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Comment by _delirium | Hacker News Reader

Even though I've been researching with interest, so far I haven't run across much in the American healthcare system that makes me question my decision (as an American) to move to Denmark. My taxes are higher, but my costs are very predictable, and by design cannot ever bankrupt me: I pay a flat 8% of my income to support the national healthcare system. I won't end up with a charge equal to 20% or 50% or 500% of my income in any circumstance, not even if I get cancer or find myself unemployed. So it's guaranteed that I will always be able to pay my healthcare costs without great hardship.

I do hope someday to move back to the USA (mix of language / "feels like home"), and am mildly hopeful that PPACA will make it feasible, by 2014, for an individual to buy private health insurance without worrying about preexisting conditions and rescissions and whatnot. But we'll see. For now, Danish is growing on me. :P

Incidentally, this kind of emergency care would be free even for a tourist in Denmark. Regular use of the national health system is only available to legal residents, but acute emergency care is considered a basic service not subject to billing, like police and fire response.

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8% sounds great. US currently spends around 16% of GDP on health care every year. I think the majority of Americans would support a universal health care system that provides far more coverage at half the cost. Instead our total spend is expected to double by 2020.

Source: http://money.cnn.com/2011/07/28/news/economy/healthcare_spen...

Worth noting that the US leads Europe in outcomes for serious illnesses (particularly cancer), and the US provides access to specialists in days where other countries often have multi-week or even multi-month delays.

Careful--the US does more early cancer screening than is typically done in Europe. This boosts the US score on 5 year survival rates, but it doesn't necessarily mean we actually get better outcomes. E.g., if an American and a European each get a cancer that will eventually kill them in 7 years, and the American finds out in 1 year and the European doesn't find out for 3 years, then the American will show up in the 5 year survivor statistics, and the European will not.

We do gain some outcome advantage from earlier screening, in that it means we will catch some cancers early enough to treat that Europeans would miss, but the outcome differences aren't nearly as big as the 5 year survival stats lead some people to believe.

As far as seeing specialists goes, the US does do well, although I believe Germany and maybe Japan have us beat--showing that universal affordable coverage can be achieved without having to give up reasonable wait times to see specialists.

The thing that makes me sad about the US system is this. Take the top, say, 10 non-US systems. They have quite a diverse range of approaches, ranging from straight up socialized medicine to highly capitalistic market-based systems. All they have in common is that in most areas they have equal or better outcomes than the US, with universal or near universal coverage, for a lot less cost per patient or as a percent of GDP. Based on the evidence, it doesn't appear hard to design a good healthcare system for a first world country. Only the US seems to be able to botch this. WTF!?

By what measure do European countries have better health outcomes than the US? We're seeing in this thread why the most obvious metrics don't work well:

* Cancer survival rates, because of the 5 year survival heuristic, capture people who's illness is detected early but isn't actually cured.

* Life expectancy captures the fact that people drive more and faster in the US, that the US has more violent crime, and that more people in the US kill themselves

Intuitively, "high cost" plus "shortest wait time to specialist" plus "problematic overprescription" (a problem common to all first-world health systems) plus "earliest cancer detection" just doesn't add up to "worse outcomes than Europe".

But, it does make sense that despite the money we pay, our outcomes are not different enough to justify the expense.

I strongly agree: the way we finance health care in the US, primarily through a system of employer-provided health insurance policies that give way to a single-payer socialized system that kicks in right when patients are most engaged with the health care system, all without giving patients control or a stake in the cost of their care --- this system makes no sense.

Yes, but, europeans generally see a healthcare provider more often and are more often diagnosed before they reach an acute stage. If you look at the graphs [1][2][3] that compare per capita expenditures per country with life expectancy per country. You'll see that they are generally getting equivalent or better outcomes at less than half the cost.

And I can tell you that for my own part, even with health insurance, the deductible is so high that it might as well not exist as far as basic checkups and doctor visits go.

1 http://ucatlas.ucsc.edu/spend.php

2. http://blogs.ngm.com/blog_central/2009/12/the-cost-of-care.h...

3. http://www.economist.com/blogs/buttonwood/2011/03/health_cos...

Life expectancy is a poor proxy for health care effectiveness. By some methodologies, once you take out things like auto accidents, the United States snaps right back into first place in those rankings. Meanwhile, in disease-by-disease rankings, the US routinely leads.

