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Why conventional wisdom on health care is wrong (a primer) (2020)

• deleted 2y ago
  [deleted]
• psd1 2y ago
  Well, that was interesting. What I'm unclear on is whether "health spending", in this analysis, is defined as money paid to care providers such as hospitals and dentists, or money paid by citizens for healthcare. Because you've got insurers and PBMs taking profit. The ratio of those two numbers is the efficiency of the American insurance model. How does it compare to the administration of a single-payer system such as the NHS? Until I see some data indicating otherwise, I'm going to look at my £200pcm national insurance and my £9.90 prescriptions and my free ambulances, and Americans' $500pcm insurance and their unlimited prescription costs and their four-figure bills even when insured, and I'm going to continue to believe that Americans are punching themselves in the face.
  • naming_the_user 2y ago
    NI does not pay for the NHS, it comes from general taxation, you’re comparing the wrong figures.
    • tonyedgecombe 2y ago
      NI is part of general taxation in all but name. Nominally there is an NI fund but any money deposited there is immediately lent back to the government to be spent on whatever they want.
    • psd1 2y ago
      Oops. I've spoken enough already in the thread, but I do want to thank you for the correction. In my defense, I'm attempting to perform data operations on a kilo of fatty grey meat from a savanna hominid. I've been meaning to upgrade but have you seen gpu prices lately.
  • xvedejas 2y ago
    Well, there's also the rate of new drug and procedure discovery. I've heard it quipped that Americans are subsidizing the discovery of new medical techniques for the rest of the world. Whether that's worth a higher cost is arguable but I think the effect is there.
    • bozhark 2y ago
      Exactly this, example: biologics. I am currently prescribed a medication that is over $30,000 per injection every 12 weeks. Because we have absolutely atrocious health organization. Pharmaceutical companies can set their prices regardless of anything but their profit.
      • nradov 2y ago
        How should pharmaceutical prices be set?
        • BobaFloutist 2y ago
          In general, anything that's mandatory for life/basic quality of life but still needs to be produced by industry should should be regulated to artificially reduce prices in order to compensate for inelastic demand and prevent price gouging. This regulation should include supply-side subsidies and dynamic, carefully considered price controls. This should apply to food, water, housing, health care, transportation, internet; all those good things that you can't do without and are extremely vulnerable to market manipulation.
          • claytongulick 2y ago
            It's worth researching the inevitable consequences of price controls, it's a predictable outcome that's been tested many times. Price controls are Hobson's choice: Would you prefer expensive bread, or no bread?
            • ElevenLathe 2y ago
  • nradov 2y ago
    Profit margins for insurers are pretty low on a percentage basis. The Affordable Care Act (Obamacare) imposed a minimum medical loss ratio on commercial payers. You can read the financial statements for those that are publicly traded. Some of the largest insurers such as Blue Cross Blue Shield Association members are non-profit. The NHS isn't really a "single-payer system" in any meaningful sense. In the UK, most healthcare providers are employed directly by the government and their wages are fixed below the market rate to control costs. There are internal financial transfers but there aren't really arms-length negotiations and payments between separate payer and provider organizations. If the USA was to adopt a single-payer system like the various "Medicare for All" proposals that politicians have floated that wouldn't do much to reduce costs. Any meaningful cost reduction for the system as a whole would require driving down provider wages, rationing care, and ending the way that we subsidize drug development costs for the rest of the world. Those measures might be good things to do on balance, but they aren't politically popular.
    • bozhark 2y ago
      For profit non profits exist. There is no “metric” for how much a 501(c)(3) must ratio in order to be considered tax exempt. They must follow their own discipline set in their founding documents. Calling blue cross blue shield nonprofit is disingenuous as they made $749,000,000 in 2022. Per their 990’s: https://www.causeiq.com/organizations/view_990/135656874/101e210d488d1ec5d98cfa6e592a75a1 https://www.causeiq.com/organizations/view_990/135656874/101...
      • wahern 2y ago
        $749 million is revenue. Revenue less expenses (i.e. profit) was $57 million, which admittedly is a decent 7.5%. But as a nonprofit there are no shareholders or partners to siphon off that profit. The common argument is that management siphons off that money through salaries, and I can't say they don't, but if you look at their assets & liabilities it seems like some significant amount of their profit is going into savings. Anyhow, the Blue Cross/Blue Shield system has a very complex structure so if you're looking to find where the real money is being siphoned off it's unlikely to be at the top. BC/BS affiliates are independent, that's why the org at the top for a system insuring over a hundred million people pulls in less than a billion dollars in revenue.
  • vundercind 2y ago
    We spend even more money on healthcare administration than what’s directly spent on it. HR departments screwing around with insurance. Various government benefits & other agencies having to mess with private health insurance issues. Attorneys general offices and state rep offices spending time to get insurers’ and hospital billing departments’ heads out of their asses (they do a lot of this). There are also untold hours lost in unpaid labor on the part of “clients” messing with insurance and hospital billing departments. It’s not uncommon for someone who is, or is connected to a person who is, seriously sick for even a few days to spend a work-week or more of time that year messing with the billing from the incident. This can include uneventful pregnancies and births.
    • eszed 2y ago
      The amount of wasteful overhead in the American "healthcare" system never fails to shock me. The last two companies I've worked for (one a self-insured non-profit, the current a "conventionally"-insured for-profit) have both, coincidentally, had ~500 employees, and each dedicated about one-and-a-half full-time positions to administering their healthcare plans. Now scale that up across every company in the country: it's... Insane. Forget any of the squishy humanitarian impulses behind "socializing" medicine; eliminating all that un-productive labor would be of immense economic benefit. (Health-plan administrative cost is a moat which advantages large businesses to the detriment of small. That goes some way to explaining why an economic-efficiency / dynamism argument has never gained traction in American political discourse.)
