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.
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.
> 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.
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.
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"
In the UK, with the NHS, it seems the focus of the NHS became management, rather than clinical care. One example I read of stuck with me; a superb nurse, who ran her ward extremely well, had to leave clinical nursing because as a career path, it was a dead end. She had to move into management, and her former ward descended into chaos.
NHS budget has last I knew increased many times over since 1948, but the bed count went from about 450k down to about 100k - and those numbers were from more than ten years ago.
A theory is presented to explain this, which is that the more money you put in, the more management you get, and the more management you get, the less time clinical staff have for clinical work; more money results in less clinical output - but more managerial output, which theory argues is the primary focus and product of NHS.
This problem is far broader than health care. Doesn't matter whether your actual "product" is hospital wards, sheet steel, romance novels, or mowed lawns - if your sector of the economy is not structured to have draconian penalties for bloated management/bureaucracy/overhead, then it will quickly develop ever-worsening bloat. Because it's always quicker & easier to scale up the desks & paperwork. And guess who makes the decisions about where to allocate resources?
> 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.
Aside from the prescription part, this is exactly 1:1 how it works in the US. I say this having myself and my family utilize all of it extensively, public tax-funded emergency treatment, inpatient coverage, private doctors and specialists.
The public system in Hong Kong doesn't really cost anything. It's not that you get costs "waived" if you whine hard enough that you ought to be a charity case (which, by the way, is degrading,) and it's not that costs are passed on to a middleman. Medical treatment is transparently priced and simply inexpensive -- so it's simply not a cause of bankruptcy in Hong Kong, whereas, in the US...
Also, perhaps because it's a lot more laissez faire, the private system in Hong Kong is almost unimaginably superior to the private system in the US. It's far cheaper because pricing is transparent and most people pay cash! (Cutting out that middleman.) It's higher quality because there's a lot more competition, rather than collusion among a few major providers.
Nearly identical with a coat of paint. Every "horror story" I've heard about having to beg with the health system here is tellingly parroted by people who do not have experience with the system. It is the default to get itemized bills when you are insured and the outcome is the same. And again, there is nothing unusual about private care in the US - I pay cash, direct, a small amount monthly, for excellent private care. The ghost people claim to haunt US healthcare is mostly propaganda that for some reason is consumed wholesale by people outside the US who have no stake in it.
On reread: worth noting that the link you provided for some reason includes "missed more than 2 weeks of work" under "medical bankruptcy". I won't dismiss that out of hand without knowing more but that smells bad.
How free do you want it? Emergency healthcare is free at point of service in the US. Most other healthcare is covered partially or entirely if you're employed, which you should be. I've had hundreds of thousands of dollars of inpatient medical care for my family that I paid nothing for. Every other metric just starts to deal with the impact of taxes on the definition of free. I'm sure there are countries with systems that are fuzzier feeling to use, but this one works just fine until someone invents infinite unlimited free doctors to replace it.
I agree the US system mostly works for well-employed people.
It is worth recognizing though that not all employed people get medical benefits. Indeed many minimum wage jobs, low income jobs, "casual" jobs etc come with no medical benefits.
It's also worth noting that I some states it's OK to get fired for being sick. At which point you may lose those benefits.
Plus in poor economic times (like being a federal worker right now) losing your medical because you lost your job, seems like a suboptimal outcome.
But I agree with your last statement, this system works just fine, for a large enough group, so there's little political incentive to change it.
> 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.
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.
Doubt european numbers count insurance (public or private) pharmacy etc or all the jobs that support healhcare in general (powerplants, construction workers, restaurants, etc)
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).
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.
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.
> Whereas the software industry, with near zero government involvement, has had enormous improvements in function and has pushed the cost to literally zero.
What's most frustrating about this-- just take the poultry industry. To bring the cost to zero, all it would take is a single hacker to steal one government-regulated chicken and click "Copy" in its elusive little context menu[1].
Try telling that to a young person today. If you're like me you'll get the so-called "Gen Z Stare" in response.
Sorry, but I'm completely lost on the chicken point. Would you mind expanding on that just a little more? Is the gov't keeping secret vat-grown super-chickens?
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.
It's actually kind of refreshing to use free market lightly regulated medicine. I live in the UK where it's NHS government funded or related but travelling in Asia without insurance you can actually shop around and buy stuff - how much for a doc, how much for an xray etc. It's mostly quite cheap too. If you remove most of the regulatory barriers things work quite well. Obviously doctors and the like should pass exams for competence but I'm not sure you need to restrict it to only x people through y colleges in z country to restrict the supply. If the US said that to practice medicine and all you needed was a medical qualification from any respectable country it could drop costs like 10x I'd guess.
> Most other advanced nations have nationalized health care which works much better.
That's not true by the definition of "nationalization" (government ownership)
Switzerland and Netherlands are entirely private insurance. Most European countries have a public system and private system. It's very common for people to purchase supplemental insurance on top of what the government provides.
In the case of Switzerland, basic health insurance is provided by private companies but the price is mostly fixed by the Federal government.
Prices do vary between companies but many people just use the official insurance comparison tool and choose the cheapest as the services are completely identical. I'm completely against that system and would prefer a national health insurance like Japan.
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.
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.
> It's complicated, yes, but simplifying somewhat the "US" does not subsidize pharma startups.
This is utterly false. Agencies like NIH, BARDA, and NSF fund early-stage biomedical R&D by providing SBIR/STTR grants to biotech and pharma startups. They also fund basic research and clinical trials as well as translational studies.
There is the Orphan Drug Tax Credit and R&D Tax Credit. Also, access to NIH labs, etc.
There is a whole plethora of funding. Moderna’s mRNA platform was heavily backed by NIH and BARDA even before COVID.
“USA is very very good at complicated, cutting edge medical care” - i hear this but haven’t seen it in practice or in statistics. Everyone I know that has needed such things has had the same poor quality of care that primary care providers have - long waits, insurance issues and mediocre outcomes.
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.
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.
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.
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.
My youngest and I were discussing how removing zoning barriers to ADU (in-law suites) can be a big win for families and small win for housing in general.
In short, build an efficiency apartment on family property for an alone-living relative. Family can better provide support; the relative's residence goes back into the housing supply.
The municipality provides usual construction inspections but doesn't prevent the construction for non-pragmatic reasons.
There's another interesting twist to this. The insurance company is willing to pay a certain hourly rate to home health care providers. There is a limited number of health care providers willing to work for this rate. Supplementing the rate is not permitted. Lo and behold, it is sometimes not possible to find a health care provider which the insurance will pay for.
The best way to do long-term care for a loved one is to hire the nurses they like at a facility they stay at for a short while to treat the sick person at home. This is vastly cheaper than doing so in a facility, and the nurses earn more and are incentivized to keep the person as healthy as possible because the job pays very well since there is no facility extracting enormous overhead and executive salary costs from their salary.
I wonder if moving his father to an assisted living facility at some point will be a better option. I have little experience with this topic so I am genuinely curious.
In my experience, these facilities are all in crisis. They can't find people to staff the facilities and provide care and when they do, they can't afford to pay them.
My father has a neurodegenerative disorder and we've struggled to find a place that will provide consistent care. My mother, a retired nurse, is the one who tends to do a significant amount of the work to feed, clean, and otherwise care for him despite paying over $10k/month. It's infuriating.