We do spend a lot for health care in the US, and we probably aren't realizing comparable value, but it is also probably not true that the actual quality of care in the US lags that of Europe.

Why is it a poor proxy? What would be a better one?

Something that wasn't confounded with deaths by suicide and high-speed automobile accidents, both of which are so anomalously high in the US that when you factor them out of life expectancy the rankings are totally different.

Say what you will about the worldwide quality of mental health care, but there's not a whole lot a good hospital can do once you've set out to harm yourself, and that one particular tragically underserved health problem is not what people are thinking about when they suggest "Americans pay more money to get less than what Europeans do". That last notion is dubious at best.

> the US provides access to specialists in days where other countries often have multi-week [...]

This is a view that's strongly distorted by the UK. It's seems to hold there, and the wait times sound terrible, but it's definitely not the case in the majority of countries, by a long shot. As far as I can tell from personal experience, wait times are not an issue in The Netherlands, Sweden, Germany, or France; outside of that I've never heard of really long waits in any country of Europe, with the exception of the UK.

The European systems are all different in sometimes surprising ways, throwing them together into one bucket is an incorrect generalization. E.g. the UK system with the NHS is entirely tax funded, where the Germany system has insurance paid 50/50 by employee and employer, and the Swiss system has 100% privately paid but mandatory and state regulated insurance.

These are really massively different systems, and the effects on e.g. waiting times are huge. They are all state regulated and sometimes state funded, but that's by far not the only interesting characteristic of medical systems.

For procedures that aren't time sensitive, like eye surgery, wait times in France are upwards of 2 months.

I don't know what Germany's wait times are, but Germany isn't a pure single-payer system like France, the UK, and Canada; it's guaranteed-issue mandatory-coverage.

The great thing is that this expense grows at a rate of 9%/year while the economy is stagnant. If GDP miraculously and immediately begins to grow at 5%/year, health care spending will completely eclipse it in 50 years. If it does not, health care spending will completely eclipse it in 28 years.

Herbert Stein's Law: "If something cannot go on forever, it will stop."

The only question is how the rate of growth will slow/stop.

Should be noted that there is not a direct correlation between tax paid for health care and cost of health care. It's heavily subsidised by the government, from taxes taken elsewhere.

In Norway it's like this: Senior citizen: 4,7% Employed: 7,8% Self-employed: 11%

Last time I checked we spent around 9% of GDP on healthcare.

Having experienced emergency care in both Denmark and the U.S., this is also the main reason I won't relocate to the U.S. until this is sorted out. I had what was thought to be a broken ankle in Denmark thanks to icy conditions and I was so well looked after, and charged nothing, I was awe inspired and wish there had been some way to pay it back. I sliced a finger in the U.S. and was made to feel like a statistic, with a $1000 bill. Thanks to inexpensive travel insurance that cost me just $100, but how I am supposed to feel when my travel insurance is less than quarter of the price that actual insurance would be if I lived there?

(Edit from reading other comments: probably not charged in Denmark because of European health reciprocity, but they never verified this at the hospital).

It's not fair, and not right, but it is a fact that for the most part, most of us here don't have to worry about that.

If you're a software engineer or systems administrator or similar type of professional earning a fair living it's not at all uncommon to have completely free health insurance for yourself, and affordable options to cover your family. I haven't worked for a place with an individual premium in 5 years.

Again, not saying the system isn't broken, but rather that there's a reason all Americans aren't vocally supporting the ACA and the president: this is mostly a lower-middle-class-and-below problem

It's a huge problem if you want to start a company. It's an even bigger problem if you want to hang up a sign and do business as a freelancer.

I agree with your point: the reason the country isn't completely behind health care reform is that they get it from their employer and don't understand how it works. Of course, they're also getting screwed financially in the process.

As others have said, it's a problem for anyone who wants to do work outside of the "middle class employment cocoon".

I'm self employed, and even if I go back to working for a larger company, I would prefer to continue to keep my private insurance. I have private homeowner's insurance. I have private car insurance. I have private life insurance. Why oh why do we demand/insist that employers provide health care, to the detriment of market forces favoring individual purchasing?

Conservatives in this country should be in an uproar that the 'free market' isn't allowed to run its course because of the combined interference of big business, big labor and big govt over the past several decades, but they're not.

