6 ms·

Healthcare in the US is broken and they won’t let you fix it because the money is too good. Think about the fact that PBMs, which is there to save and manage on

by lvl155 1y ago

Healthcare in the US is broken and they won’t let you fix it because the money is too good. Think about the fact that PBMs, which is there to save and manage on pharma is incentivized to promote drug price inflation. That’s just one “small” piece of this clusterf*k. It’s layers and layers of these convoluted system of incentives. As to OP, the simplest solution is to move out of the US early enough or become “poor” enough and be in a wealthy blue state by the time you get to this predicament.

wnc3141 1y ago
I think the broader extrapolation is that the social contract has emerged around giving private enterprise wide latitude to promote the public welfare. However that does mean that the quality of said welfare entirely revolves how profitable you are to said enterprise. While great for airline tickets, its a tragedy for healthcare.
silisili 1y ago
Healthcare is little more than a jobs program at this point. I believe it is the largest industry by employment in every single state now. That compounds the problem even further. Really fixing it would put a double digit percentage of people out of work. I'm all for it, but I can see why politicians are hesitant.
- Avicebron 1y ago
  > Really fixing it would put a double digit percentage of people out of work. I'm all for it, but I can see why politicians are hesitant. I'd love to hear what you think "really fixing it" is, please share. I can report that all (almost all?) of the hospitals and their networks both big and small in the area I am in have had layoffs this year of admin staff and healthcare professionals (nurses, doctors, etc). They have reduced bed counts, and cut programs and treatment options available. All of this was done in the name of the "affordability crisis" and is kind of like the 3rd wave of this kind of consolidation, belt-tightening behavior. And..prices haven't gone down, and they keep cutting.
  - silisili 1y ago
    I don't know all the answers, but I can tell you that cutting doctors and services is not what I had in mind. Mainly the behemoth that is everything tangential to that, namely insurance and pharma, for two. I worked on the insurance side(in tech), and most people wouldn't believe the number of people involved between the doctor getting money from the patient. On the contrary of your statement, I would also do everything I could to allow more (capable, of course) people to become doctors each year, though I'm not sure what all that would entail. It feels criminal to me that we limit residency while a) every doctor I've ever visited is way oversubscribed and in a hurry, and b) specialist appointments are months out.
    - Avicebron 1y ago
      Ok, I pretty much agree with everything you suggest. Browsing HN has conditioned me to react to sentiment like "healthcare...it's a jobs program...solve it by putting people out of work (the market will magically fix it)" to essentially be code for "I support continued abuse and further deprivations against the poor"
      - SR2Z 1y ago
        Healthcare is one of the rare examples where pretty much any reasonable-sounding change probably can't help but make things better.
    - hcknwscommenter 1y ago
      Get rid of Pharma and there will be zero new drugs or treatments ever again. Have fun with that.
  - deleted 1y ago
    [deleted]
  - A_D_E_P_T 1y ago
    > I'd love to hear what you think "really fixing it" is, please share. I'm not that poster, but there's a really easy fix: Just model the system after Hong Kong's. There's a tax-funded public system available to every citizen, so that everybody gets treatment. In practice, this is mostly utilized by the poor, and for emergencies like broken bones. You can see specialists via the public system, but there can be a wait of weeks to months. This is all effectively free. You'll never see a bill, or the bill will be extremely small. (e.g., $100 for four days of inpatient care.) There's a private system for those willing to pay. This is unrestrained capitalism with little regulation and no parasitic middlemen. Want to see a specialist right now -- like later this afternoon, or first thing tomorrow morning? Sure. It'll usually be $200 or $300 out of pocket. No insurance necessarily involved. Diagnostics are also super fast -- same day or next day, usually. If you want an elective surgery, or if you want a superior tier of care (like a nicer hospital room, better food, more flexibility re scheduling,) you can pay for it privately... And usually without getting insurance companies involved. There is effectively no "prescription" system. With very few exceptions for narcotics and certain stimulants, if you need a drug of any kind, you can buy it OTC. This includes steroids, weird nootropics, viagra (lol at needing a prescription for this), and all kinds of stuff. This vastly reduces the burden on the system. Hong Kong's system is superior in every respect, and it's especially better at treating you like an adult. The American system is simultaneously complex and infantilizing.
- 2OEH8eoCRo0 1y ago
  My father's doctor says she doesn't want healthcare reform or more doctors because then their salaries will tank.
  - EvanAnderson 1y ago
    This was the reason behind the AMA lobbying for the freeze on federally-funded residency slots back in the mid-90s (which is still being felt today, even after AMA has changed their tune).
  - nobodyandproud 1y ago
    We now have noctors, and the physician role is now in danger of becoming supplanted by incompetent mid-levels with better people skills.
- JTbane 1y ago
  >Really fixing it would put a double digit percentage of people out of work. Eh, I kind of disagree. It would put a lot of insurance people and hospital admins out of a job, but the boots-on-the-ground providers would be fine.
- wahern 1y ago
  > I believe it is the largest industry by employment in every single state now. This made be curious, so I looked around. FWIW, healthcare constitutes ~11% of the workforce in the US. It's ~16% in Germany, ~10% in the UK, and ~5% in France. As a percentage of GDP healthcare is far higher in the US, of course.
  - silisili 1y ago
