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Comment by toomuchtodo | Hacker News Reader

....which would explain why every first world country uses it except the US?

I'd much prefer we don't devolve into a political argument. My question, I thought, was relevant due to ACA kicking in, which is the first step towards universal healthcare/single payer in the US (which would eliminate the business model in question).

In closing, here is healthcare spending as a percentage of GDP by country (almost all first world countries): http://upload.wikimedia.org/wikipedia/commons/a/a1/Internati... The US leads in spending, and only spending.

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The US is 5-10x larger in population than the other single-payer-ish systems usually cited. (And, more culturally/politically/geographically varied.)

Also, we in the US tend to have bigger problems running giant federal bureaucracies, compared to these other smaller, more-unified nations. (How many government shutdowns have they had in the past 40 years?) Our existing single-payer-ish health bureacracies, like Medicare, suffer more fraud and cost-problems, and have a harder time enforcing steely-eyed rationing (aka "death panels") than elsewhere.

These smaller systems also benefit as free-riders from positive externalities thrown off by the United States' eccentric overexpenditures - like drug and new-treatment beta-testing. (If we become more like them, their own medical indicators could get worse.)

So the argument can't just be, "make it work like over there", when nothing here works quite like there, and our challenges of scale, culture, and politics are larger.

> The US is 5-10x larger in population than the other single-payer-ish systems usually cited. (And, more culturally/politically/geographically varied.)

I see this argument all the time, and never an elaboration.

I understand going from 1,000 to 1,000,000 people incurring growing pains, but I have a hard time understanding why people seem to think a system that works for 80,000,000 people in Germany wouldn't be scalable to 300,000,000.

Germany…

…isn't quite single-payer, more like a "public option".

…has far more labor-business-government cooperation than the US.

…has the oldest tradition of social insurance, but still their current system was the result of gradual expansions over many years.

…runs lots of government services better than the US.

…is only half the area of Texas, but that area is as population-dense as Maryland (our 5th densest state).

Why can't any 300 million people in Africa just adopt US-levels of public services by willpower and legal fiat? Why can't the US make our 50-million-member Medicare as efficient as the German system? These structural, historical, cultural, and political path-dependencies matter.

"Make it work because I don't understand how it couldn't" isn't a good basis for the largest nationalization experiment ever.

> The US is 5-10x larger in population than the other single-payer-ish systems usually cited.

Which doesn't explain the vastly higher per capita (and even per GDP) costs.

> Also, we in the US tend to have bigger problems running giant federal bureaucracies

That doesn't explain why the US costs (again, per capita or per GDP) are still higher than the total costs in many countries providing universal coverage even if you exclude the slightly-less-than-half of US spending that is public spending.

> Our existing single-payer-ish health bureacracies, like Medicare

Medicare isn't single-payer-ish, as for decades there has been policy to move from traditional single-payer-ish "Original Medicare" to (usually partially, with a personal premium as well) publicly subsidized private insurance "Medicare Advantage" plans.

> These smaller systems also benefit as free-riders from positive externalities thrown off by the United States' eccentric overexpenditures - like drug and new-treatment beta-testing.

Er, a lot of drugs and new treatments are tested and accepted overseas before they are in the US.

You're right: our costs are off-the-charts. There's something about our culture and politics that's making that happen, even in a system with centralized price-setting like Medicare.

If you can't answer why Medicare seems to do worse than your favorite "single-payer-ish" models, you haven't explained how making the entire system into a single-payer system, a bureaucracy of unprecedented size, will improve things over a smaller bureaucracy that's failing at controlling costs.

Some drugs and new treatments start elsewhere. A disproportionate number start in the US. Fancy new (and often unnecessary) treatments are one of the things driving our costs up.

"There's something about our culture and politics that's making that happen, even in a system with centralized price-setting like Medicare"

It's not a difficult puzzle: nobody in our system is incentivized to care about costs. The insured consumer never sees the cost, the physician is incentivized to be cost-blind when choosing treatment options, and the insurance companies pass the costs back to employers, who don't get any say in treatment. The only other people who know what health care costs are unemployed and/or poor, and well...screw them, right?

You couldn't possibly choose a worse economic model for allocating health care. Medicare is much cheaper and more efficient than employer-based healthcare, but it can't overcome the structural expenses created by a system dominated by people who are almost totally cost-insensitive when it comes to their health.

I don't see why employers and insurance companies wouldn't worry about costs. And also patients who pay a percentage of their bills.

And yet they don't. Do you know that the cost of prescriptions can vary greatly between pharmacies? Of course, you only pay your co-pay, but your insurance company pays the difference.

When's the last time you comparison-shopped your prescriptions or other medical services?

Drugs aren't the best example since they are inexpensive (at least the ones I've purchased). But if I had a more expensive surgery where I was on the hook for 20-40%, I might be incented to negotiate or shop around. And you'd certainly think the insurance company would be highly incented to negotiate.

"Drugs aren't the best example since they are inexpensive (at least the ones I've purchased)."

There are some very expensive drugs, and they're not uncommon. For example, valcyclovir is a very common anti-viral drug, and costs something like $300-400 per course. The similar drug acyclovir is $20 as a generic, but is more annoying to dose. As a result, doctors will nearly always prescribe valcyclovir over acyclovir. For patients with a chronic infection, that's a mundane decision with an impact of tens of thousands of dollars per year. But unless you're a doctor or a pharmacist, you'd probably never know about the choice.