      • vundercind 2y ago
        Right, it’s so bad that if we Did A Socialism and somehow had the worst cost outcome for such a move on the planet such that our direct healthcare spending remained identical(ly crazy-high)… it’d still be a win because of the huge drag on the rest of the economy and our QOL the current system imposes in indirect costs.
        • actionfromafar 2y ago
          But that would be morally wrong and lead to communism and satan worshipping.
  • frsoafdslfdlsa 2y ago
    Have you tried phoning a GP or for an ambulance recently?
    • psd1 2y ago
      No, let me instead tell you about my healthcare experience in America. I wanted to get travel vaccinations in New Orleans. In my ignorance, I just looked up a clinic and went. Apparently I don't understand the coding for black clinic. It was a shack with 30 poor rural black women sitting motionless on mismatched folding chairs. We sat and sweated for an hour; no practitioner or even receptionist appeared. I don't think there was a phone at that shack. There weren't many cars about, so those women probably walked a decent distance to sit and wait. One of them had an enormous tumour on her face. It could be that we just killed the vibe. But these women were motionless. Like waiting was all they did. I believe they waited in that shack for days in a row. We went to that clinic from a bar where we'd been drinking seven-dollar beers while a waspy college band played poor-hillbilly music to oyster-guzzling yuppies in raybans. I've generally found Americans to be smart, humble, funny, kind and warm. But when I encounter an American being arrogant or self-centred, I think about that New Orleans shack.
      • frsoafdslfdlsa 2y ago
        I could trade stories about experiences with UK and US healthcare (I've lived in both countries), but the facts speak for themselves. The UK and US are near opposite ends of the scale of healthcare expenditure per capita in the developed world, yet the average life expectancy is about the same. I am not defending either system - I would strongly prefer something like the rest of continental Europe, which is a pragmatic mix of private and public healthcare. However, the idea that fully-public healthcare (a unique experiment in the world) is a sustainable model is a joke. It's hard to defend, when our current standard healthcare at the point of service could charitably be called "usually better than the 3rd world".
        • psd1 2y ago
          Yep. Or Australia, where all providers are private but most are free at point of service, should you choose, or if you pay out of pocket you can claim a rebate. I went as a young man. I may have misunderstood how it works. I don't know how cost-effective it is.
  • deleted 2y ago
    [deleted]
  • sarah_eu 2y ago
    Americans look at their 9k a month salary and don't care about loosing an extra 300 USD on health insurance. I've experienced the British and Swiss systems - Swiss is like the American - pay roughly 600 CHF a month - and it's way better than the NHS. You can see a specialist the next day, get a scan the next day etc.
    • psd1 2y ago
      Is medical bankruptcy common in Switzerland? 600chf sounds like passable value for money, as long as you get excellent care and as long as that's all you pay. But my concern is always what happens to the poor. Yeah, yeah, the Swiss are rich - but not literally every Swiss, I presume.
      • TMWNN 2y ago
        >Is medical bankruptcy common in Switzerland? Only 4% of US bankruptcies are because of medical bills <https://www.washingtonpost.com/blogs/post-partisan/wp/2018/03/26/the-truth-about-medical-bankruptcies/ https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...>. A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect in any country.
        • psd1 2y ago
          I was asking about Switzerland, since you brought it up. It's a fascinating place, I'm keen to hear your observations. Don't conflate bankruptcies. _Purely financial_ bankruptcy is recoverable, given good health and time. (Not to trivialise it.) But, for a peasant with terminal cancer: _medical_ bankruptcy generally means a miserable and undignified death. There's worse pain than pain, you know? So, while I have to respect the dispassionate argument that "not _that_ many people die in a ditch", I reply that my £200 buys me not just passable healthcare but also some pride in my nation finding some fucking compassion. That moral point is also an economic point, but I'm not ready to articulate it concisely. Let me say simply that a nation needs to find character on the way up and then again on the way back down, and America is currently fumbling for the second step. A nation is founded on its citizens. The cost of a zeitgeist of rage and distrust is, eventually, everything. What price empire?
  • nonameiguess 2y ago
    It is surprisingly hard to track down what is meant exactly. It is not either of the options you listed here, but closer to the first. Chasing a very long chain of citations to other citations, it appears this paper contains the original explanation of where the data come from: https://sci-hub.st/10.1007/s11205-015-1196-y https://sci-hub.st/10.1007/s11205-015-1196-y. They survey all of the possible healthcare goods and services available across OECD nations, make their best attempt to select a representative basket that is both available across all nations and reasonably similar, then estimate what they call a "quasi-price" per unit of good and/or service, to account for the fact that the actual charged price is often artificially suppressed or set to zero by government fiat. This seems to be done by scouring management accounting databases to figure out what the payers and providers consider to be reasonable reimbursement rates for accounting purposes, whether or not that is what they actually receive. I get what they're trying to do, but this probably explains some of the counterintuive results, because mostly people are probably thinking more along the lines of "add up all premiums paid to insurers, out of pocket expenses paid directly by consumers to providers, and all government outlays classified as healthcare" and that's how much your country spends on healthcare. That's a reasonable comparison to make, but as the blog and the OECD report both point out, it does nothing to account for differences in quantity and quality of healthcare goods being paid for. The problem is this discourse then inevitably leads to "well the US gets worse outcomes," but to what extent is that fair? The only reason I can walk today is because of US healthcare. If you incur a musculoskeletal injury that requires intervention in various different countries, how likely are you to fully recover? If you get cancer, how likely are you to go into remission? I don't necessarily know exactly what should be measured, but I know that when the discussion goes straight to lifespan, that is heavily confounded. Americans drive more, own more guns, are fatter. There has been tremendous industrial pollution in various places, though I don't know how that compares to the rest of the OECD. I wouldn't be surprised if we have more backyard pools. There are many, many reasons we might live shorter lives that have nothing at all to do with the quality of the healthcare we receive.
