries do you need a prescription for eyeglasses In both Australia and France, you need a prescription. This assertion makes me question the accuracy of the rest of your comment.
AndrewKemendo 3y ago
Probably the best comment here What are your thoughts on how effective something like Medicare for all would be?
- duffpkg 3y ago
  I don't mean this to offer any political commentary one way or another but as someone who has worked at length with Medicare, HHS, CMS, VA, HRSA, and more or less every alphabet soup federal appendage remotely related to healthcare and medicine. No, I do not think any version of "medicare for all" is a remotely plausible solution to any healthcare problem other than getting healthcare lobbyists much larger yachts.
robocat 3y ago
https://archive.ph/Typim https://archive.ph/Typim Interesting points. The Economist is great (so long as you read it with an eye open for their normal media bias). Nitpick: > In almost no other countries do you need a prescription for eyeglasses. In New Zealand the eye details from your optician are called a prescription. Opticians and eyewear is mostly paid for privately (except people on government benefits and children get theirs paid for by the public). I'm not sure if private insurance offers a glass coverage option. Mostly, this article is pointing out emergent behaviours of a set of rules. How can we design self-optimising economic systems that are better than capitalism & democracy?
jseliger 3y ago
we would be better served looking at boring things like medicares 3 million pages of medical claim guidelines, clearing house operations and conflicts of interest, better incentives for state level responsibility, antitrust litigation, lots of practical things that don't make click bait headlines. It would also be nice to reform the FDA and the clinical trial system: https://bessstillman.substack.com/p/please-be-dying-but-not-too-quickly https://bessstillman.substack.com/p/please-be-dying-but-not-... "Antitrust litigation" covers this, but to spell it out, the increasing monopolization of many local healthcare systems is a huge problem.
- duffpkg 3y ago
  My opinion about the FDA is that it suffers from two major faults, it is always regulating the "last war" and it has the standard federal government incentive structure for policy making which is "do not do anything that according to civil service regulations can get me fired". In defense of the FDA, which I promise is not an instituion I have much affection for, they are asked to strike an impossible balance. More or less the same regulatory impulse that allowed Richard Sackler to build an empire on the killing of millions of americans is the same one that allows very sick people to access very, at times dubious, drugs and trials that sometimes save their lives. Most of medicine is very centrally built around the "first do no harm" approach, even at the cost of lives by non-intervention sometimes. With the FDA most people want a "do some harm, some of the time for the greater good" approach which is a really difficult thing for a federal agency to put into practice. I think they do an especially awful job with it but I appreaciate that it is a really hard balance to strike.
  - sneak 3y ago
    Tobacco kills 7x as many people each hour, day, and month as opioids in the USA, and it’s available everywhere without a prescription. The Sacklers aren’t the problem here, corruption is.
    - polygamous_bat 3y ago
      > The Sacklers aren’t the problem here, corruption is. Why not both?
neotrope 3y ago
Thanks for this. How much are regulations to blame for this mess? ie if we cut regulation, would that lead to lower cost and better outcomes? What is the path to fix this?
- duffpkg 3y ago
  There is not one silver bullet or even hundred or thousands of bullets that are going to magically re-engineer 1/5 of the US economy. Measuring costs is really hard, measuring outcomes is even that much harder -- maybe more or less impossible in the aggregate. The heart of the question comes back to what you actually want to fix. I don't know you. A lot of people would just like to pay less for the thing they currently receive which is a nice sentiment but often hard to resolve. A large set of those people are actually upset because they have been led to believe they are paying a lot more than other people for the same thing, which I do not believe to be actually true. One solution that does seem palatable to a lot of people, not me, but a lot, is "I would like like to appear to pay less for what I receive while the real costs are hidden and subsidized in a way that is much less visible to me". While popular this view is not popular enough to adopt legislation to that effect. In practical terms detailed policy legislation that makes losers out of a lot of low value transactional middle men would see some very meaningful across the board cost reductions, probably 7-10% (500 billion or more). Top of that list would be intelligent standardization and regulation of transactional medical billing process. This would/could look a little bit like how we regulate banking between financial institutions. Very sexy I know.