> Conservatives in this country should be in an uproar that the 'free market' isn't allowed to run its course

Because unlike cars and homes you only have one life. If you let a profit seeking entity control and dictate what happens to your health, you might not have a chance to go back fix the problem by choosing a better one. You could be dead.

There was just recently a story on Reddit about someone who's relative a was killed by a driver and his dead relative' insurance company effectively provided council for the defendant. That's the kind of stuff you'd be dealing with. You health insurance company would be interested in killing you promptly as soon as you develop a chronic or expensive condition. And they'd all want to do it. All 1 of them after they merge into a giant conglomerate (since you know can't be messing with the free market and stuff, there will be nobody protecting against monopolies).

I agree, and I feel it used to work even better in that respect, when educated Americans typically had lifetime employment. I would guess that's one reason the debate is growing louder lately. The West basically solved the healthcare problem via collective coverage, but in different ways: the European countries did it nationwide, but the US did it with employer group plans. That was almost equivalent, for people with good jobs, as long as people stayed in jobs for life: having the IBM group plan was about as good as having state health coverage, as long as the IBM job was more or less for life.

It's more broken if you're middle-class-or-below (as you mention) or an entrepreneur who isn't either early-20s-and-healthy or raking in huge piles of cash. The part that seems most out of keeping with the American ethos is how anti-entrepreneur it is: you get good collectivized coverage if you work for IBM or Microsoft or Google (because it's socialized across their employee base), but if you start your own company or are trying to buy insurance for a 10-person company's employees, well then you're screwed.

It's not hard to get insurance for a 10 person company, but it is expensive.

Interesting. I mostly know people trying to buy individual health insurance, whose difficulty really varies, depending on age and health history. Is even a 10-person company big enough that buying it isn't a problem, if you're willing to pay the "10-person company" premium? In particular, do they inquire into the distribution of health among those 10 people? I would've guessed that if 1 of your 10 employees happened to have some disqualifying condition you'd be SOL.

Not entirely a theoretical question, b/c one of my friends has a congenital heart defect, and is himself not 100% sure how his condition would impact a small company. They aren't allowed to inquire into such things when hiring, but could it possibly tank their group health-insurance plan, if 1 of [small-N] members had a major preexisting condition?

You can get group coverage (by which I mean, "insurance plans in which individual members of the team will not need to fill out applications") for teams smaller than 10 people, but probably not much smaller.

In the US, group health coverage is distinguished in part by not "qualifying" patients, so that latter example doesn't really come up. There are horror stories about companies being forced out of their insurance plans by prohibitive cost spikes after major medical events, but I don't have any of them ready to deploy on this thread.

I disagree. It's really common for small software companies not to provide insurance, and of course anyone who wants to strike out on their own, either selling software or contracting, has to deal with the question. I would wager that the average programmer is more exposed to the problem of health insurance than the average.

Having experienced emergency care in both Denmark and the U.S., this is also the main reason I won't relocate to the U.S. until this is sorted out.

LOL. Go to the emergency room now in the US, with a real emergency, wait for hours. After this is sorted? Wait for days, maybe?

Our health system is completely broken in every way, and building up more bureaucracy is just going to make it worse.

I am counting on hospital visits not even being an option in the future, in the US.

Exactly what part of an emergency room visit is going to change in 2014, when PPACA is fully implemented? Please be as specific as you can, while limiting the detail you provide to the "amount of time taken to see someone at an emergency room" example you've used in this comment.

I expect the continued growth of socialized medicine to continue the trend of less and less competence among medical professionals, and less and less medical professionals period (particularly doctors--which seem to be in acute shortage already). So, nothing will change overnight, but this certainly isn't going to allow things to get _better_, which would eventually happen in a more free-market medical system.

Americans are exceptionally good at everything the free market touches (consider the tech world). Medicine could, and should, be a lot like going to the vet. Extreme competence, speed, and low price. The difference? There honestly isn't that much of a difference, except veterinary practice is pretty much a free market.

By the way, I've personally been forced to undergo unreasonably waits at the ER (I was kicked out of the building by a security guard because I wouldn't take a seat or stand - I couldn't physically do either, and I went and laid down in a parking lot outside). I've also seen a loved one hurt--potentially very severely over what could have been the case, but who knows--by not getting competent attention during a stroke. And there is at least one other bad story I won't get into here.