  • AnthonyMouse 2y ago
    > What I'm unclear on is whether "health spending", in this analysis, is defined as money paid to care providers such as hospitals and dentists, or money paid by citizens for healthcare. Because you've got insurers and PBMs taking profit. > The ratio of those two numbers is the efficiency of the American insurance model. The ratio of those two numbers is quite divorced from the efficiency of an insurance model. On the one side, this would count wasteful spending on unnecessary tests or overpriced services as an efficiency improvement because proportionally more money is going to providers. On the other side, if insurers better at preventing fraud have lower premiums and therefore get more customers and make more money, that would count as "inefficiency" and the fraud prevented would also count as inefficiency (because that money went to "providers"), even if the net result is less fraud and lower premiums. That isn't to say that the US system is efficient. It's clearly quite broken. But its brokenness is because the government has been thoroughly captured by the industry -- which is the providers as much as the insurers -- and they oppose any measures that would improve actual efficiency because the inefficiency is their profit. Which is why the US system costs more than the systems in other countries regardless of whether the other countries use public or private systems. An efficient regulatory system for a private insurance market would be something like, a schedule of service codes where each provider is required to publish a fee schedule representing the uniform fee paid by all institutional insurers, eliminating the overhead of "negotiating prices" (a major source of inefficiency) in favor of price transparency and allowing patients and insurers to choose a provider on the basis of price and distance, while still subjecting providers to competitive pressure because people would naturally favor providers with lower fees. But the existing US system doesn't do that at all.
    • nradov 2y ago
      I generally agree with your points, but the US healthcare system does now have pretty much the level of price transparency that you want. Commercial health plans have been required to publish their negotiated network provider fee schedules since 2022. You can just download the files and take a look. Of course as an individual health plan member that won't tell you your out-of-pocket cost for a particular service, but it is useful to self-insured employers comparison shopping between health plans. https://www.cms.gov/healthplan-price-transparency/plans-and-issuers https://www.cms.gov/healthplan-price-transparency/plans-and-... Longer term though we should move away from the fee-for-service model based on providers submitting claims for service codes. A value-based care model where provider organizations bear at least some financial risk and are accountable for patient outcomes will probably work better for everyone.
  • TMWNN 2y ago
    Studies have found that Kaiser Permanente (an integrated health insurance/care provider—basically a non-governmental equivalent of the NHS in comprehensiveness—that is available in many US states) is more efficient and effective than the NHS for about the same cost. Examples: * <https://www.bmj.com/content/324/7330/135 https://www.bmj.com/content/324/7330/135> * <https://www.bmj.com/content/327/7426/1257 https://www.bmj.com/content/327/7426/1257>
    • twoodfin 2y ago
      Kaiser’s effectively an HMO, right? Consumers (i.e. employees evaluating their corporate benefits) hated HMO’s at their peak in the ’90’s so much that the initials became politically toxic. Cheaper plans with more restrictions could exist more broadly. Consumers don’t want them, politicians make hay on the consumer unhappiness and ban the things that allow the plans to be cheap in the first place.
      • TMWNN 2y ago
        Kaiser is like the NHS in that it does everything in-house. Kaiser members go to Kaiser doctors, stay at Kaiser hospitals, and get prescriptions fulfilled from Kaiser pharmacies. I agree on "HMO" being tainted. Kaiser has a good reputation in its territories, as does Intermountain, the other big western US integrated system.
  • zaptheimpaler 2y ago
    Anecdotally anyone can talk to a few doctors and find out just how much time they spend on updating charts/documenting information that's not directly relevant to the care, its just to protect against liability or work with insurance. Or how many hours they spend on phone calls fighting with insurance companies. The people who actually understand medicine wasting hours with some clueless rep with 0 understanding and a flowchart who's only job is to deny claims. Dr. Glaucomflecken on youtube has many videos about that too. So on the ground level, it's already clear some of our highest paid most valuable people spend 20-30% of their time on a flavor of administrative junk which isn't necessary in a single-payer system. I'm skeptical of claims that this waste doesn't translate into the higher level metrics.
    • xapata 2y ago
      It'd still occur in a single-payer system. The problem is fees for services instead of fees for results.
      • looping__lui 2y ago
        So the wealthy can finally cheat death efficiently once and for all ;-) On a more serious note: that might be hard in medicine per se to pay for “results”. And I found some of the insights from “Outlive” quite interesting: how we focus in cure but not prevention; and how in the bigger scheme of things Antibiotics was almost the only “real big invention” in western medicine for a very long time (e.g., in terms of actual medical impact)
      • contrast 2y ago
        Any evidence for that claim? The issue is not whether there is administrative overhead, but the amount of it. It’s not obvious to me that completely different funding models would incur the exact same amount of overhead on the practitioners.