Oh wow, that's frustrating! I hope you find someone to provide consistent care at a reasonable price. Btw do your parents live in a state with high cost of living or this is a general situation across the country?
Midwest, so cost of living is relatively low to moderate. I don't have firsthand experience elsewhere but it's my understanding that what we experience isn't uncommon.
This is the third facility he's been in and options are limited because a lot of facilities aren't staffed to provide memory care. Unfortunately, there just aren't many options unless you're wealthy enough to have in-home care.
> they each paid about $14,000 in annual premiums for 10 years, and the daily benefit started at $200 per day.
Insurance companies have to make money, but that's not that good of a deal, and the payout isn't that high ($73k annually) considering you won't be doing much else.
Consider also that by the time you need a nursing home or some other form of continual skilled care you are probably going to die within that year.
"Long-Term" is sort of a scare tactic that is used to get you imagining that you're going to be needing expensive skilled care for years. That can happen, but isn't normal.
Severe dementia id exactly when it does happen, though. Most patients die within months of moving into a nursing home. Dementia patients average ten years.
“That can happen but isn’t normal” is exactly the kind of thing that insurance should be for. Unfortunately, US health insurance is more oriented towards covering everything rather than spreading out the risk of rare high-cost events.
A lot of people think of insurance like a savings account rather than something like a sequence of options being rolled over so when they experience the reality of what they've been spending money on they tend to get very upset.
It has been a terrible deal. These policies have been a disaster for the industry. They're very expensive and they've raised premiums to cover rising costs, which causes people to drop the policy unless they're sure they'll need it. And then those people often require care for many years, generating massive losses.
Insurance is wonderful when it works, but the conditions for it to work can be quite fragile.
From the European POV this is awful and marginally scary. A commenter down the article writes that she is gonna sell her mother's house in order to serve her and even that will not last long.
The way US health care functions is an argument that the nation's principles (all free capitalism and no public intervention) are problematic.
If I were POTUS for a season, I would make a volcanic erruption in the health system. If I needed to care an elder without insurance, I would pay out of pocket a willing friend or even a homeless and not proceed to euthanasia as a commenter suggested.
I don't know about LTC insurance. I can tell you though; how it works in Texas where I live. If you want to go into a reputable facility, meaning one that is actually staffed and pays their staff a livable wage, it is very expensive; you pay out of your own pocket and after you had exhausted your savings etc. then they will apply for Medicaid on your behalf and use those government funds to continue your care.
As for me, when it is my turn, I plan to do "home attendant services". My understanding is that Medicare will pay, after a doctor has declared I am home bound, medical services at my home. I will have to arrange for meals, bathing, etc. out of my own pocket. When that time comes, I hope to find people at my church who are willing to do this. When it comes close to my time, I would need the doctor to say I need "at home hospice". Then an attendant will stay with me 24 hours a day and give me painkillers etc. until I pass in my own home.
We have a ton of public intervention in health, it’s just not very well done. The US government spends more per capita on health care than other developed countries, while covering only a fraction of the population. We’ve had universal health care for almost forty years, it’s just bad and nobody wants to call it that. A law called EMTALA says hospital emergency rooms can’t turn people away for being unable to pay, so anyone can get care, just in a very inefficient way. Properly covering everybody is Socialism(tm) and therefore isn’t in the cards.
I wrote a longer response but deleted it as it was just a personal anecdote. Suffice it to say I'll never buy LTC insurance or participate in any elder care such as "assisted living" or "nursing care." It's all (IMO) engineered to drain old people of their assets before they die. Providing care is nowhere on the list of motivations of anyone involved.
I could not agree more. My father has a neurodegenerative disorder that requires 24 hour care. He did tons of research and purchased LTC insurance decades before he was diagnosed. Experiencing first hand how difficult and predatory both the insurance company and the care facilities are has made it so I will never put my own children through it. My plan is to just euthanize myself when the time comes.
Washington imposed a LTC tax where some percentage of your income is taxed and goes into a fund for LTC. At the time they implemented it, you could opt out by procuring private LTC insurance. Most tech people I know did, because it was cheaper than the tax imposed. We’re still waiting to see if it’s safe to cancel our private policies.
It’s a stealth income tax. Most high income people saw through it and opted out by buying their own LTC (which isn’t indexed to income) and then canceling it once their exemption was recorded.
I only know a couple people who have since canceled their private policies due to a fear the laws will be amended requiring periodic attestation. I’m still holding my policy, though I am eager to cancel it.
It's an income tax in all but name because your income is taxed a certain percentage in order to fund the benefit.
There was a brief window where you could get LTC insurance from any provider and use it to opt out of the tax. High income earners did that because it was cheaper than paying the tax and also because receiving the benefit required you to stay in WA. The opt-out window has since closed, and if you haven't opted out by now, you will forever pay that tax if you work in WA.
Medicare provides a long term benefit as well, anyways the LTC is insolvent and is mostly a ploy to get everyone to pay for expensive unhoused neighbor care (well, the homeless industrial complex gets most of the money, it probably isn’t being used to help many). It doesn’t transfer if you ever leave the state, and doesn’t pay out very much if you ever need it.
As has been planned and legislated for years, it does transfer out of state as of 2030, which is such well advertised information that people who don’t know it are clearly operating entirely on curated propaganda, not their own thoughts.
You were right in one thing: that yes, it’s going to be insolvent. Why? Because the idiots in legislature were convinced by the anti-safety-net bastards to add an exemption carve-out that fucked the entire financial plan. If you let anyone opt out of Medicare it wouldn’t have existed for six weeks. And now those bastards have the nerve to turn around and say oohhhhh noooooo it’s not even fiscally stable!
But, homeless industrial complex? Ridiculous conspiracy theory nonsense.
For anyone not blinded by that nonsense - the WA LTC benefit would fill in the gaps for people who do not qualify for Medicare long term care, which is basically everyone who is going to need the Medicare benefit, and keep them from going bankrupt, destroying their family or simply dying for lack of care in that year it takes before Medicare kicks in for them.
The crucial understanding is that incentives are cross aligned because the product is risk coverage.
The more immediate/pressing your need for risk coverage, the worse it is for them to sell it to you. The less you need it, the better it is for them to sell it to you and the worse for you to buy it.
Pretty different than ice cream or cars or housing. Too many people just think “oh corporate greed” without thinking about the underlying economics (partly because of how us culture pretends markets are magic).
In the past, insurance companies (think: liability, fire, life, shipping) responded to a claim by hiring a lawyer and negotiating down. Like most contracts.
So states began creating insurance commissions, which serve as law firms that defend consumers from insurance companies. In practice, their existence forces insurance companies to pay what they are owed.
We need insurance commissions for health insurance. If there is a reason why the policy shouldn't pay (services received after policy expired, for example), the insurance commission has to sign off.
This is how normal insurance works. Health insurance, of course, is not normal insurance.
Yes indeed. Part of the problem is having “insurance” draining part of the resources. Long term care means it isn’t an “accident,” but a constant recurring cost. Saving the money up front, producing income, and paying directly for what you need is often a better strategy.
Companies are not in business to lose money, and you have to fight them to collect. That there are some low probability exceptions is not enough in their favor imho.