    It's actually a really hard thing to track, and BLS does a poor job of it in my opinion. That 11% covers most but not even all people at a clinic or hospital. It counts people from doctors to records specialist, but not say, janitors or IT, and nothing outside of that like insurance. And that's not necessarily wrong to do, but makes it hard to grasp the whole size. If you add in everyone in insurance, pharma, devices, and the jobs those support, that number seems to be closer to 17% of the workforce from what I could put together. Not sure if those in Europe do it similarly, but it just feels like a huge number of people. Maybe that is the result of demographics and a topheavy population, though.
    - victorbjorklund 1y ago
      Doubt european numbers count insurance (public or private) pharmacy etc or all the jobs that support healhcare in general (powerplants, construction workers, restaurants, etc)
      - Yeul 1y ago
        Well when you get really down to it what is the most important thing in the world? Your health. Not much point being rich if you're in chronic pain. And thanks to technology and science our first world society's got really good at keeping people alive and relatively comfortable.
    - mjevans 1y ago
      It also doesn't count family members providing care for loved ones 'unpaid'. Nor does it count any of the people who really should have more or better care but don't get it.
- esseph 1y ago
  I'm not so sure. If we fix healthcare costs we can spend more on hospitals. With more hospitals means more jobs and more competitive care costs. In addition, a lot of those insurance jobs are facing pressure from "AI".
- Yeul 1y ago
  That is not exclusively an American thing. In my country currently 17% of the workforce is in healthcare. Probably need to start exporting more old folks to 3rd world countries where they can live out their days in resorts.
  - Ekaros 1y ago
    Or simply let them die when they are too old to survive without most basic automatable care. Say robot dropping food at the door.
- BobbyTables2 1y ago
  I find the real problem is not the doctors, but the hospitals. For a simple outpatient procedure, the fee from the hospital dwarfs that of the anesthesiologist and surgeon. For an inpatient stay, the hospital charges thousands of dollars per night for a room! Makes the Ritz Carlton look cheap!
- nly 1y ago
  To be fair, the NHS is the largest employer is the UK as well https://en.wikipedia.org/wiki/List_of_largest_United_Kingdom_employers https://en.wikipedia.org/wiki/List_of_largest_United_Kingdom... Keeping people healthy is labour intensive.
elgenie 1y ago
Like 5-10% of the US's total GDP gets wasted annually on the layers and layers and layers of healthcare middlemen… for worse outcomes.
- emchammer 1y ago
  That is crazy. That is more than the defense budget.
- loeg 1y ago
  Eh. Most of the US' "worse outcomes" are upstream of the healthcare system and would be upstream of it under any other country's healthcare model too. (Diet/exercise, and vehicle-related injury.) Feel free to criticize the spending, but the worse outcomes angle is kind of disingenuous.
- refurb 1y ago
  Where did you get that number from? It doesn't even pass the sniff test. 17% of GDP is spent on healthcare. Claiming 60% of that is just "middleman overhead" makes no sense when the highest European countries spend 70% of what the US spends on healthcare. If you want an actual analysis of why US healthcare costs are higher, I'd recommend the McKinsey study that compared category spending vs OECD countries. Exhibit 2 on page 4. https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/Health%20International/HI08_American_health https://www.mckinsey.com/~/media/mckinsey/dotcom/client_serv... Administrative costs are way higher in the US, but it only accounts for 15% of the higher cost. The biggest driver is outpatient care - Americans get way more healthcare and it costs more (quantity * price).
WalterBright 1y ago
Is it a coincidence that the industries with the most heavy government involvement - health care, education, and housing - are the most messed up with perverse incentives? Whereas the software industry, with near zero government involvement, has had enormous improvements in function and has pushed the cost to literally zero.
- joe_the_user 1y ago
  Most other advanced nations have nationalized health care which works much better. The US health care system is broken because health care is a natural monopoly that US free-market ideology dictates be run with (fake) "free markets" with result being a variety of companies profiting by abusing the system.
  - apwell23 1y ago
    other nations get benefits from 1. US subsidizing pharma startups and 2. less people with chronic diseases 3. offer lower quality of care at lower price point 4. import doctors vs solely rely on homegrown USA is very very good at complicated, cutting edge medical care but not efficient at delivering routine care.
    - bruce511 1y ago
      It's complicated, yes, but simplifying somewhat the "US" does not subsidize pharma startups. Yes, VCs do put money into pharma, but that's private money very much expecting an (overall) profitable return. (Ironically most of that profit comes from Americans who have little or no way to collectively bargain on pricing.) And yes, for bigger companies, there are tax breaks etc, but most of those are regular tax breaks that any company gets. I won't get into the chronic disease stats. Other than to say that good primary Healthcare tends to reduce the incidence of chronic diseases. Quality of care is hard to gauge on a national basis. It's a highly localized product, so experience can be different in very small geographic areas. Equally "quality of care" is s metric with many axies. Naturally for-profit medical advertises a lot, and they strongly push the "quality of care" message. So the general perception of that is "private is better". How much of that is true, how much is perception, is up for debate. My personal experience (which counts for nothing) having experienced both, is that the standard of medical care is the same. (Fewer tvs in public care though.) I'm not sure what importing doctors has to do with anything, or if it's even true. Personally I don't really care where a Dr is from.
refurb 1y ago
The fun part is that government intervention has driven a lot of the messed up things about US healthcare. Super inflated prices nobody pays? - law on “U&C prices” Consolidation of small oncology clinics into huge hospital systems? - law on 340B prices All of these laws were put into place in an attempt at regulating prices, and as a result, entities exploited the law to give themselves even more profit than if the laws never existed. Now that’s not to argue the government is solely at fault, but it’s remarkable how much government intervention had made the US system worse, not better.