        • cmrdporcupine 2y ago
          It does happen in a fashion in the Canadian system where family doctors at least operate as private businesses that bill the gov't, and because of that have to spend quite a bit of time on paperwork which then requires a whole edifice which there has been a lot of complaint about recently. A search will find you plenty of articles about this. That and the nature of the relationship introduces conflict. Plus the bulk of provincial governments administrating the thing are ideologically biased against it because they are conservative or neo-liberal in bent, and have been chronically underfunding it for years....
  • akira2501 2y ago
    > I'm unclear on is whether "health spending", They list their source as 2017 OECD data. OECD seems to define this as: "Health spending is the final consumption of health care goods and services including personal health care and collective services." Their charts are also drawn in a standard and more understandable way.[0] > Americans are punching themselves in the face. Hurtful, but okay, I do hope you realize it's the rampant monopolization of health care that is the problem in this country. Yours solved it by simply creating a single publicly held monopoly. It's not as if either system is perfect and doesn't create it's own share and particular style of inhumane healthcare outcomes. Prescription label prices are noticeably different but are they meaningfully different where outcomes are concerned? [0]: https://www.oecd.org/en/data/indicators/health-spending.html https://www.oecd.org/en/data/indicators/health-spending.html
  • WalterBright 2y ago
    Health care prices in the US were reasonable until the government got involved in it in the 1960s. Prices rose with inflation until 1968, when they started angling up steeply. 1968 was soon after the advent of Medicaid and Medicare. The 1962 FDA amendments also resulted in a steep rise in drug costs, and a sharp reduction in new drugs being developed.
    • keldaris 2y ago
      If that's true, how are they so much more reasonable in most developed countries with far greater government involvement still? Is the US government just uniquely bad at healthcare somehow? Why?
      • WalterBright 2y ago
        It is true. Look at graphs of it. > Why? I don't know how other countries manage their health care systems, though I know that the British one is facing bankruptcy, and while health care was free in the Soviet Union patients had to pay for anesthetic for root canals, and bribery was the norm. Here's a link to what's wrong with the American system: https://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/ https://www.theatlantic.com/magazine/archive/2009/09/how-ame...
        • tonyedgecombe 2y ago
          >British one is facing bankruptcy No it isn't.
      • deleted 2y ago
        [deleted]
      • tightbookkeeper 2y ago
        By reasonable do you mean 30-50% of your income for your entire life? Regardless of whether you use the services?
        • 2y ago
  • Amezarak 2y ago
    The US government(s) spend about as much money per capita on health care as the average European country. Obviously US health care costs are out of control for other reasons than the existence of private insurance. To be clear because that's easy to misunderstand: despite the fact Americans do not have universal public health care, the government already spends as much as many European countries that do, per capita. Part of this, of course, is because US public health care spending is concentrated on the old (Medicare) and disabled/poor (Medicaid). But it's still a shocking testament to US health care costs.
  • o11c 2y ago
    Certainly a significant number of its points were defined to explicitly exclude insurance overhead, which I have often seen cited as "very high in the US". It's also completely ignoring the possibility of Hollywood-style accounting. One thing I'm curious about is any correlations to number of grandchildren.
  • refurb 2y ago
    > Until I see some data indicating otherwise, I'm going to look at my £200pcm national insurance and my £9.90 prescriptions and my free ambulances, and Americans' $500pcm insurance and their unlimited prescription costs and their four-figure bills even when insured, and I'm going to continue to believe that Americans are punching themselves in the face. This is a odd position to take. You're going to firmly hold onto a view despite admitting it's not that informed? Not to mention you're not even comparing the right costs. What the patient pays is not the total cost.
    • psd1 2y ago
      I don't know, or care, how the fuck you got that. Please block me.
      • refurb 2y ago
        That’s a remarkably angry response to someone suggesting you look deeper into a topic.
        • psd1 2y ago
          You're pushing my buttons like a pro. It looks deliberate. Let the record state that this account got into my inbox in the seconds between my reply and me blocking it. Zero time spent in reflection. If there's a human behind that account, be told that when you grossly misrepresent a person, the injustice tends to make them angry. I put thought, into my top level, on the best way to spark a discussion. There was none before, yet my comment has received a bunch of detailed and thought-provoking replies. I have encouraged a tolerably productive conversation. People are continuing without me. This is my first good HN comment. I put my beliefs, _which I hold lightly_, up in the air expressly to be shot down. I've read every reply, and learned things I didn't know. I'm proud of that top level comment. Hopefully, the block works this time. I really _really_ do not want you in my inbox, amongst the valuable people. So please, have the courtesy to ## FUCK OFF
  • simonh 2y ago
    You forgot to mention the taxes they pay to support CHIP, Medicaid and Medicare. Which are not far off what many Europeans pay for universal health care, before most Americans even start to look at private health insurance so they actually get health care for themselves.
    • tightbookkeeper 2y ago
      > Which are not far off what many Europeans pay for universal health care, Effective tax rates of 40-70% do not exist in the Us. It’s still a ridiculous amount of the economy to tax and spend. But what I think is more annoying is that the US has health systems for special interest groups: - seniors - veterans - native Americans - women and children - government employees (especially teachers) - immigrants seeking asylum This must be getting close to half the population. Either get rid of them, or pay for everyone.
      • 9dev 2y ago
        > Effective tax rates of 40-70% do not exist in the Us. It’s still a ridiculous amount of the economy to tax and spend. That isn’t true. In Germany, where we have fairly high taxes, I get to keep about 60% of my gross income, and I’m in the maximum taxation group. This 40% includes universal health care, pensions, tax, and mandatory insurance for job loss.