So every area of our lives that feels like it doesn't work like it used to - cost of living, healthcare, education, antitrust enforcement, journalism, accountability at the highest levels - represents a segment of the economy which has been corrupted.
Through this lens, socioeconomic policies start to make sense. For example, if your goal is to skim a fraction of the income from everyone in an economy and redirect those funds to specific goals/organizations/individuals, you could put tariffs on common goods and pass the funds collected on to companies granted large government contracts. Then the largest companies like GM and Ford see their profits reduced or even show a loss, while Grok and Palantir have all the money they need for mass surveillance.
Explanations for regulatory capture aren't normally this reductive, but wealth inequality has reached such monumental proportions that the simplest answer tends to be the right one when the needs of the few outweigh the needs of the many.
So through that lens how do you explain the healthcare situation before the start of tariffs, or is your entire worldview shaped based only on the news you read in the last three days?
>> There seems to be no will to replace this dysfunctional arrangement with a social safety net unfortunately.
I think one problem is that healthcare in many cases is meant to tackle the 1.5-2 sigma problems -- so naturally few people really encounter bad healthcare. The others thing they have good healthcare, until they are unlucky enough to encounter an issue.
I'm shocked how many people on my exact same health plan at work think it is a great plan.
I’ve heard from many recent moms that Aetna regularly denies normal labor and delivery charges that are explicitly covered in their plans. That then forces you through a months long process of calling them repeatedly, tolerating hold times of 1-2 hours each time, and getting virtually no help. And maybe at the end of it, when your child is almost one year old, they may pay out. That’s for a normal delivery with no complications.
Aetna knows exhausted and stressed moms are less likely to persist. It is blatantly fraudulent but they get away with it because no one has the time or money to get their executives thrown in jail.
It's a massive shame how he is treated right now. Right after the deposition of one mass murderer CEO, another would-be mass murderer insurer backtracked their plans to limit time under anesthesia.
Deposition works.
Even those who believe human lives are equal (they are not) have to admit the price of one dead (bad) person outweighs the number of people who would have died or had serious complications from rushed procedures.
But there are plenty of countries with functioning healthcare systems that are private? The Swiss, for instance. Moreover depending on what counts as "government’s gotta run it" (paying for it? administering it? actually providing care?) you can argue that the German or even Canadian systems aren't government run, at least to some degree.
In the Swiss system the private insurance companies are required to be non-profits. The government sets the standard for care and coverage and all the companies can do is compete on price.
Basically what Obamacare was originally intended to be before they had to compromise to get it passed.
They were trying to get Republican votes so that the law would be bipartisan. In the end it passed on a party line vote, so maybe the compromises were a mistake...
The parties weren't yet ideologically sorted. The Democratic majority included dozens of members of the Blue Dog coalition, a conservative group who (among other things) didn't support healthcare reform.
Also the us Congress is blocked by the senate needing 60 votes/supporters to reach cloture on every single bill, except the once per year thing that got the bbb passed. So it's very easy to block the other side. https://en.wikipedia.org/wiki/Reconciliation_(United_States_...
I've heard good things about the Dutch system of healthcare and that it may be adoptable to the US. I'd totally agree that healthcare corporations become non profit like Kaiser here in the US. They aren't perfect, but they seem to be better than the their for profit competitors.
Dutch system and original Romney care (and early versions of Obama care) had a lot in common. Health care providers are private, insurance companies private, gov dictates a basic list of treatments which count as "basic care" and must be covered by insurance, sets max deductible / copay etc, insurance companies are not allowed to refuse any customers, everyone must have insurance, if you can't afford it gov will pay for your insurance.
Afaik that's the gist of it. The ACA has been maimed on various fronts (e.g. the mandate "everyone must have health insurance" is no longer practically in effect), but it originally started out very similar. Far more than to, e.g., the UK's NHS which is fundamentally quite different.
If you only ever look at the way a system works at a specific point in time you only observe it at that point in time.
America has had multiple attempts at solutions for healthcare over the years, each started with good intent and then waylaid by various causes to produce what we have right now.
A sibling comment mentions political compromise to pass the ACA, as an example of this.
Another example is that HMOs were started with inherent goodness, but got “corrupted” (in my mind) by profit seeking.
To directly answer your question: a core tenet of the Republican tent is minimal government involvement in day to day lives of the citizenry. Ergo, the Swiss system won’t work because it involves a lot of bureaucracy. Republicans link bureaucracy to cost, and feel this is not an appropriate use of tax payers dollars.
The holes in this political doctrine are not part of my answer here fwiw. Please no “but…” comments to that end :)
To be fair the tenet is minimal involvement in the day to day operations of the economy and maximal involvement in the day to day lives of the citizenry.
I do find the ironies in political platforms quite beautiful. I also love how they provides endless fodder for largely fruitless internet discussion ^_^
In speaking with my republican father in law on his opposition to universal healthcare, it dawned on me that he views it as a sort of zero sum game. If he has healthcare today, and then universal healthcare offers it to folks that don't have it today, it is a loss for him.
It’s absolutely the case that public health coverage will benefit some people who make bad health decisions at the cost to some of those who make good decisions (or the decisions themselves must be made by a central authority).
That doesn’t make it the wrong policy decision. Lots of systems we happily manage with similar dynamics. But I don’t think denying that basic fact is the right path forward. The moral hazard is real and worth acknowledging.
Ironically the people who make bad health decisions are often benefiting the medical system by dieing more often around retirement age rather than going on to live 20+ years past retirement with age-related healthcare problems that cost WAY more than any other health conditions they could encounter when they are younger.
Smokers for example have more lung disease and cancer which cost money to treat, but usually not until they are in their 60s so they still spend their entire life paying into the system, but then they die soon after, saving on age related healthcare costs. And that is on top of smoking disqualifying someone from many treatments and surgeries, making smokers a net-win for healthcare costs to society.
Being really fat also seems to have similar effects, although the the finances are much closer so perhaps the second order effects from being fat cancel them out. But on paper they are still a bit cheaper than the average person.
Many people will argue against it because it "feels wrong" and they think unhealthy people should be punished (for example with higher insurance fees) and don't want to admit that unhealthy people are subsidizing their own healthcare, doubly so if you add in the sin taxes they have been paying their whole life that often result in more state income than their entire life-time medical costs add up to. But there has been numerous studies across the decades in Europe and the US showing how much cheaper unhealthy people that die earlier are to care for compared to the 90 year old granny walking everyday and risking broken hips and taking 30 different medications a day.
This is going to be the ultimate issue if we do achieve some sort of post scarcity world where human labor is redundant. The idea that it’s not someone’s fault their indenture is unnecessary let alone a moral failing deserving of punishment is foreign to a lot of American thinking. The puritanical labor is godly mentality combined with the long term warping of anti Soviet propaganda is going to lead to some serious wide spread suffering that would take what should be the greatest achievement of man kind and turn it into a scourge.
Obamacare was a replica of Romneycare, which was implemented in Massachusetts. It was the republican approach of leveraging private enterprise and encouraging consolidated medical networks.
The difference now is the republicans have changed, and nuanced issues are just not welcome on the platform of a party following a cult of personality.