By the way, I do think my stories are representative of a larger trend. The above-mentioned incidents occured in different hospitals mixed between the east and west coast. That still isn't enough to prove anything. But I'm hearing complaints from a lot of people. Also, if you talk to someone applying to med school, you'll see that the number of doctors is being artificially restricted.

The public discussion about healthcare is missing a huge component, which is: why is our healthcare so completely shoddy and incompetent today? What can we do to change that? And, why aren't there enough doctors? I'm talking totally independent of the _cost_, which admittedly is also a problem.

"Medicine could, and should, be a lot like going to the vet."

Yeah, and patients whose cures are more expensive than they can afford should be put down painlessly, eh?

There are some aspects of health care where free market mechanisms can improve efficiency, but efficiency is not by itself the ultimate goal a health care system should have.

How much does it cost to treat a dog for the most serious medical problems, like cancer? I bet it's trivial compared to the cost of a human. I bet it's so little, that we could actually think about treating everyone for everything, if we could get human treatment to that level of efficiency.

Seriously, it's the most humane way to go.

In the meantime, I'll be thinking about going to India if I or loved ones need serious medical care.

It seems that most people get confused between ER & "trauma" service. If it was a "real emergency" (chest pain/stroke etc) the patient would go straight to the trauma service. Not so critical emergencies are treated in the ER, and that can involve 3-4 hour wait.

Quite a few hospitals with ERs also have a 'urgent care' or 'express care' clinic attached which are quite effective as they can a lot of things a ER can do, and expedite transfer to the ER if can't be treated there.

What is your legal status in Denmark, and how did you achieve it? Are you a "resident alien" or an immigrant or what? What restrictions/hoops did you have to jump to get permanent residence status? What did it cost?

Unfortunately it's not the most friendly country for immigration, partly as a result of the right-wing coalition that tightened rules over the past few years (Sweden is better, as far as the Scandinavian countries go). But there are some exceptions: it's easy for EU citizens (due to being in the EU), and it's easy if you have a professional-level job offer (no US-style H1B quotas).

I'm a researcher hired by a Danish university, which made for a fairly easy fast-track visa under the "researchers scheme" [1]. In fact the entire process was by mail and took one round-trip: I mailed my passport, offer letter, photos, and application to the NYC consultate, and they mailed back my passport with a visa pasted into it. Most professionals with an offer will also be able to get a visa; it's not nearly as restricted as getting U.S. visas is. If you have an offer that pays more than 375,000 DKK ($63,500), you qualify under the "pay limit scheme" for similarly preferential treatment [2]. Getting permanent residency depends on if you're an EU citizen. If yes, it's just a matter of remaining in the country as a legal resident for at least 5 uninterrupted years. If you're from outside the EU, there are more requirements [3], including that you must be employed for 3 of the 5, and must pass a language exam establishing basic competence in the language (which is unfortunately quite difficult to speak, though the grammar and vocabulary are not particularly difficult).

I must also give them kudos for giving all of this information in not only English, but straightforward, non-legalese English. Dealing with the Danish state is generally not a horrible experience so far, even for someone who speaks no Danish.

[1] http://www.nyidanmark.dk/en-us/coming_to_dk/work/researchers...

[2] http://www.nyidanmark.dk/en-us/coming_to_dk/work/pay-limit-s...

[3] http://www.nyidanmark.dk/en-us/coming_to_dk/permanent-reside...

I don't entirely understand the permanent residency for EU citizens part. As far as I understand, EU citizens have work permits and no restrictions on residency in all European countries, what would permanent residency get you on top of that?

The "free movement of labor" in the EU isn't a completely free right to live anywhere and be treated as a resident. Every EU citizen has the right to reside in another EU country for up to 3 months for any reason, and to be hired without having to apply for a work permit. But after 3 months they must register, subject to certain restrictions of the host nation, usually that the person must either have employment, be a student, or be able to show that they have sufficient funds to support themselves. In that case they get a temporary residency status that allows them to live in the country and be treated as a resident for certain purposes (such as healthcare).