        • inglor_cz 2y ago
          Don't forget the effects of VAT and various consumption taxes. If you buy stuff with your net income, ~ a sixth of the money spent will be indirect taxes again.
      • bdauvergne 2y ago
        Those tax rates have nothing to do with healthcare, to take France as an example most of it is for other things, like pay-as-you-go pension plan or free education. Budget of french "assurance maladie" is 25% of the PIB or 450 billion euros for 68 million people, most of it paid by salary taxes. All things being equal, for the USA the same system would cost 2322 billion dollars. https://www.securite-sociale.fr/la-secu-cest-quoi/chiffres-cles https://www.securite-sociale.fr/la-secu-cest-quoi/chiffres-c...
  • djtango 2y ago
    This may be tangential but the NHS is not without some sickening expenses. The costs are just opaque and hidden but ultimately taxpayers are paying for £300 for a stainless steel bucket for patients to pee in thanks to bureaucracy and government contracrs. (that figure is pre 20s inflation) So every month the government siphons off 40-45% of your income and donates a lot of it to Big Healthcare. So a case of being damned if you do and damned if you don't...
  • snarf21 2y ago
    We should also not forget the $1B in drug advertising spend that must be recouped. People from other countries are frequently dumb-founded when they see US tv with prescription ads. Also look at all the companies buying up old drugs and immediately raising the price 10X or more.
    • oceanplexian 2y ago
      Doesn’t advertising drive prices down? For example there is currently a booming industry for GLP-1s and the prices are dropping as the drug is becoming more available. Consumers know they have lots of choices and therefore price discovery is occurring.
  • ericjmorey 2y ago
    If you used those two profit numbers you would be missing all of the expenses that medical insurance companies have, none of which do anything for providing healthcare. Furthermore, you would be missing all of the expenses which exist to accommodate the systems insurance companies invented to account for things that only they care about. Insurance is the least efficient method of providing healthcare and we've committed hard to it for the benefit of few.
    • FredPret 2y ago
      The most efficient system would be direct payments only. The downside is only the very roch can afford expensive medical emergencies. But with insurance individuals get to pull the value of future premium payments forward to pay for large expenses in the present. There’s also a degree of socialization. The downside is there will always be an overhead. Government health care is insurance writ large and has the same tradeoffs, just on a larger scale.
      • miki123211 2y ago
        > Government health care is insurance writ large I would argue that it has even more tradeoffs; unlike private insurance, it's usually both mandatory and a monopoly, and that can go very wrong very quickly. The US system is extremely overregulated and preventing true competition, even though US insurance is private, so there aren't really any good data points to compare, though.
        • actionfromafar 2y ago
          Public systems can work very well and I can’t name one system which went downhill very quickly.
          • fao_ 2y ago
            Exactly, the NHS is only going downhill because the dominant ideology among MPs has been that the NHS is the first place to get gutted for cheap savings. A lot of very efficient systems were removed and farmed out for "cheaper" private systems, that end up being rather costly in the long term with respect to increased error, price rising, and all the myriad ways incompetence and explicit money-grabbing messes with healthcare. They gutted the administration systems and now doctors have to work overtime on the weekends just to get their notes in the system, and now because doctors are overworked, they're putting more work into the hands of the incredibly underqualified PAs. And on top of all of this, repeated mismanagement of the money that is distributed to the NHS — including, of all things, incredibly inept bartering, putting hospitals on a "target system" where underfunded hospitals are given less money for not hitting targets, etc. It's a complete joke, but every step was damned near deliberate for the case of farming public money into the pockets of the friends of MPs.
  • detourdog 2y ago
    It does feel that way. The worst part is that enough of our elected officials insist we enjoy the abuse.
• throwme0827349 2y ago
  This is fine as a high level economic discussion, but I think it misses the point of the complaints from actually US consumers: when I consume healthcare as an individual I am paying with a blank check, and I am therefore likely to be tricked into consuming more health care than I would otherwise choose to afford, perhaps to a ruinous degree. I think ordinary consumers care much less about whether their country spends a nominal share of GDP on the heath sector, than about whether they will be unexpectedly bankrupt by consuming health services, and this is why people are actually mad.
  • kcsavvy 2y ago
    I started and sold a company in the industry, and agree that macro level analysis misses this. In the us healthcare as a “product” has an AWFUL customer experience. On so many levels. And the worse it gets the more people want to “burn it all down”, despite the fact that it might not be as dire as we think when we do the high level analysis. Whether or not that’s a good thing is up for debate.
  • darth_avocado 2y ago
    > The claim that US health care prices are inexplicably high was never well-evidenced I can provide anecdotal evidence that prices inexplicably high. A primary care physician will charge anywhere between $200-$500 for a visit. If you have good insurance, you don’t pay out of pocket. In the same city, I once had to go to a PCP who would only work without insurance. I had to wait a lot because of how many people were lined up in front of the office, but I paid $50 for the visit. I’m already paying 4-10x in a comprable market for the same services. When I was abroad, I had to visit a doctor’s office for food poisoning. I paid 200 in the local currency. I could have gone to a hospital and they would charged me 500 in the local currency. But what’s important to know is that the median monthly wages in the country were 25000 in the local currency. So all in all, you’d pay a smaller portion of your wages for a simple checkup. And that tbh is why people are actually mad.
    • _DeadFred_ 2y ago
      I recently had skin cancer surgery. I was offered a 20% discount to self pay. Because of my deductible I would have paid more if I used insurance than if I just paid. We are now to the point where it's not cost effective to use our private insurance for cancer surgery. How anyone is defending this system is crazy to me.