  - s1artibartfast 3y ago
    I think One "silver bullet" would be to give the patient more skin in the game when selecting treatments and balancing cost/benefit. The current system is a tragedy of the commons. Costs are opaque and distributed. Patients have insurance and may as well buy the most expensive treatment (everybody else is doing it). There is nobody in the entire health system with incentives to trade 1% less benefit for 99% cost reduction. In Europe, this is often handled by government purchasing discretion (not price caps as many simplistically believe). If X treatment is too expensive, it simply isnt covered. If generics medication get 99% of the job done, that is what you get. This might mean replacing employee healthcarecare with employee payments, MORE copays, and more transparent pricing (there has already been some improvement in this area). If a CT cost is 10x at one hospital, and 1x at the other, the patient needs an incentive to seek out the 1X cost. Similar, if one cancer drug is 10k and the other 100k, with a life extension of X days, the patient is the only one that can really make the call.
scotty79 3y ago
> In the US healthcare is 1/5 or more of the entire economy, so who profits from 1/5 of all US economic activity is a silly premise. It's really not. If you asked the same question about Russia and their oil economy and oligarchs it would be perfectly reasonable despite the size.
- deleted 3y ago
  [deleted]
scotty79 3y ago
> Europe does not have one healthcare system. And yet pretty much every single one of those is more equitable and efficient than what US can muster.
- saiya-jin 3y ago
  Well the starting premise is very different, so yes the results are also dramatically different. US, for better or worse, is much more individualistic society, without much emotions for plight of other citizens. Sort of buddhistic/hinduistic approach - if you suffer now, you must have done terrible things in your past life to deserve it, and why should I interfere. This results in tons of wonderful things in economy but messes up quite a bit too and brings some bad incentives where they shouldn't be. You don't want to be below average/median income (and say have some health issues on top of that), the quality of life is significantly worse than similarly-positioned peers in say Western Europe. But everybody looks at the top 0.1%, which fares, at least financially better. Strange place and setup for me and not in a good way, but maybe our more egalitarian and friendly/helpful approach is too naive and harsher society is more robust. We shall see.
  - qwytw 3y ago
    > But everybody looks at the top 0.1%, which fares, at least financially better. Let's be fair it's at the very least 10% (maybe up to 30-40% if not more) that are doing better financially than they would in Europe under similar circumstances (education, career etc. wise). In certain sectors like tech it's not even close. e.g. real estate even in SF, NY, San Jose is significantly cheaper than for instance in Munich, Rome, Paris, Milan, London etc. when compared to median income. Also it's not that obvious to me that Americans are that much less likely to care about 'the plight' of others on an individual level. For instances Americans donate many times more to charity on average than Europeans do (which makes sense if you expect the government to take care of everyone, but let's not equate that with intervening directly...)
    - saiya-jin 3y ago
      > e.g. real estate even in SF, NY, San Jose is significantly cheaper than for instance in Munich, Rome, Paris, Milan, London etc. when compared to median income. You are just hiding in complexities of real life and reducing it into few trivial numbers that are easy to compare. Count in good education for say 2 kids (500k-1 million per head?) which is free here, count in healthcare costs if you live long enough to start accumulating health problems that are basically unsolvable by today's medicine. Free here. I don't know the actual numbers, and they are very individual so what you say may be actually true for you, but it certainly isn't true for me for example. Also, personal freedom is higher in Western Europe (debatable, but for me what I define as personal freedom is severely lacking in US). High criminality. Basically police state. Effectively a caste society based on your wealth/income. Your taxes sometimes pay for killing innocent poor people half around the world (true for few european states too, but definitely not mine). And so on. But its nigh impossible to put some simple numbers on those things we generally call quality of life.
fzeroracer 3y ago