Because it's any amount of government spending for one. And for two (this one is more of my opinion than the last one) the US has a problem where we, as a culture, view poor people as somehow morally or ethically broken, which is what causes them to be poor. Therefore, we shouldn't spend money that could positively impact them, regardless of its overall benefit. I got mine, so anyone can, but as the cultural zeitgeist.
Almost nobody in US politics who talks about something doesn't understand it or thinks it through. That's for people on the left and and on the right. They just repeat talking points that are given to them by wealthy party donors.
They were advocating for it before Obama tried to get it done. It was implemented in Massachusetts and termed "Romneycare" as Mitt Romney was the governor. Once Obama tried to implement it, it was government overreach and had to be watered down to get consensus. Personally I think we should have a govt option along side others, but all healthcare should be nonprofit (as in the Swiss model). Profit extraction is antithetical to healthcare.
It’s not a matter of acceptance. We can’t accept the cost of anything consistently growing at a rate faster than GDP. That’s just math, not ethics or political choice theory or anything else. Health care cost growth is going to slow one way or the another.
Watch what happens to the GDP if they don’t tackle the health care problem. You think it’s expensive now? Negotiating drug prices isn’t going to solve the problem. Having “health insurance” isn’t going to work when an AI decides whether your illness warrants saving you.
You all need to think about what’s going to happen to you when you can’t move anymore. Will you have enough money? Triple it. Maybe 6x it. Only the rich will be able to live healthy unless you’re diligent about your own health or strike it rich in an IPO.
It has more to do with demand than being anything. Demand for healthcare is highly inelastic. If the price of Pokémon’s grew faster than GDP consistently we would be fine. But if the price of a necessity for life does, we will not be fine.
This is why life necessities are often treated as a public responsibility. Health care is one of the few that is treated as a luxury.
But growth is also going to slow due to demographics, and this is unavoidable. Are we going to prioritize caring for humans? Or line goes up? Because line goes up is going to hit the demographic wall eventually.
Your first point doesn't mean that universal health care in the US would not be expensive. It definitely would, not that the USG couldn't afford it, but it wouldn't be cheap.
Computers and software used to be extremely expensive about 30 years ago, yet private industry advanced the state of the art and brought the prices down.
There seems to be very little talk about making medical education cheaper and more accessible. Why wouldn't it be cheaper if we had more MDs and nurses? What if we made it easier to become an MD ?
The insurance system is a cartel and they are greedy. However the regulations (upheld by the government) enable it.
We've done that to some extent via the legal enablement of nurse practitioner and physician assistant led care. Of course, largely speaking all they do is supervise the recording of patient metrics and prescribe drugs in label-consistent ways, but that often works out reasonably well for the patient. When the patient needs specialty care then the NP or PA simply punts them into the winds of referrals and insurance justifications.
I'm not sure there's any realistic way to enhance the availability of specialists. You can't 'stub' your way through providing the care of a skilled gastroenterologist by substitution with a NP, though PAs in specialty care are becoming common.
Why not open more medical schools? And eliminate the matching system? If you want to be an ____-ologist, here is the list of requirements. Meet the requirements and you are the ___ologist. Not whether or not a practice group likes you, or your parents knew which colleague to talk to. Don't allow the supply of MDs to be constrained.
The bigger restriction is number of residency positions which has been limited by government funding constraints. Also you need sufficient skilled doctors to train these residents. There is also the issue of physician burnout and preferences of doctors to be specialist vs being in primary care. So what often happens is foreign medical grads apply for these kind of roles. Also foreign medical doctors have a couple of requirements to work in the US. Get their foreign degree reviews to meet requirements, pass the US medical exams and finally they have to redo their residency even if they have significant experience. Some of this is largely controlled at the state level. Some states are considering loosening the residency part to a shorter period for primary care position for foreign doctors that are willing to work in underserved areas. I know California is also reducing restrictions on foreign dentists.
Hey now. America is a broad spectrum of people — some of us are heretical and believe governments have a role in everyday life, some of us believe the opposite.
You need to get this long before you need it, but also ensure it is good plan that will take care of you. The person in the article is lucky to have kids doing that, if you don't have kids who care who will care for you.
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.
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.
> 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.
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.
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"
Get rid of Pharma and there will be zero new drugs or treatments ever again. Have fun with that.
In the UK, with the NHS, it seems the focus of the NHS became management, rather than clinical care. One example I read of stuck with me; a superb nurse, who ran her ward extremely well, had to leave clinical nursing because as a career path, it was a dead end. She had to move into management, and her former ward descended into chaos.
NHS budget has last I knew increased many times over since 1948, but the bed count went from about 450k down to about 100k - and those numbers were from more than ten years ago.
A theory is presented to explain this, which is that the more money you put in, the more management you get, and the more management you get, the less time clinical staff have for clinical work; more money results in less clinical output - but more managerial output, which theory argues is the primary focus and product of NHS.
This problem is far broader than health care. Doesn't matter whether your actual "product" is hospital wards, sheet steel, romance novels, or mowed lawns - if your sector of the economy is not structured to have draconian penalties for bloated management/bureaucracy/overhead, then it will quickly develop ever-worsening bloat. Because it's always quicker & easier to scale up the desks & paperwork. And guess who makes the decisions about where to allocate resources?
> 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.
Aside from the prescription part, this is exactly 1:1 how it works in the US. I say this having myself and my family utilize all of it extensively, public tax-funded emergency treatment, inpatient coverage, private doctors and specialists.
The public system in Hong Kong doesn't really cost anything. It's not that you get costs "waived" if you whine hard enough that you ought to be a charity case (which, by the way, is degrading,) and it's not that costs are passed on to a middleman. Medical treatment is transparently priced and simply inexpensive -- so it's simply not a cause of bankruptcy in Hong Kong, whereas, in the US...
> https://worldpopulationreview.com/country-rankings/medical-b...
Also, perhaps because it's a lot more laissez faire, the private system in Hong Kong is almost unimaginably superior to the private system in the US. It's far cheaper because pricing is transparent and most people pay cash! (Cutting out that middleman.) It's higher quality because there's a lot more competition, rather than collusion among a few major providers.
Nearly identical with a coat of paint. Every "horror story" I've heard about having to beg with the health system here is tellingly parroted by people who do not have experience with the system. It is the default to get itemized bills when you are insured and the outcome is the same. And again, there is nothing unusual about private care in the US - I pay cash, direct, a small amount monthly, for excellent private care. The ghost people claim to haunt US healthcare is mostly propaganda that for some reason is consumed wholesale by people outside the US who have no stake in it.
On reread: worth noting that the link you provided for some reason includes "missed more than 2 weeks of work" under "medical bankruptcy". I won't dismiss that out of hand without knowing more but that smells bad.
What free health services are available to me that I am unaware of?
How free do you want it? Emergency healthcare is free at point of service in the US. Most other healthcare is covered partially or entirely if you're employed, which you should be. I've had hundreds of thousands of dollars of inpatient medical care for my family that I paid nothing for. Every other metric just starts to deal with the impact of taxes on the definition of free. I'm sure there are countries with systems that are fuzzier feeling to use, but this one works just fine until someone invents infinite unlimited free doctors to replace it.
I agree the US system mostly works for well-employed people.
It is worth recognizing though that not all employed people get medical benefits. Indeed many minimum wage jobs, low income jobs, "casual" jobs etc come with no medical benefits.
It's also worth noting that I some states it's OK to get fired for being sick. At which point you may lose those benefits.