• MakeStuffAllDay 2y ago
  [flagged]
  • sebastos 2y ago
    >The more often a person has regular checkups with a doctor the shorter their life expectancy. Well I'm no expert, but I can think of an alternative interpretation to this datapoint...
  • snozolli 2y ago
    the often cited Landsteiner and Popper experiment simply showed that drilling a hole in the head of a monkey and injecting biological material into the hole causes paralysis in a few of the monkeys. Two monkeys were injected and both died within days. One of the monkeys showed paralysis. Both showed spinal lesions consistent with polio in humans. The material injected had been run through a filter small enough to stain out bacteria, and the sample was cultured to prove that no bacteria was present. Polio is caused by Poliovirus. https://pmc.ncbi.nlm.nih.gov/articles/PMC112492/ https://pmc.ncbi.nlm.nih.gov/articles/PMC112492/
  • jmcclell 2y ago
    To be clear: you're suggesting that there is scant evidence that any forms of disease arise from pathogens? Or do you have a more narrow definition of disease? For instance, is a strep throat caused by a colonization of strep bacteria in one's throat, based on your understanding?
• pessimist 2y ago
  This analysis in the end doesn't show what it claims to show and actually proves the reverse - US Health care spending is much larger than other countries, it eats up significant fraction of productivity gains in other sectors (rises faster than income as shown by the 1.8 slope in the very first graph), and does not lead to better health outcomes. It actually proves we would be better off if we spent less and focused on lifestyle.
  • YetAnotherNick 2y ago
    What was it claiming exactly that it proved to be reverse? > we would be better off if we spent less and focused on lifestyle. I didn't see any claim opposite of this.
  • betaby 2y ago
    > US Health care spending is much larger than other countries The thing is that in USA (and Canada) radiologist compensation went from 300k/yer to 500k/year over the last 10 yeas. It's the same radiologist. While spending is growing quantity of doctor per population is diminishing. In USA/Canada there is cartel enforced cap on how many new doctors can be minted per year, and this cap is not even scaling up with the population growth.
    • nradov 2y ago
      The immediate limit is a government (Medicare) funding cap on the number of residency (graduate medical education) program slots. At one time the American Medical Association lobbied to put that cap in place but they reversed course years ago. Congress still hasn't acted, and so every year there are some students who graduate from medical school but are unable to practice. https://savegme.org/ https://savegme.org/
      • smnrchrds 2y ago
        What I could never understand is why government funding is needed for residency spots in the first place. From the outside, it seems like residents are cheap labour for hospitals. Even without getting any money from the government, the value of residents' labour should exceed their relatively small salary—so hospitals should be incentivized to hire many more residents. What are the economics (or regulations) of residency that make this not work?
• neves 2y ago
  A quick reading of the summary shows a lot of debunking and just one item that explains the bad health of North Americans: Diminishing returns to spending and worse lifestyle factors explain America’s mediocre health outcomes https://randomcriticalanalysis.com/why-conventional-wisdom-on-health-care-is-wrong-a-primer/#rcatoc-diminishing-returns-to-spending-and-worse-lifestyle-factors-explain-americas-mediocre-health-outcomes https://randomcriticalanalysis.com/why-conventional-wisdom-o...
  • firejake308 2y ago
    As an armchair economist, this is my personal favorite theory. With one of the most obese populations in the world, I think it's obvious that we'll also be the most sick and we'll have to spend a lot to try to dig ourselves out.
    • pessimizer 2y ago
      How does people being fat make asthma inhalers from the 50s cost $70 when they're $5-$10 everywhere else in the world?
      • cmiles74 2y ago
        The argument here is that the US will have worse health outcomes than another country because the people are less healthy. Cost of care doesn't factor into this argument.
      • nradov 2y ago
        Which specific asthma inhalers are you referring to? Generic albuterol inhalers are available for $27 cash price, or less if you have health plan coverage. https://costplusdrugs.com/medications/albuterol-90mcg-inhaler8_5g/ https://costplusdrugs.com/medications/albuterol-90mcg-inhale... Obesity obviously doesn't cause high drug costs but it is a risk factor for asthma. Non-obese people are less likely to have to spend anything on inhalers. https://www.cdc.gov/asthma/asthma_stats/asthma_obesity.htm https://www.cdc.gov/asthma/asthma_stats/asthma_obesity.htm
• nickpsecurity 2y ago
  I skimmed what I can while on break. What I didn’t see is something I’ve heard from doctors but can’t verify. It’s that insurance companies require them to do extra procedures or have extra employees they don’t think they need. Some who didn’t take insurance say it keeps their cost down. One told me the insurance companies incentivize him to treat patients like an assembly line where cash only lets him spend one on one time with customers. He also might treat people for several things on the same bill which he claimed he’d have to itemize and charge separately for with insurance. So, do people here have specific examples (esp links) to support or refute those anecdotes? If they were true, it would mean insurance rules were driving much of the cost. Looking at their causes, my first guess would be how they respond to losses from both real malpractice and greed-driven lawsuits. I can’t imagine that costs aren’t impacted by this with all the lawyer ads I see for suing insurance companies. ;)
  • cmiles74 2y ago
    Health insurance in the US is a large, complicated mess. OTOH, hospitals and healthcare providers are also a large, complicated mess. In my opinion they are somewhat codependent and, in many cases, fighting for the same dollars. That is, I suspect any dollars you save on insurance will be eaten up by increasing money spent on providers and vice versa. I think the author made the right choice to leave these lumped together. It would be interesting to see how these costs confound over time but would make this article even longer.
