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Comment by AmericanChopper | Hacker News Reader

This is one of those nice ideas that has some pretty serious hidden costs. You’d struggle to compare healthcare in the US to other countries, because the quality of healthcare available (talking about availability, not accessibility) in the US is generally superior to other countries. So you could end up simply eroding the quality of care in the US. Another thing people tend not to talk about when discussing healthcare in the US is how much the US contributes to medical research and innovation. No other nation on earth even comes close. If you adjust the system so much that you remove the incentive to carry out that research, then the quality of care in literally the entire world would suffer.

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I disagree about quality/availability. In Japan, Taiwan, Mainland China, Thailand; I’ve had amazing health care for the fraction of the price. Shit, a full cancer check only cost me 90 dollars in Japan. Getting my eyes fully checked for retinal tears cost me nothing due to national insurance in China.

In some cases, maybe the US has better care. But the cost of that is just way too damn high.

Yes, medical research in the US is superior, but that shouldn’t be at the cost of peoples’ lives.

In the developed world, the price of routine checkups are not what people would generally be referring to when discussing _quality_ of healthcare. Generally speaking, the US has the best facilities, technology, expertise and pharmaceuticals available. Which is why people come from all over the world for procedures that simply aren’t available elsewhere. Again, I’m not talking about the problems with accessibility, merely talking about available treatments.

Reducing investment in medical research will absolutely come at the cost of people’s lives. More people’s infact, as anybody will die from a terminal illness that doesn’t have a treatment. As an example the US market constitutes something life 70% of _global_ pharmaceutical profits.

This weird argument pops up regularly. In relation to New Zealand (where I am) it’s argued that the US is subsidising the cost of drug scripts. It’s beyond me quite how NZs drug buying agency is running roughshod over the rights of drug companies that have multiple insurance companies in the US that are bigger customers. What’s the agenda behind this argument?

There’s no agenda behind it at all. If profits in the US market go down, they either have to go up elsewhere, or investment has to go down to match. This is very basic maths.

This argument does not at all reflect the actual revenue model of pharmaceutical companies here in the US.

In the private sector, far larger amounts of funding are spent on marketing than research[1]. The basic maths shows: investment in research can be maintained or even increased while providing greater access to the fruits of that research.

The money is there. What we lack is the proper incentivisation.

1. https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-p...

The U. S. is the last place drug companies can get away with it, is what the agenda is. Americans are suckers for a good capitalist argument. “U. S. customers pay more because they have to subsidize those filthy socialists.” Imma gonna have to call bullshit. You’re telling me you sell to NZ at a loss because...New Zealand tanks will roll up to your doorstep if you don’t? Does New Zealand even own a tank? No, you sell to NZ because you somehow figured out how to profit from doing so.

But as we see above, plenty are willing to carry the water of the poor, downtrodden drug companies.

>No, you sell to NZ because you somehow figured out how to profit from doing so.

The incremental cost of selling drugs you’ve already developed is quite low, so of course they can still profit from them in less profitable markets. But it’s the US that’s paying for them to be developed. This isn’t even up for debate, R&D in the US dwarfs everywhere else.

The flaw in this is that for-profit medical research optimises ... for profit, that is, the treatments for which most can be charged.

So they focus on illnesses of the rich gerontocracy while diseases of the developing world have to be addressed by public funding. Additionally, there's no real incentive to work on cost reduction.

The US health care is optimised for the the p99, top 1% of the population who can afford anything. The other countries you mentioned optimise for the p50, the average person.

p50 would be the median, surely?

Technically, mean, median and mode are all averages. Handily, parent clarified what they meant.

In my experience, Russia had a decent healthcare system in the Soviet era. Care was (obviously, I guess) pretty much free. Most physicians were female. And most of them were apparently driven by moral conviction.

The US was rather a shock for me. Costs were mind-boggling, and most physicians struck me as jerks. At least, the male ones did, and they predominated. Nurses, on the other hand, generally seemed OK.

Somehow the US healthcare system seems to attract jerks for physicians, and they seem to be mostly in it for the money. Not all of them, obviously. But enough to set the standard.

I have no clue how that happened. Or how to reverse it.

Edit: Some might ask why being "in it for the money" is bad. I mean, that's what "free enterprise" is about, isn't it? But think about it. Is it OK for priests/minster/rabbis to be "in it for the money"? Or politicians? I hope not. And then, why physicians?

This is anecdotal. To counter, my family have had very good overall experience with physicians in the US. Moreover, my college friends who went on to become physicians are all people I'd happily take my own family to see.

One of the problems with care in the US are clinics that treat Drs (and NPs and PAs) essentially as billing machines, and don't allow them any time to build any rapport or relationship with patients. Depending on your insurance coverage, your location, and your needs, your experience will vary wildly.

Yes, it's just my experience.

For what it's worth, my experience teaching premeds was also not so great :) That's also anecdotal. But colleagues had similar complaints.

Also:

> And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. ... A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.

> The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies.

> Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians.

https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...