> Instead of hand wringing about differences between ourselves and other cultures we would be better served looking at boring things like medicares 3 million pages of medical claim guidelines, clearing house operations and conflicts of interest, better incentives for state level responsibility, antitrust litigation, lots of practical things that don't make click bait headlines. This is literally what we've been doing for years. It doesn't work because we're trying to apply bandaids to a problem of fundamental rot within our healthcare system. Look at how many states and politicians blew up over the ACA and attempted to stonewall it. I'm old enough to remember my mother being denied healthcare by her insurance provider because she had a stroke and that counted as a preexisting condition. Our solution to this rot is trying to solve a problem after it occurs, rather than prevent it in the first place.
Mordisquitos 3y ago
> Comparisons to other countries that are much much smaller than the US are sort of silly to me. Europe does not have one healthcare system. True, Europe does not have one healthcare system. And yet, thanks to the EHIC (European Health Insurance Card) [0], citizens of the 27 countries in the EU, Switzerland, the UK, and the EEA (Iceland, Liechtenstein and Norway), can use the healthcare systems from any other of the 31/28 [1] participant countries if they need healthcare on a temporary visit under the same conditions as the local resident citizens. The expenses incurred are reimbursed to the system providing the healthcare by the healthcare system of the citizen who is receiving it. This is done transparently to the patient, all they need to do is provide their EHIC card. This means that each of these 32 different healthcare systems, with their own particularities (e.g. free at the point of use vs. copay), can be considered one single universal healthcare system. If 32 different countries, with their own legal systems, legislation, languages, and healthcare system design (insurance based or state funded) can cover approximately 500 million citizens, then 50 US states under one single federal government should have no problem doing the same for their 333 million citizens. [0] https://en.wikipedia.org/wiki/European_Health_Insurance_Card https://en.wikipedia.org/wiki/European_Health_Insurance_Card [1] In the case of the UK, the EHIC only reciprocal with EU and Switzerland, not the EEA.
- petre 3y ago
  We have a friend that had a ski accident in Switzerland (broken arm, open fracture). The EHIC was next to useless. They had to pay a "few" grand CHF out of pocket for the surgery. I think the private insurance covered some of that after many phonecalls and a few months. Needless to say, I won't be going skiing in Switzerland anytime soon.
  - yread 3y ago
    Was it a private hospital/ward? Operations and stay at public hospital should be covered https://ec.europa.eu/social/main.jsp?catId=1021&langId=en&intPageId=1760 https://ec.europa.eu/social/main.jsp?catId=1021&langId=en&in...
    - 3y ago
digi59404 3y ago
As a fellow author who found themselves in charge of IT and Development at a Healthcare organization. I’d like to read your book. I want to make sure I’m buying the right one and make sure you’re getting the most proceeds. Is this the correct book? And where’s the best place to buy it. https://www.amazon.com/Hacking-Healthcare-Standards-Workflows-Meaningful/dp/1449305024 https://www.amazon.com/Hacking-Healthcare-Standards-Workflow...
- duffpkg 3y ago
  That is the correct book. Acquire it however is most convenient for you, thanks though.
BHSPitMonkey 3y ago
> The US doesn't have one healthcare system, it has 50+ This may be correct to say in the de jure sense, but in the de facto sense there is a set of common norms and characteristics across all of them that makes it possible to talk and reason about them as a "system" overall (especially when talking about Federal-level policies that have potential to create nationwide changes to how Americans experience that "system", e.g. as the ACA did in a few ways).
snapetom 3y ago
> The US doesn't have one healthcare system, it has 50+ This is a fact that people, non-US but also many US Americans ourselves, have a really hard time in understanding. The vast majority of laws are left to the states. It's just incredibly hard to get national laws, and as a consequence, we have relatively few national laws. For example, there isn't a national standard for murder, there are 50+. Well, there is one if you commit the murder in a post office, but outside the post office, you're in the other 50 definitions. It's a miracle even the half-baked ACA got passed in this context.
- cogman10 3y ago