• aDyslecticCrow 2y ago
  GDP per capita and other "per capita" metrics are also unreliable metrics for household income, as they suffer from the same issue as averages. This is a common trap that is done in population statistics, as mean and averages are always easier to calculate and reduce the complexity of the calculations. Large wealth inequality makes GDP per capita and average household spending not representative of a real-world median household. If healthcare costs have outpaced median income but kept up with mean income, that is a MASSIVE societal issue. Most of the plots and arguments in the article overlook this, so I don't trust the arguments much. However, it is still interesting how strong the correlations are. It gives some interesting insights into what goes into the cost of running hospitals, I suppose.
• not2b 2y ago
  I notice that the terms "debt" and "bankruptcy" (and their variants) appear nowhere in the article.
  • cryptonector 2y ago
    So what? TFA is about national aggregates, not individuals.
• cryptonector 2y ago
  > Health spending is determined by income Whoa. That's eye-opening. If country X spends less than country Y, rather than surmise that country X is more efficient with their healthcare spending we might want to look at whether country X has less per-capita income than country Y. This makes sense, though it's very surprising. I've seen so much commentary here about how much better the Europeans are at dealing with healthcare than us Americans...
  • mullingitover 2y ago
    You can look at the health outcomes to gauge the efficiency. Does the population in country X live longer? Are infant mortality rates higher? Preventable deaths? We know the US healthcare system is a ripoff exactly because while the spending as a percentage of GDP in the US is dramatically higher, the measurable outcomes are embarrassingly bad across the board.
    • getnormality 2y ago
      Why would we assume that the health of a country is mainly determined by its healthcare system? I think the big drivers of worse American health outcomes are things like obesity, car-based lifestyles, and long working hours, all of which have nothing to do with our healthcare system. The healthiest countries succeed by rarely needing their healthcare system because people behave in healthy ways. Needing the system a lot means you've already failed.
      • mullingitover 2y ago
        I don't think lifestyle explains our problem with infant mortality rates. That's something where you, first thing in life, depend on the health care system before you even have a lifestyle. In addition, yes, I think we can blame obesity on (the lack of) healthcare. If people routinely met with a physician and got advice, they might be able to turn things around before merely being overweight becomes obesity. We're effectively in a shortage situation, and by design. If you don't get preventative care, that's considered a good thing by the healthcare system because they would honestly collapse if everyone got the recommended doctor visits. So we have people not getting preventative treatment and dying of preventable causes at depressingly high rates. This is generally considered fine, because the health care system is bursting at the seams with more money than it can count, so it's considered successful.
• gcanyon 2y ago
  N=1, or, Story Time! In 2017 my wife and I were living in Portugal for several months. When we needed to refill her prescriptions, our short-term rental host said, "Go to the ER." Backstory: we're well familiar with ERs in the U.S. Due to various conditions, we've been to at least a dozen ERs a total of perhaps twenty times. For anyone who doesn't know, unless you are actively dying, visiting the ER in the U.S. is sloooow. The average time to see a doctor, in our experience, is about an hour. So we replied: "the ER? seriously?" He assured us it would be fine, so we walked ten minutes to the ER and signed in. We had barely turned in the history paperwork when they called us to go back. No preliminary check-in with the nurse -- straight to the doctor. She said, "Why did you come to the ER? We could have been busy and you would have had to wait." We explained how our host had assured us this was the best way to go, and that the ER would take care of us. The doctor nodded and said, "Sure, I'll sign for the prescriptions, but just remember it might take more time the next time." We went back to the front desk. Remember, we had no travel insurance, this was full freight. "That will be twenty-eight euro." We happily paid, and walked out the door, prescriptions in hand, less than 30 minutes after we walked in. Bonus: the cost to buy the prescriptions, again with no insurance, was less than the co-pay in the U.S. with employer-healthcare. N=2: When my daughter was visiting me in Bangkok, she got a bit of a gastro issue. Same as in Portugal, we had no insurance for her. I took her to Bumrungrad, one of the best hospitals in Thailand. We were in and out in under an hour, including picking up the prescription, and the total cost was under $100. I'm not trying to rebut the article, just throwing out some details.
  • qup 2y ago
    > visiting the ER in the U.S. is sloooow. The average time to see a doctor, in our experience, is about an hour. This is such a bizarre couple of statements for me. First, I would consider an hour very, very fast. If I show up for an appointment on time, I still don't see the doctor for about an hour. And for a non-emergency emergency room visit (even a fairly serious one like a broken bone, abscessed tooth, etc) I've had family give up after 8-12 hours of waiting in the lobby without being admitted to see a doctor, often in relatively empty lobbies. (The hospital is hoping for this, I'm sure)
    • 2y ago
• obastani 2y ago
  If I'm understanding correctly, by "income", this article means "actual individual consumption", which is the amount of money spent by a household. Thus, the article is saying that for countries where households spend more, they spend more on healthcare. Given that healthcare is a huge fraction of household expenditures (almost 20%), this seems tautological. Am I misunderstanding something?