Permanent residency removes any qualifying requirements, and gives the person the right to remain indefinitely in the country with full social rights (except voting), as if they were a citizen. That means, for example, that they would be eligible for the national healthcare system and state welfare system even if they found themselves long-term unemployed, which isn't normally the case for citizens of other EU countries.

Some more information here: http://www.eurofound.europa.eu/areas/industrialrelations/dic...

Thanks so much for replying and the links. Actually the third one, permanent residency, is quite encouraging for me as I would be a "pensioner" and thus the 3-year work requirement is waived.

It's almost impossible to get a permanent citizenship in any of the scandinavian countries (besides Svalbard, which is a part of Norway, but really strange case). You either have to be some sort of highly educated person or marry someone with a permanent citizenship, and even then there are some restrictions.

Inside of EU and Schengen you should be able to get a limited work permit. Then you are usually covered by local health care after a couple of months paying tax.

That seems like a pretty low bar for "almost impossible", as I would expect most HN readers are both 1) highly educated and 2) single, and so the two avenues you mention are amongst the most accessible to them.

There are far more difficult places to gain citizenship (e.g. Liechtenstein, China).

Life saving treatment is usually like this all over the world, and in Denmark they will give you a bill unless you're apart of EU, as you'd have the EU health insurance (EHIC), which is free. This card is also valid in countries in the Schengen Area, like Norway, Switzerland and Lichtenstein.

Many countries bill for emergency stays. US emergency rooms definitely send bills, even if it's acute live-saving treatment. Even Canada, which has national healthcare for residents, will bill nonresidents who visit an ER. If you're from another country, you may get away with just not paying one of those bills, because if it's life-saving care they have to provide it before verifying you can pay. But they'll still try to collect on it. That's one reason it's common for people to buy travel health insurance that covers emergency care.

Afaik, Denmark doesn't require the EHIC for acute emergency care. Anyone is eligible for unbilled emergency care, with some exceptions to combat medical tourism (if you're found to have traveled to Denmark for the specific purpose of entering an ER to treat a health condition). The EHIC qualifies you for some additional care, e.g. childbirth. This is actually a big current sore point in Danish politics, because many other EU countries don't extend a reciprocal courtesy.

You're still stuck with a bill, if you're a foreigner. They will treat you, like they will in most of the world. But you're still stuck with a bill afterwards.

Also, unless my memory is totally off, each country has to pay up for EHIC, depending on who used what, and visa versa. So the cost should be evened out.

Edit, because I cannot reply to you later down: I think we have a different view on what emergency medical care is. In most of the world you will get fixed up so that you are no longer in life threatening condition, this is the case in USA, Denmark and Norway. But afterwards you will have to pay, even in Denmark, as long as you're not apart of EU and have the European Health Insurance Card or a citizen of any of the Nordic countries, which has a special agreement.

That isn't the case; Denmark simply does not charge for acute emergency visits, and does not send a bill. In addition, they pay for their own residents who incur such bills within the EU on trips under 30 days [1], which is part of the controversy: a French person who ends up in a Danish ER is not billed, but a Danish person who ends up in a French ER is billed, with the bill paid by the Danish government. Most Danes would prefer that each country provide free emergency care to all, like they do with fire and police.

[1] http://www.sos.dk/en/Corporate/OurNetwork/ForMedicalFaciliti...

You're still stuck with a bill, if you're a foreigner.

In the UK you are not, purely because they don't do the accounting that way in the first place as it would cost a lot of extra money to keep track of billing when no-one is being individually billed, so there is no bill to bill.

> Even Canada, which has national healthcare for residents, will bill nonresidents who visit an ER.

Even Canada? Canada by its location would be at acute risk for medical tourism from the US, if it didn't bill for ER treatment. That problem isn't as big for Europe, Australia, etc.

That makes sense, I agree. The "even" was more given its reputation: most Europeans I know are not surprised that the US sends large bills for ER visits, but don't expect the same from Canada.

I could almost imagine a financially manageable system where Canada gave free ER care to anyone except Americans, but that would produce obvious political problems.

Right. I'm currently on a work-holiday visa in Canada (BC). I went to an ER and had to pay ~$825 upfront, before seeing a doctor.

My travel insurance reimbursed everything but you'd better have money on your credit card...

Before getting my work holiday visa, I had to prove that I had medical insurance covering me during my stay in Canada.

[edit: I'm from Belgium]

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