Plus in poor economic times (like being a federal worker right now) losing your medical because you lost your job, seems like a suboptimal outcome.
But I agree with your last statement, this system works just fine, for a large enough group, so there's little political incentive to change it.
> 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.
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.
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.
Do other countries do it?
Doubt european numbers count insurance (public or private) pharmacy etc or all the jobs that support healhcare in general (powerplants, construction workers, restaurants, etc)
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.
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".
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!
>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.
My father's doctor says she doesn't want healthcare reform or more doctors because then their salaries will tank.
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).
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.
Or simply let them die when they are too old to survive without most basic automatable care. Say robot dropping food at the door.
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.
> Whereas the software industry, with near zero government involvement, has had enormous improvements in function and has pushed the cost to literally zero.
What's most frustrating about this-- just take the poultry industry. To bring the cost to zero, all it would take is a single hacker to steal one government-regulated chicken and click "Copy" in its elusive little context menu[1].
Try telling that to a young person today. If you're like me you'll get the so-called "Gen Z Stare" in response.
1: Assume a 2d chicken.
Sorry, but I'm completely lost on the chicken point. Would you mind expanding on that just a little more? Is the gov't keeping secret vat-grown super-chickens?
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.
If they're fake free markets then free market ideology doesn't apply.
> health care is a natural monopoly
It obviously isn't, because it wasn't a monopoly before the 1960s when the government got involved in it.
It's actually kind of refreshing to use free market lightly regulated medicine. I live in the UK where it's NHS government funded or related but travelling in Asia without insurance you can actually shop around and buy stuff - how much for a doc, how much for an xray etc. It's mostly quite cheap too. If you remove most of the regulatory barriers things work quite well. Obviously doctors and the like should pass exams for competence but I'm not sure you need to restrict it to only x people through y colleges in z country to restrict the supply. If the US said that to practice medicine and all you needed was a medical qualification from any respectable country it could drop costs like 10x I'd guess.
> Most other advanced nations have nationalized health care which works much better.
That's not true by the definition of "nationalization" (government ownership)
Switzerland and Netherlands are entirely private insurance. Most European countries have a public system and private system. It's very common for people to purchase supplemental insurance on top of what the government provides.
In the case of Switzerland, basic health insurance is provided by private companies but the price is mostly fixed by the Federal government.
Prices do vary between companies but many people just use the official insurance comparison tool and choose the cheapest as the services are completely identical. I'm completely against that system and would prefer a national health insurance like Japan.
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.
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.
> It's complicated, yes, but simplifying somewhat the "US" does not subsidize pharma startups.
This is utterly false. Agencies like NIH, BARDA, and NSF fund early-stage biomedical R&D by providing SBIR/STTR grants to biotech and pharma startups. They also fund basic research and clinical trials as well as translational studies.
There is the Orphan Drug Tax Credit and R&D Tax Credit. Also, access to NIH labs, etc.
There is a whole plethora of funding. Moderna’s mRNA platform was heavily backed by NIH and BARDA even before COVID.
> (Ironically most of that profit comes from Americans who have little or no way to collectively bargain on pricing.)
Thats what i meant by US subsidizing pharma for the whole world. I didn't mean the us govt.
Would they continue to exist if every single country in the world is doing "collective bargaining"?
“USA is very very good at complicated, cutting edge medical care” - i hear this but haven’t seen it in practice or in statistics. Everyone I know that has needed such things has had the same poor quality of care that primary care providers have - long waits, insurance issues and mediocre outcomes.
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.
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.
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.
That is crazy. That is more than the defense budget.
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_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).
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.
My youngest and I were discussing how removing zoning barriers to ADU (in-law suites) can be a big win for families and small win for housing in general.
In short, build an efficiency apartment on family property for an alone-living relative. Family can better provide support; the relative's residence goes back into the housing supply.
The municipality provides usual construction inspections but doesn't prevent the construction for non-pragmatic reasons.
ref: https://duckduckgo.com/?t=h_&q=zoning+to+allow+ADU%2C+in-law...
There's another interesting twist to this. The insurance company is willing to pay a certain hourly rate to home health care providers. There is a limited number of health care providers willing to work for this rate. Supplementing the rate is not permitted. Lo and behold, it is sometimes not possible to find a health care provider which the insurance will pay for.
The best way to do long-term care for a loved one is to hire the nurses they like at a facility they stay at for a short while to treat the sick person at home. This is vastly cheaper than doing so in a facility, and the nurses earn more and are incentivized to keep the person as healthy as possible because the job pays very well since there is no facility extracting enormous overhead and executive salary costs from their salary.
his notes are EXACTLY my experience. bookmark it.
Same here…three times so far.
I wonder if moving his father to an assisted living facility at some point will be a better option. I have little experience with this topic so I am genuinely curious.
In my experience, these facilities are all in crisis. They can't find people to staff the facilities and provide care and when they do, they can't afford to pay them.
My father has a neurodegenerative disorder and we've struggled to find a place that will provide consistent care. My mother, a retired nurse, is the one who tends to do a significant amount of the work to feed, clean, and otherwise care for him despite paying over $10k/month. It's infuriating.
Oh wow, that's frustrating! I hope you find someone to provide consistent care at a reasonable price. Btw do your parents live in a state with high cost of living or this is a general situation across the country?
Midwest, so cost of living is relatively low to moderate. I don't have firsthand experience elsewhere but it's my understanding that what we experience isn't uncommon.
This is the third facility he's been in and options are limited because a lot of facilities aren't staffed to provide memory care. Unfortunately, there just aren't many options unless you're wealthy enough to have in-home care.
> they each paid about $14,000 in annual premiums for 10 years, and the daily benefit started at $200 per day.
Insurance companies have to make money, but that's not that good of a deal, and the payout isn't that high ($73k annually) considering you won't be doing much else.
Consider also that by the time you need a nursing home or some other form of continual skilled care you are probably going to die within that year.
"Long-Term" is sort of a scare tactic that is used to get you imagining that you're going to be needing expensive skilled care for years. That can happen, but isn't normal.
Severe dementia id exactly when it does happen, though. Most patients die within months of moving into a nursing home. Dementia patients average ten years.
“That can happen but isn’t normal” is exactly the kind of thing that insurance should be for. Unfortunately, US health insurance is more oriented towards covering everything rather than spreading out the risk of rare high-cost events.
Given that my only experience with such homes is indeed long-term, I'd be curious to see actual statistics on this
A lot of people think of insurance like a savings account rather than something like a sequence of options being rolled over so when they experience the reality of what they've been spending money on they tend to get very upset.
$140,000 in premium and $73,000/year in payout seems like a terrible deal for the insurance company.
Two sets of my grandparents have needed daily helpers for years. And that’s just for regular day to day care. Not in response to a particular trauma.
It has been a terrible deal. These policies have been a disaster for the industry. They're very expensive and they've raised premiums to cover rising costs, which causes people to drop the policy unless they're sure they'll need it. And then those people often require care for many years, generating massive losses.
Insurance is wonderful when it works, but the conditions for it to work can be quite fragile.
Certain types of insurance can be funny because of how much information asymmetry there is.
It is a terrible deal. Most don't offer LTC insurance anymore.
LTC policies are such a bad deal they almost bankrupted General Electric.