  > It's a miracle even the half-baked ACA got passed in this context. Federal law trumps state law. And, in fact, we do have 3 national healthcare implementations, Medicare, Medicaid, and Vertaren Affairs healthcare. Socializing healthcare could be done easily under the commerce clause of the constitution, but that doesn't happen because it's not popular among elected officials (it's only popular among the most progressive Democrats, for everyone else it's a no). ACA was so half baked and all over the board because there was a lot of carve outs to win over centrist Democrats. A much simpler "Medicare for all" could be implemented simply by changing the Medicare statute's enrollment age to 0. The reason national laws are so hard is the filibuster in the Senate and the fact that Republicans are pretty much universally opposed to expanding government healthcare. It's got nothing to do with there being 50 states.
  - cityofdelusion 3y ago
    This is overly-simplified. I’ve worked in healthcare IT, specifically billing and coding. The reforms needed are much, much more than simply setting Medicare’s enrollment age to 0, especially with the thousands of pages of weird exclusions and conditions enshrined into Medicare over the years. Also this is slightly pedantic, but your examples are NOT national health systems. The closest thing in the U.S. is military medicine, which is (mostly) federally funded with doctors working for and paid by the government.
    - 3y ago
dosethree 3y ago
If I lose my job I lose health care. How does that make any sense? Preventative medicine is cheaper
- throwawaymaths 3y ago
  It's not necessarily. If you live long enough you die of things like Alzheimer's or diabetes, chronic lived disease, e.g which are incredibly expensive.
  - dosethree 3y ago
    Yeah I actually looked up whether preventive is cheaper, and while it may be in some cases not in all. It does sound overall BETTER though because it will result in better health outcomes. but the aging population is obviously a massive drain on medical costs and theres not much we can do
- bentt 3y ago
  Are you sure you can’t just buy insurance through the ACA? Many people in the US seem to still think that they will be way more screwed if they leave their job than they actually would be.
  - red-iron-pine 3y ago
    the average American cannot afford a sudden $500 expense. you think they can afford to pay for healthcare? plus the quality of coverage, while better than nothing, may still bankrupt them if they need something major
    - jjk166 3y ago
      Note that if you are insured by your employer, you are still likely both paying a significant portion of the cost directly, and what your employer is paying is part of your compensation so that's money you would have in your pocket if your employer weren't insuring you.
refurb 3y ago
Agree. This is a pretty terrible article. Random "facts" that quote big revenue numbers tell you almost nothing. Vertical integration tells you nothing. It's a relatively old analysis (2009), but McKinsey did some research that I think highlights some pretty important differences in the US healthcare system that actually points to where the money is going. https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/Health%20International/HI08_American_health.ashx https://www.mckinsey.com/~/media/mckinsey/dotcom/client_serv... If you look at Exhibit 2, page 4, they basically compare US spending, as a percentage of GDP, and breaks down the difference between price and volume. The result are some very interesting facts that run counter to common belief: - health administration and insurance is a tiny contribution to high costs, accounting for about 5% of excess spending - spending on pharmaceuticals and "non-durable" (supplies) is pretty small and only contributes to 5% of excess spending - in-patient care (where the patient stays in the hospital overnight) spending is only 10% higher than the OECD average relative to GDP - 68% of the higher spending is out-patient care (where the patient doesn't stay in the hospital overnight); price is a factor here, but in reality, Americans get way more out-patient procedures than other countries
jjav 3y ago
> This is a result of a lot of accidents of history. These are not accidents though. For example in Puerto Rico there was a good, affordable public health care system many decades ago (El plan Arbona). This was meticulously dismantled by the insurance industry through political lobbying and support of insurance-friendly politicians. Now they have the same debacle as in the US, sky high insurance profits and terrible health care. This was very intentional, not an accident of history.
- duffpkg 3y ago
  Respectfully I would say there are a lot more problems than that going on. The federal government has an incredibly dark history with Puerto Rico regarding health, the rhoads scandal alone https://en.wikipedia.org/wiki/Cornelius_P._Rhoads#Scandal https://en.wikipedia.org/wiki/Cornelius_P._Rhoads#Scandal but also human experimentation and other misdeeds compounded by the complex status of it as an american territory.
  - jjav 3y ago
    That's true and a part of history everyone should learn more about. But also, unrelated to the current discussion. The insurance companies dismantling a good public system was a pretty recent action, mostly in the 90s although the damage has taken a while to propagate.