Insurance companies pass these costs on to the risk pool first, then onto employers. By the time the cost increases hit you (through employers cutting or reducing your health benefits), the implications are so far removed from the initial expenses that there's no way to close the cycle.

Medicare is only for 65yo+.

Of course it's going to be more expensive, with worse health outcomes, than a general population pool. That's how aging works.

It's worse at cost control than other countries, even for comparable cohorts.

But better at cost control than private insurance in America, with much better cohorts. They're in America, medicare can't get you british-cost healthcare.

> ....which would explain why every first world country uses it except the US?

Every first world country except the US has something approximating universal coverage, but not all of them use single-payer (or even a single basic coverage insurer with supplemental coverage from other payers.) Compulsory-purchase insurance models similar to those in the ACA (but, you know, actually universal) with private insurers are not unheard of (e.g., Switzerland uses that model)

Switzerland's is interesting in that it goes a step further than Obamacare and really makes it compulsory, rather than simply fining you for not having insurance. A colleague was a postdoc there for a while and didn't understand the system, and after ignoring a few letters telling him he needed to buy insurance, he got a follow-up letter telling him that, as he had not yet enrolled in a plan, a default one had been chosen and he was now enrolled in it.

I would like to point out we're also significantly more overweight, have higher rates of heart disease, have a quickly aging population of baby boomers etc.. Your argument is not logical as there are plenty of other reasons we have higher healthcare costs other then that we're not single payer.

Actually, the reason real reason US health costs are much higher is that the unit-cost is much higher.

Check out the unit cost differences here:

http://voices.washingtonpost.com/ezra-klein/2009/11/an_insur...

http://www.pbs.org/newshour/bb/health/july-dec12/medicine_09...

"But I think the biggest single driver is our fee-for-service system that rewards volume instead of value and quantity of medical services instead of quality. And as a result, we end up doing a lot of things that cause more harm than benefit for patients."

Also:

"What that dramatic variation tells us is that there's a lot unnecessary medical care that's being delivered and a lot of room to eliminate some of that wasteful spending."

> I would like to point out we're also significantly more overweight, have higher rates of heart disease, have a quickly aging population of baby boomers etc..

Those are all, arguably, consequences of the poor access to health care in this country and the short-term incentives in this country to delay care. IOW, they are products of the system that we pay more for (per capita or even per GDP -- or even either way only considering public expenditures and excluding the private costs) than first world countries that provide universal coverage through government single-payer systems.

I see this argument a lot: people go without care, or delay early treatments that would be cheaper, because they can't afford to go to the doctor. I'm sure this is true to a degree, but making terrible diet choices, being sedentary, and being 100 lbs overweight is not a consequence of not having health insurance.

And I really don't see the avoidance of primary care being primarily financial either. A yearly routine physical is not very expensive, and is often free at many public health clinics. Likewise common preventive care like flu shots, pap smears, and prostate exams.

A big reason a lot of people don't go to the doctor is that they don't like going to the doctor. I'm in that group. Having insurance doesn't change that.

There is a huge cultural difference between almost every single payer nation and the US. For example, I haven't seen a regular doctor in 3 years for any kind of check up, because I'm uninsured. Meanwhile, I have friends in Canada that get quarterly or even monthly checkups. It isn't even a cost thing, they say it is cultural - their parents and peers expect them to regularly see a doctor to make sure nothing is wrong with them, and if they sneeze wrong they see the doctor.

I dislocated my knee this spring and reset it and just stayed in bed for 2 weeks. Never saw a medical professional, because they would want to x-ray (it might have broke, it was much more painful than a normal dislocation to me, and swelled huge for a while) and I'd be stuck with a $3 - 5k bill minimum just for that, combined with any treatment, and I'd laugh if they'd want me in physical therapy for it.

So it isn't just about not haivng a doctor to say 3 bic macs a day is bad for you, it is that in most other places people do see their doctors, regularly, and for most issues, beucase it doesn't bankrupt them. That adds up over a lifetime.

I haven't been to see a doctor in at least 5 years, and I have insurance.

> ....which would explain why every first world country uses it except the US?

Which is why almost every country outside of the US has a lower standard of care than we do. I'd be fine if we had a "minimum safety net" which covered catastrophic care, but thats not what was put into law. I also think a government mandated requirement to purchase a commercial product is probably not a good thing.

> Which is why almost every country outside of the US has a lower standard of care than we do.

You just like to make up shit I see. Every country that provides public healthcare has a higher standard of care than we do because for 10's of millions of American's there is no care at all beyond emergency care. People die daily for lack of health care in this country, to call that a higher standard than countries with public healthcare is beyond absurd. Our system has a fantastic standard of care for those with money, it has shit for care for the rest.

> Which is why almost every country outside of the US has a lower standard of care than we do.

Uh, where do you get that from? The JAMA study, one of the most comprehensive such studies done, concluded that the US health care outcomes are far worse than comparable nations, yet we pay significantly more for it.

The biggest reason we pay more is that provider costs are much higher than the GDP-adjusted average. $500,000,000,000 more. (And before you say it, that's factoring out defensive medicine and the results of tort reform.) A lot of that has to do with insurance companies inability to negotiate reasonable rates with the providers. And of all the insurers in the US, which is the only one that can and does negotiate reasonable rates? Medicare.

I think many/most would disagree with your contention that other countries have a lower standard of care. It's particularly annoying that your so matter of fact about it.

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