From the European POV this is awful and marginally scary. A commenter down the article writes that she is gonna sell her mother's house in order to serve her and even that will not last long.
The way US health care functions is an argument that the nation's principles (all free capitalism and no public intervention) are problematic.
If I were POTUS for a season, I would make a volcanic erruption in the health system. If I needed to care an elder without insurance, I would pay out of pocket a willing friend or even a homeless and not proceed to euthanasia as a commenter suggested.
I don't know about LTC insurance. I can tell you though; how it works in Texas where I live. If you want to go into a reputable facility, meaning one that is actually staffed and pays their staff a livable wage, it is very expensive; you pay out of your own pocket and after you had exhausted your savings etc. then they will apply for Medicaid on your behalf and use those government funds to continue your care.
As for me, when it is my turn, I plan to do "home attendant services". My understanding is that Medicare will pay, after a doctor has declared I am home bound, medical services at my home. I will have to arrange for meals, bathing, etc. out of my own pocket. When that time comes, I hope to find people at my church who are willing to do this. When it comes close to my time, I would need the doctor to say I need "at home hospice". Then an attendant will stay with me 24 hours a day and give me painkillers etc. until I pass in my own home.
We have a ton of public intervention in health, it’s just not very well done. The US government spends more per capita on health care than other developed countries, while covering only a fraction of the population. We’ve had universal health care for almost forty years, it’s just bad and nobody wants to call it that. A law called EMTALA says hospital emergency rooms can’t turn people away for being unable to pay, so anyone can get care, just in a very inefficient way. Properly covering everybody is Socialism(tm) and therefore isn’t in the cards.
> all free capitalism and no public intervention
Who is going to tell them?
Delay, deny, defend --- this is the insurance industry's modus operandi.
Insurance is the only industry where customers are the enemy.
I wrote a longer response but deleted it as it was just a personal anecdote. Suffice it to say I'll never buy LTC insurance or participate in any elder care such as "assisted living" or "nursing care." It's all (IMO) engineered to drain old people of their assets before they die. Providing care is nowhere on the list of motivations of anyone involved.
I could not agree more. My father has a neurodegenerative disorder that requires 24 hour care. He did tons of research and purchased LTC insurance decades before he was diagnosed. Experiencing first hand how difficult and predatory both the insurance company and the care facilities are has made it so I will never put my own children through it. My plan is to just euthanize myself when the time comes.
Some states are forcing you to buy LTC insurance. I’ve heard Washington does this through some convoluted laws.
Washington imposed a LTC tax where some percentage of your income is taxed and goes into a fund for LTC. At the time they implemented it, you could opt out by procuring private LTC insurance. Most tech people I know did, because it was cheaper than the tax imposed. We’re still waiting to see if it’s safe to cancel our private policies.
It’s a stealth income tax. Most high income people saw through it and opted out by buying their own LTC (which isn’t indexed to income) and then canceling it once their exemption was recorded.
I only know a couple people who have since canceled their private policies due to a fear the laws will be amended requiring periodic attestation. I’m still holding my policy, though I am eager to cancel it.
I don’t understand. How is it an income tax? It’s a requirement to get a particular kind of insurance right?
It's an income tax in all but name because your income is taxed a certain percentage in order to fund the benefit.
There was a brief window where you could get LTC insurance from any provider and use it to opt out of the tax. High income earners did that because it was cheaper than paying the tax and also because receiving the benefit required you to stay in WA. The opt-out window has since closed, and if you haven't opted out by now, you will forever pay that tax if you work in WA.
https://wacaresfund.wa.gov/how-it-works
Yea, just like the country forces you to buy Medicare, except convoluted because people hate social safety nets.
Medicare provides a long term benefit as well, anyways the LTC is insolvent and is mostly a ploy to get everyone to pay for expensive unhoused neighbor care (well, the homeless industrial complex gets most of the money, it probably isn’t being used to help many). It doesn’t transfer if you ever leave the state, and doesn’t pay out very much if you ever need it.
As has been planned and legislated for years, it does transfer out of state as of 2030, which is such well advertised information that people who don’t know it are clearly operating entirely on curated propaganda, not their own thoughts.
You were right in one thing: that yes, it’s going to be insolvent. Why? Because the idiots in legislature were convinced by the anti-safety-net bastards to add an exemption carve-out that fucked the entire financial plan. If you let anyone opt out of Medicare it wouldn’t have existed for six weeks. And now those bastards have the nerve to turn around and say oohhhhh noooooo it’s not even fiscally stable!
But, homeless industrial complex? Ridiculous conspiracy theory nonsense.
For anyone not blinded by that nonsense - the WA LTC benefit would fill in the gaps for people who do not qualify for Medicare long term care, which is basically everyone who is going to need the Medicare benefit, and keep them from going bankrupt, destroying their family or simply dying for lack of care in that year it takes before Medicare kicks in for them.
I disagree. Getting a $3800/mo payment for up to 3 years sure was nice when I had to put mom in a $4000/mo assisted living facility.
There’s a reason companies got away from offering these policies, they were losing money on them.
In my case they never paid. According to the lawyers I had involved, this isn't uncommon.
The crucial understanding is that incentives are cross aligned because the product is risk coverage.
The more immediate/pressing your need for risk coverage, the worse it is for them to sell it to you. The less you need it, the better it is for them to sell it to you and the worse for you to buy it.
Pretty different than ice cream or cars or housing. Too many people just think “oh corporate greed” without thinking about the underlying economics (partly because of how us culture pretends markets are magic).
This is why state's have insurance commissions.
In the past, insurance companies (think: liability, fire, life, shipping) responded to a claim by hiring a lawyer and negotiating down. Like most contracts.
So states began creating insurance commissions, which serve as law firms that defend consumers from insurance companies. In practice, their existence forces insurance companies to pay what they are owed.
We need insurance commissions for health insurance. If there is a reason why the policy shouldn't pay (services received after policy expired, for example), the insurance commission has to sign off.
This is how normal insurance works. Health insurance, of course, is not normal insurance.
We need to just nationalize these things as basic civic infrastructure that everyone funds as part of the social contract.
LTC insurance is covered by insurance commissions.
Yes indeed. Part of the problem is having “insurance” draining part of the resources. Long term care means it isn’t an “accident,” but a constant recurring cost. Saving the money up front, producing income, and paying directly for what you need is often a better strategy.
I think this underestimates the "cost" of LTC.
And also doesn't consider when the LTC starts. It could start at any time, even before working age.
Companies are not in business to lose money, and you have to fight them to collect. That there are some low probability exceptions is not enough in their favor imho.
There seems to be no will to replace this dysfunctional arrangement with a social safety net unfortunately.
Because injustice is corruption.
So every area of our lives that feels like it doesn't work like it used to - cost of living, healthcare, education, antitrust enforcement, journalism, accountability at the highest levels - represents a segment of the economy which has been corrupted.
Through this lens, socioeconomic policies start to make sense. For example, if your goal is to skim a fraction of the income from everyone in an economy and redirect those funds to specific goals/organizations/individuals, you could put tariffs on common goods and pass the funds collected on to companies granted large government contracts. Then the largest companies like GM and Ford see their profits reduced or even show a loss, while Grok and Palantir have all the money they need for mass surveillance.
