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Comment by nicoburns | Hacker News Reader

For comparison, in the UK we spent £197.4 billion in 2017, or approximately £2,989 spent per person [0]. Which works out as:

~£250/per person/per month. Which is $330. Or $350 adjusted for inflation since 2017.

That covers everything: emergency room, ambulances, giving birth, cancer treatment. Everything: no copays (except very small ones (<£10) for prescription medicines). And it covers the entire population.

* Except dentistry. For some reason that is separate.

[0]: https://www.ons.gov.uk/peoplepopulationandcommunity/healthan....

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Its also fascinating to note that US public spending on healthcare is greater than the UK, both in terms of absolute numbers and as share of GDP [0].

[0]. https://www.bbc.com/news/uk-42950587

Just the tax subsidy for employer-sponsored health insurance costs the Federal government $273 billion per year: https://www.taxpolicycenter.org/briefing-book/how-does-tax-e...

The US healthcare system is a Rube Goldberg machine.

Tax deductions are not costs. They are shifts in weighting between taxpayers.

What? Tax deductions absolutely are costs. They are represented as expenditures on the Federal budget. The deduction isn’t a default, it’s an affirmative benefit by the Federal government, and one that causes a heavy market distortion.

The not-so-secret reason the business community is fighting single payer in the US is because 18-20% of our economy depends on the healthcare industry. A good portion of that is paper shuffling, marketing, accounting, and related middle/upper management -- they would serve no purpose in a system where you show up with identification, prove you're a citizen, and then get healthcare. So single payer means maybe 8-10% of the country is out of a job.

That's why Medicare/Medicaid is cheaper per person even though they serve the poor and elderly.

Sometimes I wonder if the way to make changes in these sorts of industries (with a powerful rent seeker that prevents change... e.g. health insurance, tax prep, etc) is to bite the bullet and just agree to bribe them... say, "we are winding down private insurance... we will pay you guys what your profit has been each year, diminishing each year, for the next 10 years. You can take that money and try another industry."

It might seem expensive and wasteful, but it might be better than the status quo.

Not trying to draw too much of a comparison here, but Britain did this when they formally abolished slavery. It's still very controversial today, but it did thwart the opposition to abolition among Parliament's pro-slavery lobby and plantation owners, particularly in the Caribbean. Paying off health insurers for years' worth of profits would be very expensive, but on the flip side I doubt it would be as unpopular as the slavery payments.

https://en.wikipedia.org/wiki/Slave_Compensation_Act_1837

I believe that's called a transition period and we saw how it worked with Obama care.

We could also drag the obstructionist leeches into the capital and roast them like Jim gaffigan just roasted Karen.

When someone's abusing an entire country you don't pay them to stop, you throw them in jail. People are dying are dying by the truckload and we care about

Or just roast them considering the number of people that are dying every year due to their greed.

That's how Japan abolished the samurai. The Meiji emperor promised very generous pensions to all samurai if they turned in their swords and retired.

A few years later, there was a budget crisis and the government cut the pension to a fraction of what was agreed on. But the ex-samurai were too demobilized to overthrow it by then.

Insurance companies are already making money from Medicare, and not just on Medicare Select. The Feds pay the bills, but there are 5 regional contracts under which private insurance companies actually administer Medicare.

If you work for a large company it’s pretty much the same thing. Your employer brings a risk pool and then a private insurance company like Cigna quotes for how much it takes to “fill” it while taking their vig.

I would expect the same under M4A: 5 really big insurance companies would continue to cost-plus bill the Feds, and then maybe there would still be a few re-insurance companies to cover stuff M4A doesn’t cover.

Probably applies to other cases as well. I think many people would be ok with "ok Disney, you have Mickey mouse exclusivity for 200 years if you stop messing with copyright extensions".

> maybe 8-10% of the country is out of a job

what do all these people do in the UK, Scandinavia and other countries with single-payer health care?

Hopefully something more useful but the point is that nobody wants to be the administration that created 10%+ unemployment overnight and the ensuing ripples.

Instead of employing them to shuffle paper, we could just directly pay them to burn money?

They work in small businesses or for themselves[1] because they don't have to worry about health insurance. Or they become a teacher[2]. Or they don't have to work at all because they are raising kids or getting a better education - again, because they don't have to worry about health insurance.

Eventually, they would join other parts of the economy in the US, but in the short term, the unemployment rate would spike and the economy in general would suffer.

[1] https://www.cepr.net/documents/publications/small-business-2... [2] https://www.nationmaster.com/country-info/stats/Education/Se...

> Eventually, they would join other parts of the economy in the US, but in the short term, the unemployment rate would spike and the economy in general would suffer.

And if an administration managed to get this through in the beginning of their first term, they'd never get re-elected, and most of the Congresspeople who supported it would be out as well. The next group voted in would dismantle it and put things back the way they were.

