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?
Seems like large tech companies never have a shortage of management.
Between the matrix style organizational structure and the many layers (project manager, program manager, director, VP, senior VP, BU president, etc…), I would love to know what, if anything, the higher levels actually DO.
> I would love to know what, if anything, the higher levels actually DO.
In many org's, they mostly compete with other higher-levels for status.
And the biggest signifiers of status are usually (1) how many lower-level managers ultimately report to you, and (2) how many layers those lower-level managers span.
I have a perspective shift that may help: Physicians are the peak of blue-collar work.
Yes, a lot of physician work involves diagnoses; but it also involves getting one’s hand dirty. Hospitals are the peak of shop and factory work.
My wife, who worked as an RN in the OR is far handier with shop tools than I am as it’s time-sensitive physical labor!
Meanwhile the jobs program are all of the white collar variety; jobs that purport to support our healthcare workers includes 100% of the health insurance companies and programs.
Thanks to a generational messaging since the 1980s and 1990s, we white collar workers have wormed our way into all aspects of industry.
Beyond it being normally weird, that's a very weird thing to do.
With the aging population, we'll need more and more health care professionals. I'm not just referring to people over 60, even people 40 upwards require more care.
I am not trying to start any sort of political discussion. However, I do not think many of the layoffs that have hit healthcare workers are due to maximizing profits for hospitals nor due to the lack of demand for healthcare.
If I am not mistaken, the current administration has enacted changes that have caused a significant reduction in federal grant funding for hospitals. So, many of the layoffs, as I understand it, are to make up for the coming losses in funding.
I live in a state with plenty of rural areas. There are growing fears of some rural hospitals being forced to completely shut down due to funding cuts.
> 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.
You are completely wrong, and I can almost hear in my mind how you think something you are promoting as true, is 'basically true' - but please know there are plenty of people reading HN from afar and may come to expect 'free healthcare in US (just go to the ER!)' from your comments.
No it is not.
Lots of experience with the health system in the US, for me, and helping many other navigate the systems.
It's not even close to identical. If you go to ER here and you can't pay, they may provide you with a certain level of 'care' to 'stabilize you' (as the law says they are supposed to, and the feds send some money to hospitals to cover some of this), and you will get billed, and collections calling, and credit report issues, and threats to sue and have your property auctioned (have held one of these letters in my hand, complete with a list of property that was in my name.
Even worse, the 'care' you may get is normally crap. For example I have seen the same people with same condition, at one hospital get a quick surgery and leave with a colostomy bag for rest of life, and other person at other hospital with insurance get placed in a room and treated for weeks - then left with a warning to avoid seeds.
I have seen so many examples of places leaves humans to rot with no insurance - hospitals.
Even with insurance, you can find yourself waiting 6-8 weeks for a doc appointment. I have so many examples.
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.
No, it’s not. Yes, we have Medicaid in the U.S., which makes everything free for the poor, but GP is saying that effectively everybody (including the not-so-poor) can get this level of care in Hong Kong. Definitely not true in the U.S.!
Pricing transparency also does not exist here as GP is claiming it does in Hong Kong. I am supposed to get certain imaging tests done every year, and I never know how much those will cost me until after I have already done them (in the U.S.). Maybe there is some way to get a non-binding estimate ahead of time, but I have never received such a thing and am not even sure it is possible. So I can’t easily “shop around”—or if can, tell me how because I (and I think most people) don’t know how.
I most certainly cannot pay $300 to see a specialist the same day in the U.S. I would have to pay that much to see my GP after waiting 6 weeks despite my employer paying more than $20k/year to insure my family. To see a specialist, I would have to wait a few months and probably pay $1-2k for one visit, not counting any tests or imaging that is ordered.
The description of Hong Kong’s system sounds amazing if true.
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?
I think they're implying that software is completely unlike healthcare or chickens. One can be multiplied for free but the others cannot, no matter if regulated or not.
When it comes to healthcare, we didn't used to have so much regulation.