Also see https://www.politico.com/agenda/story/2017/10/25/doctors-sal...

Medical research in the US comes out to something like $500/year per capita. It’s doesn't come anywhere close to accounting for the cost differences between the US and other first-world countries.

I didn’t say research alone did. I said that when you compare investment in research, as well as the quality of care, you’d expect the cost of healthcare in the US to be higher. As much higher as they are? I don’t think so. But if you want to fix the accessibility issues without impacting innovation and quality of care, then you’re going to need a solution slightly more thought out than hamfisted price fixing.

> as well as the quality of care, you’d expect the cost of healthcare in the US to be higher

If the quality of care is so amazing I'd expect Americans to have longer life expectancy, and they don't.

As a parent poster noted, the system is optimized to provide amazing care for the people who can afford it ... and those people do have longer life expectancy.

https://www.vox.com/science-and-health/2018/1/9/16860994/lif...

You're implying that both the quality of care and the amount of medical research done is a result of the profits of the medical companies. I'm not sure that this is the case.

Profit is the only thing that drives investment in care and research. You’re asserting that you can reduce profits via price fixing and still deliver the same outcomes in both care and research.

Whose profit?

If you refer to the professionals’ compensations that’s correct, but not that useful as it applies to all of the adult working population.

If you’re referring to the capital accumulation of investments in healthcare companies, you’re off the mark, as there are several examples that falsify your statement, even in the US

Profit is the only thing that drives investment in care and research

This is manifestly untrue in so many domains, including medicine. Most research is heavily government funded, particularly pure research, and most academics are not interested in profit. The only orgs motivated by profit (drug companies, insurance companies) are the ones who push this misconception, because they profit from it. As one example, the UK runs large trials comstantly to improve care, without a profit motive.

Nobody has to postulate that price fixing (as you call it), or single payer healthcare without insurers works better, because the rest of the developed world outside the US uses that system and delivers very similar outcomes for radically lower cost. The facts are clear.

I disagree from personal experience. Location of where you are in the US matters. I'm in Montreal right now and the mental healthcare here is superior than what I experienced in the US in Michigan (majority of my life). I would even go as far to write the mental healthcare in USA, which I received ruined my life. If only I had the pleasure of what is available in Canada for my whole life.

The further toward the poles you go, the more mental healthcare is needed, so it makes sense they would have the experience and infrastructure! (Completely serious.)

This isn't necessarily the case with my situation. There was only one hospital for where I lived in Marquette, Michigan. My mental healthcare was pertaining to gender dysphoria and not depression which I think you're associating with longer winters. Anyway place I grew up was filled with religious nuts to make things short. They forcibly prescribed me with antipsychotics while ignoring my right & modern medical approach of gender dysphoria. Montreal is a large city compared to that place and is progressive like California. So basically where you're located when it comes to social structure is huge.

I think small rural town versus major metro center has more to do with the quality than US vs Canada.

It’s no different in Canada - small towns don’t offer as good of care particularly when it’s something that’s not common.

I think I might have heard this at some point in the past.

Anyway, I found a reference to support your claim:

Also consistent with the conclusions of Torrey1 and Saha et al,2 our analyses shown in table 3 found a strong tendency for prevalence to increase with latitude.[1]

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669590/

I'm not aware from the article of how the illness "schizophrenia" foreshadows all of mental health. My illness being Gender Dysphoria.

Vitamin D deficiency from what I've read is common everywhere. It does make sense that longer winters would impact a person such as staying inside more. Yet I doubt any evidence can confirm lack of Vitamin D is associated with the illness schizophrenia.

Ah, yeah, that's a good point. Schizophrenia is probably a poor proxy for all mental illness.

And there's probably at least quite a few things that aren't mental illness that benefit from mental healthcare.

The Indians have better cardiac surgery outcomes. I don't care about anything but outcomes. It's no surprise, though. Their guy has done 150 surgeries in the last year. This guy has done maybe 40. No good. If things are so much better here, why are outcomes not as good? IMR, MMR, even with companies that have comparable or stronger definitions.

The evidence is constantly against US healthcare except for experimental or rare treatments. The doctors aren't any worse, surely.

At the top end, this will be true. Surely, a well-trained surgeon is a well-trained surgeon and mechanically they should all have roughly equivalent skills. The difference lies in experiential knowledge: knowing what to do whilst in a surgery, based on practical experience and seeing similar patients. We've interviewed four of the top pediatric cardiology centers in the past two months, searching for the best treatment option for our daughter, and only 1 of them has a research focus in the needed area, accompanied by a specific treatment protocol and specifically trained staff. That's not because the other hospitals are "worse". It's a result of our daughter's need being extremely rare, with very low demand. Even the above-mentioned hospital only sees ~1 patient per month (compared to maybe 1 per year or fewer at the other hospitals).

I 100% agree: experience is key ... but so is a clinic's/hospital's internal investment in any given speciality. And if it's a teaching/research hospital, so then is publishing by its clinical experts.

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