rozenmd 3y ago

> In almost no other countries do you need a prescription for eyeglasses In both Australia and France, you need a prescription. This assertion makes me question the accuracy of the rest of your comment.

AndrewKemendo 3y ago

Probably the best comment here What are your thoughts on how effective something like Medicare for all would be?

duffpkg 3y ago
I don't mean this to offer any political commentary one way or another but as someone who has worked at length with Medicare, HHS, CMS, VA, HRSA, and more or less every alphabet soup federal appendage remotely related to healthcare and medicine. No, I do not think any version of "medicare for all" is a remotely plausible solution to any healthcare problem other than getting healthcare lobbyists much larger yachts.

robocat 3y ago

https://archive.ph/Typim https://archive.ph/Typim Interesting points. The Economist is great (so long as you read it with an eye open for their normal media bias). Nitpick: > In almost no other countries do you need a prescription for eyeglasses. In New Zealand the eye details from your optician are called a prescription. Opticians and eyewear is mostly paid for privately (except people on government benefits and children get theirs paid for by the public). I'm not sure if private insurance offers a glass coverage option. Mostly, this article is pointing out emergent behaviours of a set of rules. How can we design self-optimising economic systems that are better than capitalism & democracy?

jseliger 3y ago

we would be better served looking at boring things like medicares 3 million pages of medical claim guidelines, clearing house operations and conflicts of interest, better incentives for state level responsibility, antitrust litigation, lots of practical things that don't make click bait headlines. It would also be nice to reform the FDA and the clinical trial system: https://bessstillman.substack.com/p/please-be-dying-but-not-too-quickly https://bessstillman.substack.com/p/please-be-dying-but-not-... "Antitrust litigation" covers this, but to spell it out, the increasing monopolization of many local healthcare systems is a huge problem.

duffpkg 3y ago
My opinion about the FDA is that it suffers from two major faults, it is always regulating the "last war" and it has the standard federal government incentive structure for policy making which is "do not do anything that according to civil service regulations can get me fired". In defense of the FDA, which I promise is not an instituion I have much affection for, they are asked to strike an impossible balance. More or less the same regulatory impulse that allowed Richard Sackler to build an empire on the killing of millions of americans is the same one that allows very sick people to access very, at times dubious, drugs and trials that sometimes save their lives. Most of medicine is very centrally built around the "first do no harm" approach, even at the cost of lives by non-intervention sometimes. With the FDA most people want a "do some harm, some of the time for the greater good" approach which is a really difficult thing for a federal agency to put into practice. I think they do an especially awful job with it but I appreaciate that it is a really hard balance to strike.
- sneak 3y ago
  Tobacco kills 7x as many people each hour, day, and month as opioids in the USA, and it’s available everywhere without a prescription. The Sacklers aren’t the problem here, corruption is.
  - polygamous_bat 3y ago
    > The Sacklers aren’t the problem here, corruption is. Why not both?

neotrope 3y ago

Thanks for this. How much are regulations to blame for this mess? ie if we cut regulation, would that lead to lower cost and better outcomes? What is the path to fix this?