by lvl155 1y ago

wnc3141 1y ago

I think the broader extrapolation is that the social contract has emerged around giving private enterprise wide latitude to promote the public welfare. However that does mean that the quality of said welfare entirely revolves how profitable you are to said enterprise. While great for airline tickets, its a tragedy for healthcare.

silisili 1y ago

Healthcare is little more than a jobs program at this point. I believe it is the largest industry by employment in every single state now. That compounds the problem even further. Really fixing it would put a double digit percentage of people out of work. I'm all for it, but I can see why politicians are hesitant.

Avicebron 1y ago
> Really fixing it would put a double digit percentage of people out of work. I'm all for it, but I can see why politicians are hesitant. I'd love to hear what you think "really fixing it" is, please share. I can report that all (almost all?) of the hospitals and their networks both big and small in the area I am in have had layoffs this year of admin staff and healthcare professionals (nurses, doctors, etc). They have reduced bed counts, and cut programs and treatment options available. All of this was done in the name of the "affordability crisis" and is kind of like the 3rd wave of this kind of consolidation, belt-tightening behavior. And..prices haven't gone down, and they keep cutting.
- silisili 1y ago
  I don't know all the answers, but I can tell you that cutting doctors and services is not what I had in mind. Mainly the behemoth that is everything tangential to that, namely insurance and pharma, for two. I worked on the insurance side(in tech), and most people wouldn't believe the number of people involved between the doctor getting money from the patient. On the contrary of your statement, I would also do everything I could to allow more (capable, of course) people to become doctors each year, though I'm not sure what all that would entail. It feels criminal to me that we limit residency while a) every doctor I've ever visited is way oversubscribed and in a hurry, and b) specialist appointments are months out.
  - Avicebron 1y ago
    Ok, I pretty much agree with everything you suggest. Browsing HN has conditioned me to react to sentiment like "healthcare...it's a jobs program...solve it by putting people out of work (the market will magically fix it)" to essentially be code for "I support continued abuse and further deprivations against the poor"
    - SR2Z 1y ago
      Healthcare is one of the rare examples where pretty much any reasonable-sounding change probably can't help but make things better.
  - hcknwscommenter 1y ago
    Get rid of Pharma and there will be zero new drugs or treatments ever again. Have fun with that.
- deleted 1y ago
  [deleted]
- A_D_E_P_T 1y ago
  > I'd love to hear what you think "really fixing it" is, please share. I'm not that poster, but there's a really easy fix: Just model the system after Hong Kong's. There's a tax-funded public system available to every citizen, so that everybody gets treatment. In practice, this is mostly utilized by the poor, and for emergencies like broken bones. You can see specialists via the public system, but there can be a wait of weeks to months. This is all effectively free. You'll never see a bill, or the bill will be extremely small. (e.g., $100 for four days of inpatient care.) There's a private system for those willing to pay. This is unrestrained capitalism with little regulation and no parasitic middlemen. Want to see a specialist right now -- like later this afternoon, or first thing tomorrow morning? Sure. It'll usually be $200 or $300 out of pocket. No insurance necessarily involved. Diagnostics are also super fast -- same day or next day, usually. If you want an elective surgery, or if you want a superior tier of care (like a nicer hospital room, better food, more flexibility re scheduling,) you can pay for it privately... And usually without getting insurance companies involved. There is effectively no "prescription" system. With very few exceptions for narcotics and certain stimulants, if you need a drug of any kind, you can buy it OTC. This includes steroids, weird nootropics, viagra (lol at needing a prescription for this), and all kinds of stuff. This vastly reduces the burden on the system. Hong Kong's system is superior in every respect, and it's especially better at treating you like an adult. The American system is simultaneously complex and infantilizing.