Any plan to dismantle the US private insurance industry will need to ensure a very soft, cushy landing for the people employed in that industry, or it'll never work.

My mom worked very hard and well for a company that administered benefits for union employees. The way that things worked would be that if you worked at least a certain number of hours in January you would have medical insurance coverage in March. But not February. If you worked the required number of hours in February, you'd be covered for April. And so on.

In going through her things after she died, I found letters to her bosses about how well she'd treated the plumbers, electricians, etc. I know she would take work home and do it off the clock.

What was really unfortunate, for me, is believing that her job shouldn't exist. To me it's crazy the expenses we have a universal healthcare system.

Of course, that also applies to avoiding taxes, etc. There was an attorney interviewed on a recent podcast about tariffs - he specialized in finding things like shipping bikes from China without tires and the tires from Vietnam would be much less in tariffs than just shipping from China.

Medicare/Medicaid is cheap because it is legally required to be the lowest price, so providers make up the cost by raising prices for other users.

Medicare for all wouldn't put 10% of the population out of a job. Not even close. Also, Medicare/Medicaid are cheaper primarily because they pay providers a lot less than private insurers for the same service.

> Also, Medicare/Medicaid are cheaper primarily because they pay providers a lot less than private insurers for the same service.

Do you have numbers to back this up? I'm not saying you're wrong, but my mom worked for a GP for ~20 years (recently retired) and listening to her talk about it this was not true for her employer at all. She said that in many cases the private insurer paid less, and on top of that required more back and forth to get claims addressed.

That is the the exact opposite of my parents, who are both doctors.

https://www.google.com/search?q=medicare+vs+private+insuranc...

I'm not trying to be an ass, just trying to point out that many, many sources all say the same thing.

Well we were 15% unemployed not too long ago...

The median salary in the UK is £24,400 (ONS, 2018)

    +£2,033 paid per month
    -£  149 national insurance (healthcare, welfare, etc.)
    -£  198 income tax
    =£1,686 take home pay (=$2,224)

The median salary in the US is $49,764 (BLS, 2020)

    +$4,148 paid per month
    -$  317 social security 
    -$  357 federal tax
    =$3,474 take home pay

=$1250 per month in favour of the US median earner.

$1250 per month should go a fair way to covering health insurance premium, deductible, co-pays & drugs (these are all £0 in scotland)

For comparison purposes, it's useful to think of things like retirement contributions and healthcare premiums as taxes, even if they're not formally taxes. There is an article comparing this across countries that argues that if you take this view, US taxes are actually pretty high, because our health insurance is so expensive. https://www.peoplespolicyproject.org/2019/04/08/us-workers-a...

For national financial comparisons - sure.

The real difference, of course, is that taxes will ensure you're covered even if you're low income.

In the US, you're already covered if you're low income, through Medicaid and ACA subsidies, that's part of where the current taxes go. It's certainly debatable if the existing programs are optimally structured.

Do you get the same level of cover when you’re low income?

Ironically, you get some of the best coverage when you're low income, since Medicaid is so generous.

> In the US, you're already covered if you're low income, through Medicaid and ACA subsidies, that's part of where the current taxes go

Talking to low income folks, it's not the same as in other countries. They still have financial stress because of medical concerns.

Medicaid experience differs greatly depending on the state you're in. And how it compares with people who have the means to buy insurance also varies quite a bit.

In general, Medicaid is one of the more generous health insurance plans available in the US. The maximum nominal deductible is $3, and the maximum nominal copay for managed care is $4. For drugs, it’s around the same: $4 for preferred drugs and $8 for non-preferred drugs.

There’s certainly variation in who can qualify, per State; some States are more generous than others. It’s debatable whether it makes sense to even consider the US as a whole, since it’s really a heterogenous collection of 50 self-governing sub-cultures. The Canadian healthcare system for eg is also provincial, with the Federal government providing minority financial support. It’s actually more Province-driven than Medicaid is State-driven, today.

You can also make the taxes progressive, so wealthier pay more. I'm also not sure if this looks at total costs or only premiums. People don't go bankrupt or have surprise bills [1] for medical reasons in other countries the way they do here.

[1]: https://www.marketwatch.com/story/1-in-5-americans-get-hit-w...

While that may be true, its also true that people from all over the world come and pay airfare, stay, and tens of thousands of dollars to get procedures done here.

For example, Canadians going to https://surgerycenterok.com/

Here is another fact. The above has had transparency in prices since it was founded in 1990

Guess what also has not changed: the price that they charge for every single procedure since they were founded. In fact they technically charge less now because some procedures include additional services that were originally not part of the package.

So why is it that 1 clinic does not need to change pricing in 30 years, while everything else is increasing at 5-10% per year?