duffpkg 3y ago
There is not one silver bullet or even hundred or thousands of bullets that are going to magically re-engineer 1/5 of the US economy. Measuring costs is really hard, measuring outcomes is even that much harder -- maybe more or less impossible in the aggregate. The heart of the question comes back to what you actually want to fix. I don't know you. A lot of people would just like to pay less for the thing they currently receive which is a nice sentiment but often hard to resolve. A large set of those people are actually upset because they have been led to believe they are paying a lot more than other people for the same thing, which I do not believe to be actually true. One solution that does seem palatable to a lot of people, not me, but a lot, is "I would like like to appear to pay less for what I receive while the real costs are hidden and subsidized in a way that is much less visible to me". While popular this view is not popular enough to adopt legislation to that effect. In practical terms detailed policy legislation that makes losers out of a lot of low value transactional middle men would see some very meaningful across the board cost reductions, probably 7-10% (500 billion or more). Top of that list would be intelligent standardization and regulation of transactional medical billing process. This would/could look a little bit like how we regulate banking between financial institutions. Very sexy I know.
- s1artibartfast 3y ago
  I think One "silver bullet" would be to give the patient more skin in the game when selecting treatments and balancing cost/benefit. The current system is a tragedy of the commons. Costs are opaque and distributed. Patients have insurance and may as well buy the most expensive treatment (everybody else is doing it). There is nobody in the entire health system with incentives to trade 1% less benefit for 99% cost reduction. In Europe, this is often handled by government purchasing discretion (not price caps as many simplistically believe). If X treatment is too expensive, it simply isnt covered. If generics medication get 99% of the job done, that is what you get. This might mean replacing employee healthcarecare with employee payments, MORE copays, and more transparent pricing (there has already been some improvement in this area). If a CT cost is 10x at one hospital, and 1x at the other, the patient needs an incentive to seek out the 1X cost. Similar, if one cancer drug is 10k and the other 100k, with a life extension of X days, the patient is the only one that can really make the call.

scotty79 3y ago

> In the US healthcare is 1/5 or more of the entire economy, so who profits from 1/5 of all US economic activity is a silly premise. It's really not. If you asked the same question about Russia and their oil economy and oligarchs it would be perfectly reasonable despite the size.

deleted 3y ago
[deleted]

scotty79 3y ago

> Europe does not have one healthcare system. And yet pretty much every single one of those is more equitable and efficient than what US can muster.

saiya-jin 3y ago
Well the starting premise is very different, so yes the results are also dramatically different. US, for better or worse, is much more individualistic society, without much emotions for plight of other citizens. Sort of buddhistic/hinduistic approach - if you suffer now, you must have done terrible things in your past life to deserve it, and why should I interfere. This results in tons of wonderful things in economy but messes up quite a bit too and brings some bad incentives where they shouldn't be. You don't want to be below average/median income (and say have some health issues on top of that), the quality of life is significantly worse than similarly-positioned peers in say Western Europe. But everybody looks at the top 0.1%, which fares, at least financially better. Strange place and setup for me and not in a good way, but maybe our more egalitarian and friendly/helpful approach is too naive and harsher society is more robust. We shall see.
- qwytw 3y ago
  > But everybody looks at the top 0.1%, which fares, at least financially better. Let's be fair it's at the very least 10% (maybe up to 30-40% if not more) that are doing better financially than they would in Europe under similar circumstances (education, career etc. wise). In certain sectors like tech it's not even close. e.g. real estate even in SF, NY, San Jose is significantly cheaper than for instance in Munich, Rome, Paris, Milan, London etc. when compared to median income. Also it's not that obvious to me that Americans are that much less likely to care about 'the plight' of others on an individual level. For instances Americans donate many times more to charity on average than Europeans do (which makes sense if you expect the government to take care of everyone, but let's not equate that with intervening directly...)
  - saiya-jin 3y ago
    > e.g. real estate even in SF, NY, San Jose is significantly cheaper than for instance in Munich, Rome, Paris, Milan, London etc. when compared to median income. You are just hiding in complexities of real life and reducing it into few trivial numbers that are easy to compare. Count in good education for say 2 kids (500k-1 million per head?) which is free here, count in healthcare costs if you live long enough to start accumulating health problems that are basically unsolvable by today's medicine. Free here. I don't know the actual numbers, and they are very individual so what you say may be actually true for you, but it certainly isn't true for me for example. Also, personal freedom is higher in Western Europe (debatable, but for me what I define as personal freedom is severely lacking in US). High criminality. Basically police state. Effectively a caste society based on your wealth/income. Your taxes sometimes pay for killing innocent poor people half around the world (true for few european states too, but definitely not mine). And so on. But its nigh impossible to put some simple numbers on those things we generally call quality of life.

fzeroracer 3y ago

> Instead of hand wringing about differences between ourselves and other cultures we would be better served looking at boring things like medicares 3 million pages of medical claim guidelines, clearing house operations and conflicts of interest, better incentives for state level responsibility, antitrust litigation, lots of practical things that don't make click bait headlines. This is literally what we've been doing for years. It doesn't work because we're trying to apply bandaids to a problem of fundamental rot within our healthcare system. Look at how many states and politicians blew up over the ACA and attempted to stonewall it. I'm old enough to remember my mother being denied healthcare by her insurance provider because she had a stroke and that counted as a preexisting condition. Our solution to this rot is trying to solve a problem after it occurs, rather than prevent it in the first place.