Explanations for regulatory capture aren't normally this reductive, but wealth inequality has reached such monumental proportions that the simplest answer tends to be the right one when the needs of the few outweigh the needs of the many.
So through that lens how do you explain the healthcare situation before the start of tariffs, or is your entire worldview shaped based only on the news you read in the last three days?
>> There seems to be no will to replace this dysfunctional arrangement with a social safety net unfortunately.
I think one problem is that healthcare in many cases is meant to tackle the 1.5-2 sigma problems -- so naturally few people really encounter bad healthcare. The others thing they have good healthcare, until they are unlucky enough to encounter an issue.
I'm shocked how many people on my exact same health plan at work think it is a great plan.
I’ve heard from many recent moms that Aetna regularly denies normal labor and delivery charges that are explicitly covered in their plans. That then forces you through a months long process of calling them repeatedly, tolerating hold times of 1-2 hours each time, and getting virtually no help. And maybe at the end of it, when your child is almost one year old, they may pay out. That’s for a normal delivery with no complications.
Aetna knows exhausted and stressed moms are less likely to persist. It is blatantly fraudulent but they get away with it because no one has the time or money to get their executives thrown in jail.
People need to stop looking at it like this.
Healthcare is a triangle. There are three players. You, Insurance, and Doctor.
All three are adversaries and allies in different ways.
In reality the triangle is Doctors, Insurance, Hospitals, and you in the middle.
In reality what the article says is they needed adult-sitters.
Family at first but USE PROFESSIONALS. Due to scummy ins company wanting docs.
How is that health care? Babysitting is now health care???
We need a better way to deal with dementia. Not health care.
A literal babysitter to make sure they eat and don't run into the street.
I don't see dementia as sickness. Brain illness maybe.
So we have to warehouse these feeble folk. That is the problem.
We need a more humane way rather than Doctor K's method..
What about the poor old guys girlfriend?
The alternative is to depose them.
It's a massive shame how he is treated right now. Right after the deposition of one mass murderer CEO, another would-be mass murderer insurer backtracked their plans to limit time under anesthesia.
Deposition works.
Even those who believe human lives are equal (they are not) have to admit the price of one dead (bad) person outweighs the number of people who would have died or had serious complications from rushed procedures.
There are three things a nation needs to accept about universal health care:
(1) It’s expensive (2) Everybody has to pay (3) The government’s gotta run it
Government does not have to run it. Gokernment needs to ensure it is run well but there is no reason they have to run it.
Oversight doesn’t work, look at the finance markets.
works very well there - don't confuse imperfection for not working.
It works in other countries
>The government’s gotta run it
But there are plenty of countries with functioning healthcare systems that are private? The Swiss, for instance. Moreover depending on what counts as "government’s gotta run it" (paying for it? administering it? actually providing care?) you can argue that the German or even Canadian systems aren't government run, at least to some degree.
In the Swiss system the private insurance companies are required to be non-profits. The government sets the standard for care and coverage and all the companies can do is compete on price.
Basically what Obamacare was originally intended to be before they had to compromise to get it passed.
Who were they compromising with? The Congress had large Democrat majorities in both houses during the ACA legislative process.
The 60th vote was Ted Kennedy who died in office and a Republican was elected to fill the seat, forcing passage of an earlier bill.
https://en.m.wikipedia.org/wiki/2010_United_States_Senate_sp...
They were trying to get Republican votes so that the law would be bipartisan. In the end it passed on a party line vote, so maybe the compromises were a mistake...
All the Democrats bought by the private health insurance companies I assume.
The parties weren't yet ideologically sorted. The Democratic majority included dozens of members of the Blue Dog coalition, a conservative group who (among other things) didn't support healthcare reform.
Also the us Congress is blocked by the senate needing 60 votes/supporters to reach cloture on every single bill, except the once per year thing that got the bbb passed. So it's very easy to block the other side. https://en.wikipedia.org/wiki/Reconciliation_(United_States_...
Democrat senators Lieberman and Baucus mainly torpedoed it. And Pelosi refused to get republicans on board.
I've heard good things about the Dutch system of healthcare and that it may be adoptable to the US. I'd totally agree that healthcare corporations become non profit like Kaiser here in the US. They aren't perfect, but they seem to be better than the their for profit competitors.
Dutch system and original Romney care (and early versions of Obama care) had a lot in common. Health care providers are private, insurance companies private, gov dictates a basic list of treatments which count as "basic care" and must be covered by insurance, sets max deductible / copay etc, insurance companies are not allowed to refuse any customers, everyone must have insurance, if you can't afford it gov will pay for your insurance.
Afaik that's the gist of it. The ACA has been maimed on various fronts (e.g. the mandate "everyone must have health insurance" is no longer practically in effect), but it originally started out very similar. Far more than to, e.g., the UK's NHS which is fundamentally quite different.
So why don't we see Republican Americans advocating to adopt the Swiss system which provides universal coverage at a lower per capita cost?
If you only ever look at the way a system works at a specific point in time you only observe it at that point in time.
America has had multiple attempts at solutions for healthcare over the years, each started with good intent and then waylaid by various causes to produce what we have right now.
A sibling comment mentions political compromise to pass the ACA, as an example of this.
Another example is that HMOs were started with inherent goodness, but got “corrupted” (in my mind) by profit seeking.
To directly answer your question: a core tenet of the Republican tent is minimal government involvement in day to day lives of the citizenry. Ergo, the Swiss system won’t work because it involves a lot of bureaucracy. Republicans link bureaucracy to cost, and feel this is not an appropriate use of tax payers dollars.
The holes in this political doctrine are not part of my answer here fwiw. Please no “but…” comments to that end :)
To be fair the tenet is minimal involvement in the day to day operations of the economy and maximal involvement in the day to day lives of the citizenry.
I do find the ironies in political platforms quite beautiful. I also love how they provides endless fodder for largely fruitless internet discussion ^_^
In speaking with my republican father in law on his opposition to universal healthcare, it dawned on me that he views it as a sort of zero sum game. If he has healthcare today, and then universal healthcare offers it to folks that don't have it today, it is a loss for him.
Something I've run into in similar situations is the "moral necessity of punishment", sort of a reverse just-world fallacy.
"There are people not good enough for health care and helping them would violate this natural order".
It’s absolutely the case that public health coverage will benefit some people who make bad health decisions at the cost to some of those who make good decisions (or the decisions themselves must be made by a central authority).
That doesn’t make it the wrong policy decision. Lots of systems we happily manage with similar dynamics. But I don’t think denying that basic fact is the right path forward. The moral hazard is real and worth acknowledging.
Ironically the people who make bad health decisions are often benefiting the medical system by dieing more often around retirement age rather than going on to live 20+ years past retirement with age-related healthcare problems that cost WAY more than any other health conditions they could encounter when they are younger.
Smokers for example have more lung disease and cancer which cost money to treat, but usually not until they are in their 60s so they still spend their entire life paying into the system, but then they die soon after, saving on age related healthcare costs. And that is on top of smoking disqualifying someone from many treatments and surgeries, making smokers a net-win for healthcare costs to society.
Being really fat also seems to have similar effects, although the the finances are much closer so perhaps the second order effects from being fat cancel them out. But on paper they are still a bit cheaper than the average person.