2OEH8eoCRo0 1y ago
My father's doctor says she doesn't want healthcare reform or more doctors because then their salaries will tank.
- EvanAnderson 1y ago
  This was the reason behind the AMA lobbying for the freeze on federally-funded residency slots back in the mid-90s (which is still being felt today, even after AMA has changed their tune).
- nobodyandproud 1y ago
  We now have noctors, and the physician role is now in danger of becoming supplanted by incompetent mid-levels with better people skills.
JTbane 1y ago
>Really fixing it would put a double digit percentage of people out of work. Eh, I kind of disagree. It would put a lot of insurance people and hospital admins out of a job, but the boots-on-the-ground providers would be fine.
wahern 1y ago
> I believe it is the largest industry by employment in every single state now. This made be curious, so I looked around. FWIW, healthcare constitutes ~11% of the workforce in the US. It's ~16% in Germany, ~10% in the UK, and ~5% in France. As a percentage of GDP healthcare is far higher in the US, of course.
- silisili 1y ago
  It's actually a really hard thing to track, and BLS does a poor job of it in my opinion. That 11% covers most but not even all people at a clinic or hospital. It counts people from doctors to records specialist, but not say, janitors or IT, and nothing outside of that like insurance. And that's not necessarily wrong to do, but makes it hard to grasp the whole size. If you add in everyone in insurance, pharma, devices, and the jobs those support, that number seems to be closer to 17% of the workforce from what I could put together. Not sure if those in Europe do it similarly, but it just feels like a huge number of people. Maybe that is the result of demographics and a topheavy population, though.
  - victorbjorklund 1y ago
    Doubt european numbers count insurance (public or private) pharmacy etc or all the jobs that support healhcare in general (powerplants, construction workers, restaurants, etc)
    - Yeul 1y ago
      Well when you get really down to it what is the most important thing in the world? Your health. Not much point being rich if you're in chronic pain. And thanks to technology and science our first world society's got really good at keeping people alive and relatively comfortable.
  - mjevans 1y ago
    It also doesn't count family members providing care for loved ones 'unpaid'. Nor does it count any of the people who really should have more or better care but don't get it.
esseph 1y ago
I'm not so sure. If we fix healthcare costs we can spend more on hospitals. With more hospitals means more jobs and more competitive care costs. In addition, a lot of those insurance jobs are facing pressure from "AI".
Yeul 1y ago
That is not exclusively an American thing. In my country currently 17% of the workforce is in healthcare. Probably need to start exporting more old folks to 3rd world countries where they can live out their days in resorts.
- Ekaros 1y ago
  Or simply let them die when they are too old to survive without most basic automatable care. Say robot dropping food at the door.
BobbyTables2 1y ago
I find the real problem is not the doctors, but the hospitals. For a simple outpatient procedure, the fee from the hospital dwarfs that of the anesthesiologist and surgeon. For an inpatient stay, the hospital charges thousands of dollars per night for a room! Makes the Ritz Carlton look cheap!
nly 1y ago
To be fair, the NHS is the largest employer is the UK as well https://en.wikipedia.org/wiki/List_of_largest_United_Kingdom_employers https://en.wikipedia.org/wiki/List_of_largest_United_Kingdom... Keeping people healthy is labour intensive.