Hint: you dont have to throw away the baby with the bathwater. Its possible to have a system that is not going to bankrupt you and also at the same time not make you wait for 3 years for something you need today

While it's true that the UK has recently made itself a lot poorer, these kind of direct comparisons don't really capture the differences in living costs between countries since most expenses also scale with median earnings (rent, services, domestically produced goods.)

Consumer goods made abroad are incredibly cheap in the US in comparison to the UK, but as a Brit living in the US I definitely relate to this observation I recently saw go by:

> As a friend of mine from abroad who lives here put you “you don’t really get that there’s a really high standard of living and nothing works“

- https://twitter.com/__seab/status/1298342388537139200

If you make too much below the median salary in the US, you probably still can't afford health insurance.

Also consider that everything isn't covered when your employer pays for your health insurance. Americans still have a lot of out-of-pocket costs.

And remember that there are a lot of people who are unemployed or underemployed, or work under arrangements that don't provide them health insurance at all. They also probably make a bit less than the median salary. So sure, maybe 50+% of the US could afford their own health insurance, but is it ok there's some percentage, regardless of how small, that can't afford it and has to do without? I say no.

> Also consider that everything isn't covered when your employer pays for your health insurance. Americans still have a lot of out-of-pocket costs.

I have a doctor I see every 4 months. I mentioned to her that I thought my copay probably was about what she was actually making off my visit and she said, 'if that'.

She also said insurance companies are now doing things like not approving full scripts for insulin. And demanding that she prove a 50 year Type I diabetes patient still needs insulin.

If you make too much below the median salary in the US, you either qualify for Medicaid (at best) or direct ACA subsidies (at worst).

Sure, but there are several bands of income levels where you're basically screwed. The ACA subsidies have some phasing in/out based on income levels, but they're far from perfect, and depend on often-unreliable definitions of the "poverty line".

I think you're mixing up full time salaries and all salaries. For full time in the UK in 2019 it was just over £30k meaning a take-home of £2018 per month, $2662 at your exchange rate.

Still lower, we're a poorer country, but it is quite a difference.

You think that's cheap? Singapore's total per capita health expenditure in 2017 was $2,619[1] per person per year, or $219 per month.

It's just about the lowest per capita health expenditure in the developed world.

[1] https://knoema.com/atlas/Singapore/Health-expenditure-per-ca...

To compare apples to apples, note that the American number is just the premium. In my case for example, I need to spend an additional $6800 before the insurance kicks in and starts paying out.

It's more complex than that. Certain services are built into the premiums.

An annual primary care visit, cancer screening, vaccinations, and so on. So for example if you have medical need for a colonoscopy, it will be covered before the deductible has been met.

Yes, but in a system with national health case, the preventative care would be covered as well.

Preventative care is covered in the US as well, at no cost

Precisely, so why does this matter to the point at hand?

“I need to spend an additional $6800 before the insurance kicks in and starts paying out.” This line isn’t accurate, insurance in the U.S. is required to pay for some things at 100% before the deductible is met.

"To compare apples to apples..."

> Except dentistry. For some reason that is separate.

Would the reason be that British teeth are maintained like American waistlines?

It might be part of the explanation, but I think it's also cultural. People just don't care about good teeth here the same way that they seem to in the US. Or rather: they have a different idea of what good teeth are. If your teeth are actually black or rotting or missing, then that's seen as bad. But a little crooked or yellow is mostly seen as normal.

Teeth seem in the USA to be a class marker, where in the UK class markers are different (used to be accent when I lived there aeons ago).

This seems a little cliche. Personally I find the brilliant white beacons people have in their mouth in the states a little unsettling. Teeth aren’t naturally a beaming snow white - they’re bone coloured.

The Brits have better average tooth health than Americans. They don't go for orthodontia as frequently, but in terms of cavities and missing teeth, they do better.

This is largely explained by economic differences in the US. The poor have awful tooth health; the wealthy have very good tooth health. In the UK, the poor and wealthy are closer to the median.

https://www.cnn.com/2015/12/17/health/british-american-bad-t...

It appears that the obesity rate in the UK is about 30%, whereas in the US it's around 40%. For historical context, it seems that the US was at about 30% roughly around 2000.

So I guess that the US is fatter, but the UK is still one of the fattest countries in the world. The BBC claims the UK is getting fatter faster than the US too.

https://www.bbc.com/news/uk-41953530

http://www.oecd.org/unitedkingdom/Health-at-a-Glance-2017-Ke...

Teeth are probably a myth. People see Americans on TV, of course they do extreme things to make them blindingly white.

Another Brit here - wow, I had no idea the NHS was so cheap! The NHS is far from perfect, but £250/m per person seems like a bargain for what it provides. When you put that beside the US system, the US system seems even more insane.

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