Many people will argue against it because it "feels wrong" and they think unhealthy people should be punished (for example with higher insurance fees) and don't want to admit that unhealthy people are subsidizing their own healthcare, doubly so if you add in the sin taxes they have been paying their whole life that often result in more state income than their entire life-time medical costs add up to. But there has been numerous studies across the decades in Europe and the US showing how much cheaper unhealthy people that die earlier are to care for compared to the 90 year old granny walking everyday and risking broken hips and taking 30 different medications a day.
This is going to be the ultimate issue if we do achieve some sort of post scarcity world where human labor is redundant. The idea that it’s not someone’s fault their indenture is unnecessary let alone a moral failing deserving of punishment is foreign to a lot of American thinking. The puritanical labor is godly mentality combined with the long term warping of anti Soviet propaganda is going to lead to some serious wide spread suffering that would take what should be the greatest achievement of man kind and turn it into a scourge.
Obamacare was a replica of Romneycare, which was implemented in Massachusetts. It was the republican approach of leveraging private enterprise and encouraging consolidated medical networks.
The difference now is the republicans have changed, and nuanced issues are just not welcome on the platform of a party following a cult of personality.
Because it's any amount of government spending for one. And for two (this one is more of my opinion than the last one) the US has a problem where we, as a culture, view poor people as somehow morally or ethically broken, which is what causes them to be poor. Therefore, we shouldn't spend money that could positively impact them, regardless of its overall benefit. I got mine, so anyone can, but as the cultural zeitgeist.
Almost nobody in US politics who talks about something doesn't understand it or thinks it through. That's for people on the left and and on the right. They just repeat talking points that are given to them by wealthy party donors.
Because Republican Americans tend to overwhelmingly think "government bad, private business good". Even the "small-c conservatives".
Although they think government is good at controlling their version of morality.
They were advocating for it before Obama tried to get it done. It was implemented in Massachusetts and termed "Romneycare" as Mitt Romney was the governor. Once Obama tried to implement it, it was government overreach and had to be watered down to get consensus. Personally I think we should have a govt option along side others, but all healthcare should be nonprofit (as in the Swiss model). Profit extraction is antithetical to healthcare.
It’s not a matter of acceptance. We can’t accept the cost of anything consistently growing at a rate faster than GDP. That’s just math, not ethics or political choice theory or anything else. Health care cost growth is going to slow one way or the another.
Watch what happens to the GDP if they don’t tackle the health care problem. You think it’s expensive now? Negotiating drug prices isn’t going to solve the problem. Having “health insurance” isn’t going to work when an AI decides whether your illness warrants saving you.
You all need to think about what’s going to happen to you when you can’t move anymore. Will you have enough money? Triple it. Maybe 6x it. Only the rich will be able to live healthy unless you’re diligent about your own health or strike it rich in an IPO.
It has more to do with demand than being anything. Demand for healthcare is highly inelastic. If the price of Pokémon’s grew faster than GDP consistently we would be fine. But if the price of a necessity for life does, we will not be fine.
This is why life necessities are often treated as a public responsibility. Health care is one of the few that is treated as a luxury.
But growth is also going to slow due to demographics, and this is unavoidable. Are we going to prioritize caring for humans? Or line goes up? Because line goes up is going to hit the demographic wall eventually.
https://www.mckinsey.com/mgi/our-research/dependency-and-dep...
https://www.cato.org/cato-journal/spring/summer-2018/demogra...
https://www.cato.org/commentary/clear-eyed-look-our-demograp...
https://www.sas.upenn.edu/~jesusfv/Slides_London.pdf
What part of the cost of healthcare involves providing profits for middlemen?
(1) is not correct. The US spends more than other nation per capita on health care
(3) isn't correct either. It needs to be regulated in some way. Government doesn't have to run it. I think it should be treated more like a utility
Your first point doesn't mean that universal health care in the US would not be expensive. It definitely would, not that the USG couldn't afford it, but it wouldn't be cheap.
Agree with your second point.
Computers and software used to be extremely expensive about 30 years ago, yet private industry advanced the state of the art and brought the prices down.
There seems to be very little talk about making medical education cheaper and more accessible. Why wouldn't it be cheaper if we had more MDs and nurses? What if we made it easier to become an MD ?
The insurance system is a cartel and they are greedy. However the regulations (upheld by the government) enable it.
We've done that to some extent via the legal enablement of nurse practitioner and physician assistant led care. Of course, largely speaking all they do is supervise the recording of patient metrics and prescribe drugs in label-consistent ways, but that often works out reasonably well for the patient. When the patient needs specialty care then the NP or PA simply punts them into the winds of referrals and insurance justifications.
I'm not sure there's any realistic way to enhance the availability of specialists. You can't 'stub' your way through providing the care of a skilled gastroenterologist by substitution with a NP, though PAs in specialty care are becoming common.
Why not open more medical schools? And eliminate the matching system? If you want to be an ____-ologist, here is the list of requirements. Meet the requirements and you are the ___ologist. Not whether or not a practice group likes you, or your parents knew which colleague to talk to. Don't allow the supply of MDs to be constrained.
The bigger restriction is number of residency positions which has been limited by government funding constraints. Also you need sufficient skilled doctors to train these residents. There is also the issue of physician burnout and preferences of doctors to be specialist vs being in primary care. So what often happens is foreign medical grads apply for these kind of roles. Also foreign medical doctors have a couple of requirements to work in the US. Get their foreign degree reviews to meet requirements, pass the US medical exams and finally they have to redo their residency even if they have significant experience. Some of this is largely controlled at the state level. Some states are considering loosening the residency part to a shorter period for primary care position for foreign doctors that are willing to work in underserved areas. I know California is also reducing restrictions on foreign dentists.
Because your congressman gets lots of donations from doctors and hospitals. Doctors like to drive fancy cars.
In places with Catholics, you usually get the bishops advocating for the local Catholic hospital system.
So government (my congressman) IS the problem! Thanks for reinforcing what Reagan said 40 years ago.
Sure, but what these types of people fail to understand is that the only way to solve the problem is also government.
It turns out the real world is a big complicated messy place and there's rarely a simple answer like "delete government!"
Ironically, your guy Reagan was paid and supported by the AMA to fight “socialized medicine” and increasing the number of doctors in the 1960s.
This cult of personality in American politics is such a curse.
Without relgulation, the profit seekers would remain in power and the same applies to more medical staff.
The insurance system is a profit seeking institution, that functions as intended. Why dont you talk about that BURNING aspect?
You didn't address a single thing I said
Americans are perfectly conditioned to instinctively and aggressively deny all three. :(
Hey now. America is a broad spectrum of people — some of us are heretical and believe governments have a role in everyday life, some of us believe the opposite.
Nitpick all you want, but what I said is exactly right and you probably know that.
This isn’t about health care. Please read the article.
Elder care and memory care are under the umbrella of healthcare.
That they're nonsensically broken out as a separate insurance category is intrinsically linked to the problems the article describes
You need to get this long before you need it, but also ensure it is good plan that will take care of you. The person in the article is lucky to have kids doing that, if you don't have kids who care who will care for you.
"ensure it is good plan that will take care of you. "
That's basically impossible. You will only know if you made the right choice once you are actually starting to use the insurance.
not exactly - you can check on the experience of those who have it. Though of course things can change.