• gcanyon 2y ago
  Summarized into 11 bullet points by Claude: Here's a summary of the key points from the document in 11 bullet points: • Health spending is primarily determined by income levels, with higher-income countries spending more on healthcare. • The rising health share of GDP is driven by increasing quantities of healthcare consumed, not primarily by price inflation. • Technological advancements and intensity of care are major drivers of increased health spending. • The U.S. health system is not uniquely inefficient; its high spending is consistent with its high income levels. • Commonly cited utilization indicators do not show that the U.S. uses less healthcare than expected given its spending. • Physician incomes and hospital profits do not explain the high U.S. health spending. • The U.S. healthcare workforce has grown significantly, reflecting increased intensity of care rather than just higher wages. • America's mediocre health outcomes are explained by diminishing returns to healthcare spending and lifestyle factors like obesity. • Rising healthcare spending does not mean reduced consumption in other areas due to productivity gains in other sectors. • Price comparisons between countries are often methodologically flawed and do not accurately reflect true healthcare costs. • The income elasticity of health spending is high, meaning people spend proportionally more on healthcare as they get richer.
• Angostura 2y ago
  If anyone, like me was looking for the UK and the NHS on those graphs - it's labelled GBR (I guess), assuming that's not Gibralter
• bluedino 2y ago
  Nothing makes sense. One prescription I get is $1.30, another is $85. My son goes to a specialist and all $395 is paid by insurance, while my wife goes to a different one and we pay $86 out of pocket after a $14 "insurance discount", insurance pays nothing. They're both in-network. I save my old antibiotics and such because it takes so long to get into urgent care, and it's expensive, and I can't go to my regular doctor for a sinus infection because it takes two weeks to get in. Thankfully I pay $0 out of my check for Blue Cross since my employer pays for it. I just have co-pays, deductibles, etc
  • zahlman 2y ago
    >I save my old antibiotics and such because it takes so long to get into urgent care, and it's expensive, and I can't go to my regular doctor for a sinus infection because it takes two weeks to get in. I cringed so much reading this. * When you're prescribed an antibiotic, you're expected to finish the course of medication. Not doing so leads to resistant strains. * Medication has an expiration date for a reason. You generally shouldn't expect to be able to save it from one illness to the next, nor to know that the one from before is applicable to the current condition. * The large majority of disease is caused by viruses, and antibiotics won't help. Your "sinus infection" might not be a local infection at all but just some respiratory illness resulting in sinus congestion. Never mind whether it's viral or bacterial.
• NHQ 2y ago
  Healthcare became like public education in the USA, a political ideology that subverts the body politic to support jobs for people who do not have real skills but whose great granddad had 33 degrees in secrecy. In other words it is entirely a support system for the least of the privileged, while also paying huge sums to the owners and "providers" of those systems (textbooks, syringes, insurance, etc). If U.S. Americans did not have an irrational verve for education as the supposed panacea of democracy, there would be no public education system. If they did not believe the intense pseudoscience of the medical industry, they would not care about health insurance. But as they are under the sway of such false conscience, the system of gradual decline called inflation pays for unqualified people to keep a livelihood at the expense of a misled and deluded public. That expense is not only the costs of running these systems but their detriments to the health and education they pretend to treat. The increased spending on healthcare is no different than spending more on education or the "homeless problem", it is simply a politics of shifting more funds into systems that are legally obligated to pay high sums for a lot of nothing. It only appears different than education because we pretend its not completely wrapped up in public spending and politics like education is. Obama made sure that healthcare would hold such a place as education in the system with the reforms to healthcare, and the people applauded this. High incomes paying more for healthcare is simply those who can afford it using the system that ultimately pays for the health and education of the rich at the expense of the health and education of the poor. After all we know that nobody who is rich is paying any of their healthcare bills, they have excellent health insurance for that.
• efitz 2y ago
  The big problem with modern health “insurance” (as opposed to catastrophic major medical insurance, which is true insurance), is that it prevents the formation of of health care businesses that cater to different socioeconomic strata. I most other businesses, there are usually product offerings at different price points, eg Ford Fiesta vs Ford Raptor R, bespoke steakhouses vs Denny’s, Wal-Mart vs Nordstrom, etc. There are some hard to discover offerings in healthcare but overall very little differentiation. Why don’t we have multiple chains of monthly subscription diabetes centers, for instance? If it weren’t for insurance and over-regulation of every aspect of healthcare, we would see market flourishing in the US as there is an over abundance of chronic illness. I sympathize with the PoV that we want someone else to pay because it’s expensive, but another way to solve that would be to remove all the regulatory capture and industry collusion and predatory middlemen (PBMs I’m talking to you) and let new delivery mechanisms evolve. Let supply adapt to demand.
  • phil21 2y ago
    The biggest problem with modern health "insurance" is that it's not insurance - it's a health care plan that presents a giant principal agent problem throughout the entire medical system starting with the patient and cascading from there. I'm old enough to remember a time you could break an arm, show up to your primary doctor's office that day without a pre-scheduled appointment, and walk out with a cast on plus pain meds all for less than a week's take-home pay for a blue collar employee. This was largely due in part for the reason you were the one paying the bill and there was almost no overhead. Plus the doctors who charged absurd fees simply lost patients to the competition down the street. Principal agent problems are rife in modern society, starting with medical care. They basically remove almost all pricing competition from the equation.
    • insane_dreamer 2y ago
      The cost to become a doctor is now so high in the US that you have a tremendous amount of debt and have to charge high to pay it off. It’s also why no one wants to become a GP.
      • 2y ago
• Peteragain 2y ago
  Nope. The price of something is somewhere between the cost of production and what the market will bear (with exceptions not relevant here). The well-to-do in the USA will bear high prices, and The State doesn't care about the rest. This is a bit of agi-prop for the health insurance industry. The graphs go up on the right: good; and down: bad. Arrrrr!!! There MIGHT be content, but that is not the message. And btw the "(a primer)" in the tag line is (according to this linguist) setting you up to think you're stupid if you don't get it.