And, well, it sucked. People died, black people got injected with radiation, and we experimented on humans.
Ultimately, I don't want poor people to just... die. Because that's bad. So we need some sort of guarantees.
Or, we don't: in which case, I hope you're content scraping bodies off the freeway for free. Someone has to do it if we're not paying for their healthcare and disposal costs. Hope you're not busy next weekend!
I'm just not sure how you get around a private market inevitably letting people die.
If someone can't afford healthcare, and in your vision we should refuse to provide it, then they die. That means, unfortunately, you are advocating for their death.
Which is fine, maybe. Except that we still have to deal with that. If they can't afford to dispose of their own bodies, now what?
No matter how you cut it, we either go back to the government or everything is awful.
Me asking you if you want to scrape bodies off the freeway isnt rhetorical. It might seem that way, because it's so extreme, but that's the reality here.
Someone, somewhere, has to pay for that. We already established that the person themselves cannot do it.
Should it be you? Should it be me? Or should it be everyone? If you answer everyone, congratulations, you've reinvented taxes.
The issue here is that these are already solved problems. Why do you think governments invented taxes hundreds of years ago? To steal from you? Look at the big picture.
Under a free market, medical care will be cheap. There's no particular reason why health care should be so expensive, but every time the government takes it over, that's the result.
Look how cheap your cell phone is, despite the amazing engineering that went into it. Pretty much everyone has a cell phone, both rich and poor.
> Under a free market, medical care will be cheap.
This isn't an argument - this is an ideology, a pure faith.
There's no mechanism for this. Some things are just expensive.
Performing a surgery is expensive no matter what. It requires advanced machines and multiple humans with ideally decades of specialized training.
There may be "cheap" surgeries if there's no regulation, in the same way we have cheap shit on Temu - it's junk and doesn't work.
The cell phone reference you made kind of says it all - yes we have cheap cell phones. Most of them are shit.
We don't want shit medicine, shit surgeries, or shit chemotherapy. We want stuff that works.
Also, elephant in the room: products and services are necessarily different.
A phone is a PRODUCT. Medical care is a SERVICE. The difference being cheap products are good, sometimes, cheap services are bad.
We don't want a surgery to cost 100 dollars because that means the doctors are making, like, 2 bucks an hour. Which means we're living in a third world shit hole.
You don't want to live in a third world shit hole, do you? Great, then we're on the same page.
And, elephant number 2: healthcare can never, under any circumstances, be a free market. No matter how hard you try.
When you get sick and need to go to the hospital you might naively think the market of hospitals is thousands. This is wrong. Its actually a monopoly - there is only one hospital you can go to.
This is because of what healthcare is fundamentally - a service to keep you alive. You will go to whatever hospital is closest, because the human will to live transcends markets and even money as a concept.
This means, in a free market, it's not free at all - it's filled with only monopolies who can effectively charge whatever they want - which is exactly what we see.
The only places this doesn't happen is in places in which healthcare is nationalized. Because said countries know a free market is impossible, they don't even try, and they avoid the monopolization that's inevitable.
Some other people will naively point to systems in which there are both public and private options - and note that the private options are cheap and effective.
But that's only the case because of the public options. When private care has to compete with low cost public care, it will be cheap. If you remove that competition by privatizing all healthcare, then they can, once again, effectively charge whatever they want.
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.
You cannot free market healthcare because quite frankly there is no real profit in this industry.
Yeah even your high net worth client that pays 50k in premiums every year wipes you out when they get some complicated form of cancer.
Edit this actually came up in a videogame called Cyberpunk.
A lot of people here on HN consider themselves code wizards indispensable to their employer.
Google will replace your multiple sclerosis ass.
> 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 hear this but haven’t seen it in practice or in statistics
curious. what kind of statistics would that show up?
When i was looking into clinical trials for prostate cancer. almost 80% of experimental cutting edge medicine was in usa. They even have spl k2 visa for International patients to participate.
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.
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.
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.
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.
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.