Mordisquitos 3y ago

> Comparisons to other countries that are much much smaller than the US are sort of silly to me. Europe does not have one healthcare system. True, Europe does not have one healthcare system. And yet, thanks to the EHIC (European Health Insurance Card) [0], citizens of the 27 countries in the EU, Switzerland, the UK, and the EEA (Iceland, Liechtenstein and Norway), can use the healthcare systems from any other of the 31/28 [1] participant countries if they need healthcare on a temporary visit under the same conditions as the local resident citizens. The expenses incurred are reimbursed to the system providing the healthcare by the healthcare system of the citizen who is receiving it. This is done transparently to the patient, all they need to do is provide their EHIC card. This means that each of these 32 different healthcare systems, with their own particularities (e.g. free at the point of use vs. copay), can be considered one single universal healthcare system. If 32 different countries, with their own legal systems, legislation, languages, and healthcare system design (insurance based or state funded) can cover approximately 500 million citizens, then 50 US states under one single federal government should have no problem doing the same for their 333 million citizens. [0] https://en.wikipedia.org/wiki/European_Health_Insurance_Card https://en.wikipedia.org/wiki/European_Health_Insurance_Card [1] In the case of the UK, the EHIC only reciprocal with EU and Switzerland, not the EEA.

petre 3y ago
We have a friend that had a ski accident in Switzerland (broken arm, open fracture). The EHIC was next to useless. They had to pay a "few" grand CHF out of pocket for the surgery. I think the private insurance covered some of that after many phonecalls and a few months. Needless to say, I won't be going skiing in Switzerland anytime soon.
- yread 3y ago
  Was it a private hospital/ward? Operations and stay at public hospital should be covered https://ec.europa.eu/social/main.jsp?catId=1021&langId=en&intPageId=1760 https://ec.europa.eu/social/main.jsp?catId=1021&langId=en&in...
  - 3y ago

digi59404 3y ago

As a fellow author who found themselves in charge of IT and Development at a Healthcare organization. I’d like to read your book. I want to make sure I’m buying the right one and make sure you’re getting the most proceeds. Is this the correct book? And where’s the best place to buy it. https://www.amazon.com/Hacking-Healthcare-Standards-Workflows-Meaningful/dp/1449305024 https://www.amazon.com/Hacking-Healthcare-Standards-Workflow...

duffpkg 3y ago
That is the correct book. Acquire it however is most convenient for you, thanks though.

BHSPitMonkey 3y ago

> The US doesn't have one healthcare system, it has 50+ This may be correct to say in the de jure sense, but in the de facto sense there is a set of common norms and characteristics across all of them that makes it possible to talk and reason about them as a "system" overall (especially when talking about Federal-level policies that have potential to create nationwide changes to how Americans experience that "system", e.g. as the ACA did in a few ways).

snapetom 3y ago

> The US doesn't have one healthcare system, it has 50+ This is a fact that people, non-US but also many US Americans ourselves, have a really hard time in understanding. The vast majority of laws are left to the states. It's just incredibly hard to get national laws, and as a consequence, we have relatively few national laws. For example, there isn't a national standard for murder, there are 50+. Well, there is one if you commit the murder in a post office, but outside the post office, you're in the other 50 definitions. It's a miracle even the half-baked ACA got passed in this context.