elgenie 1y ago

Like 5-10% of the US's total GDP gets wasted annually on the layers and layers and layers of healthcare middlemen… for worse outcomes.

emchammer 1y ago
That is crazy. That is more than the defense budget.
loeg 1y ago
Eh. Most of the US' "worse outcomes" are upstream of the healthcare system and would be upstream of it under any other country's healthcare model too. (Diet/exercise, and vehicle-related injury.) Feel free to criticize the spending, but the worse outcomes angle is kind of disingenuous.
refurb 1y ago
Where did you get that number from? It doesn't even pass the sniff test. 17% of GDP is spent on healthcare. Claiming 60% of that is just "middleman overhead" makes no sense when the highest European countries spend 70% of what the US spends on healthcare. If you want an actual analysis of why US healthcare costs are higher, I'd recommend the McKinsey study that compared category spending vs OECD countries. Exhibit 2 on page 4. https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/Health%20International/HI08_American_health https://www.mckinsey.com/~/media/mckinsey/dotcom/client_serv... Administrative costs are way higher in the US, but it only accounts for 15% of the higher cost. The biggest driver is outpatient care - Americans get way more healthcare and it costs more (quantity * price).

WalterBright 1y ago

Is it a coincidence that the industries with the most heavy government involvement - health care, education, and housing - are the most messed up with perverse incentives? Whereas the software industry, with near zero government involvement, has had enormous improvements in function and has pushed the cost to literally zero.

joe_the_user 1y ago
Most other advanced nations have nationalized health care which works much better. The US health care system is broken because health care is a natural monopoly that US free-market ideology dictates be run with (fake) "free markets" with result being a variety of companies profiting by abusing the system.
- apwell23 1y ago
  other nations get benefits from 1. US subsidizing pharma startups and 2. less people with chronic diseases 3. offer lower quality of care at lower price point 4. import doctors vs solely rely on homegrown USA is very very good at complicated, cutting edge medical care but not efficient at delivering routine care.
  - bruce511 1y ago
    It's complicated, yes, but simplifying somewhat the "US" does not subsidize pharma startups. Yes, VCs do put money into pharma, but that's private money very much expecting an (overall) profitable return. (Ironically most of that profit comes from Americans who have little or no way to collectively bargain on pricing.) And yes, for bigger companies, there are tax breaks etc, but most of those are regular tax breaks that any company gets. I won't get into the chronic disease stats. Other than to say that good primary Healthcare tends to reduce the incidence of chronic diseases. Quality of care is hard to gauge on a national basis. It's a highly localized product, so experience can be different in very small geographic areas. Equally "quality of care" is s metric with many axies. Naturally for-profit medical advertises a lot, and they strongly push the "quality of care" message. So the general perception of that is "private is better". How much of that is true, how much is perception, is up for debate. My personal experience (which counts for nothing) having experienced both, is that the standard of medical care is the same. (Fewer tvs in public care though.) I'm not sure what importing doctors has to do with anything, or if it's even true. Personally I don't really care where a Dr is from.

refurb 1y ago

The fun part is that government intervention has driven a lot of the messed up things about US healthcare. Super inflated prices nobody pays? - law on “U&C prices” Consolidation of small oncology clinics into huge hospital systems? - law on 340B prices All of these laws were put into place in an attempt at regulating prices, and as a result, entities exploited the law to give themselves even more profit than if the laws never existed. Now that’s not to argue the government is solely at fault, but it’s remarkable how much government intervention had made the US system worse, not better.