cogman10 3y ago
> It's a miracle even the half-baked ACA got passed in this context. Federal law trumps state law. And, in fact, we do have 3 national healthcare implementations, Medicare, Medicaid, and Vertaren Affairs healthcare. Socializing healthcare could be done easily under the commerce clause of the constitution, but that doesn't happen because it's not popular among elected officials (it's only popular among the most progressive Democrats, for everyone else it's a no). ACA was so half baked and all over the board because there was a lot of carve outs to win over centrist Democrats. A much simpler "Medicare for all" could be implemented simply by changing the Medicare statute's enrollment age to 0. The reason national laws are so hard is the filibuster in the Senate and the fact that Republicans are pretty much universally opposed to expanding government healthcare. It's got nothing to do with there being 50 states.
- cityofdelusion 3y ago
  This is overly-simplified. I’ve worked in healthcare IT, specifically billing and coding. The reforms needed are much, much more than simply setting Medicare’s enrollment age to 0, especially with the thousands of pages of weird exclusions and conditions enshrined into Medicare over the years. Also this is slightly pedantic, but your examples are NOT national health systems. The closest thing in the U.S. is military medicine, which is (mostly) federally funded with doctors working for and paid by the government.
  - 3y ago

dosethree 3y ago

If I lose my job I lose health care. How does that make any sense? Preventative medicine is cheaper

throwawaymaths 3y ago
It's not necessarily. If you live long enough you die of things like Alzheimer's or diabetes, chronic lived disease, e.g which are incredibly expensive.
- dosethree 3y ago
  Yeah I actually looked up whether preventive is cheaper, and while it may be in some cases not in all. It does sound overall BETTER though because it will result in better health outcomes. but the aging population is obviously a massive drain on medical costs and theres not much we can do
bentt 3y ago
Are you sure you can’t just buy insurance through the ACA? Many people in the US seem to still think that they will be way more screwed if they leave their job than they actually would be.
- red-iron-pine 3y ago
  the average American cannot afford a sudden $500 expense. you think they can afford to pay for healthcare? plus the quality of coverage, while better than nothing, may still bankrupt them if they need something major
  - jjk166 3y ago
    Note that if you are insured by your employer, you are still likely both paying a significant portion of the cost directly, and what your employer is paying is part of your compensation so that's money you would have in your pocket if your employer weren't insuring you.

refurb 3y ago

Agree. This is a pretty terrible article. Random "facts" that quote big revenue numbers tell you almost nothing. Vertical integration tells you nothing. It's a relatively old analysis (2009), but McKinsey did some research that I think highlights some pretty important differences in the US healthcare system that actually points to where the money is going. https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/Health%20International/HI08_American_health.ashx https://www.mckinsey.com/~/media/mckinsey/dotcom/client_serv... If you look at Exhibit 2, page 4, they basically compare US spending, as a percentage of GDP, and breaks down the difference between price and volume. The result are some very interesting facts that run counter to common belief: - health administration and insurance is a tiny contribution to high costs, accounting for about 5% of excess spending - spending on pharmaceuticals and "non-durable" (supplies) is pretty small and only contributes to 5% of excess spending - in-patient care (where the patient stays in the hospital overnight) spending is only 10% higher than the OECD average relative to GDP - 68% of the higher spending is out-patient care (where the patient doesn't stay in the hospital overnight); price is a factor here, but in reality, Americans get way more out-patient procedures than other countries

jjav 3y ago

> This is a result of a lot of accidents of history. These are not accidents though. For example in Puerto Rico there was a good, affordable public health care system many decades ago (El plan Arbona). This was meticulously dismantled by the insurance industry through political lobbying and support of insurance-friendly politicians. Now they have the same debacle as in the US, sky high insurance profits and terrible health care. This was very intentional, not an accident of history.

duffpkg 3y ago
Respectfully I would say there are a lot more problems than that going on. The federal government has an incredibly dark history with Puerto Rico regarding health, the rhoads scandal alone https://en.wikipedia.org/wiki/Cornelius_P._Rhoads#Scandal https://en.wikipedia.org/wiki/Cornelius_P._Rhoads#Scandal but also human experimentation and other misdeeds compounded by the complex status of it as an american territory.
- jjav 3y ago
  That's true and a part of history everyone should learn more about. But also, unrelated to the current discussion. The insurance companies dismantling a good public system was a pretty recent action, mostly in the 90s although the damage has taken a while to propagate.