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so I take it he aint offed himself yet.

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He's got until he hits 75. Then we can hold him to it.

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kool-ade.

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He <I>opposes</i> euthanasia, so why would he support suicide, particularly?

(He seems to be against expensive or elaborate care for old people, not for killing them like an elderly Logan's run.

And one should note that this is not entirely nonsensical as a <I>personal</i> position; doctors themselves are famous for refusing "heroic" measures on their own care plans.

A lof of very expensive and painful stuff in old people still leads to their near-term death.)

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driving, too.

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I think you're conflating "heroic" with good here. In medicine heroic measures tend to mean the last ditch effort to save a life e.g. amputating a leg to stop gangrene. Heroic measures means this will probably do more good than harm but it will do significant harm.

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Jan 19, 2022·edited Jan 19, 2022

I think it's tempting to leapfrog the semi-private ones because people don't like the idea of a "two-tiered" system, that you get something better if you have more money. Me, I'm happy to let the people with more money have their better things if there's a reasonable chance for me to get it just by paying some money, instead of having to scheme or get in endless lines or go abroad or just wait.

Also, the "publicly funded but privately run" is how Medicare Advantage and, increasingly, Medicaid is run in the US, where the state/federal gov't contracts with an insurance company and pays them some kind of risk-adjusted "per capita" rate per enrollee, and the company assumes all the risks as it tries to enroll the public plan beneficiaries.

Also, one thing that makes the US system worse is its being tied to employment; I wonder how many issues with the private market might be at least partially resolved with a new equilibrium where the employer-sponsored plan is no longer required nor tax-privileged.

EDIT: Medicare ADvantage is an alternative style of Medicare plan (for old people) where all your care is covered and handled by a company, instead of the government directly. The companies offering these plans are "at risk" for all the costs, which they're expected to manage through "value-based incentives" and things like that; and they have a limited menu of incentives they can offer to get you to sign up, like free transportation and gym memberships. But it's totally voluntary for seniors to sign up. The hope is that this can optimize and streamline costs in a way "Traditional fee-for-service" Medicare can't.

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> Me, I'm happy to let the people with more money have their better things

The issue with this is it means the people with money (i.e. the people who have the most say in society) have no stake in the public system, and a big incentive to actually want as cheap and terrible a public system as possible because it will mean cheaper taxes for them.

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I mean, according to the above, Netherlands and Germany manage to have a private option which, anecdotally from a German friend, affords better treatment if you have the nice private coverage than the public option.

You can still tax high and have a decent public option, but if you outlaw all or most private payment or operation of healthcare, you make it possible only for the very rich to access anything other than your public option, which seems to be an issue in UK and Canada.

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A nice thing about a private option with a genuinely good public option is that it at least in theory lets moderately well-off people go a lot more a la carte and spend in the areas that mean a lot to them (or not spend for things they don’t care about).

One of the obnoxious things about post-Obamacare private insurance is that there are no options available between “literally nothing” and “expensive because they wanted everything notionally covered”.

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Permanent short-term health plans have been a thing since... 2017 or so? They might go away again, considering they haven't been Thanosed out of existence yet they might just quietly continue along.

These are the plans that are in between that you were looking for.

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Right, but because I have employer provided health insurance, because my employer is legally required to offer it, I don’t really have that option (or I do, but I’m leaving a pile of compensation on the table if I take it).

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They just choose to offer it. They could pay a small fee (2.5k per head after a certain number I believe) and opt out. You could seek out an employer that doesn't tie compensation to a non optimal system.

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and from experience, somehow those things arent actually covered.

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Jan 19, 2022·edited Jan 19, 2022

In The Netherlands we don't have a private system. We have the government literally set the price for 'basic insurance that the government deems is necessary', you can adjust kind of a slider between monthly cost/deductable, and that's it. Insurance companies mostly compete on like 'ten free yoga lessons!', 'we are known for better service', '$100 off your first year'.

The big exception is dental, which does not fall under basic healthcare, so companies offer extra packages, which they also do with things like a shrink or fysiotherapy, which are normally only covered when your GP says you should go.

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Yep, sounds familiar to our German way. The "secret" seems to be to have the insurances compete on low administration cost. (Some smaller insurers who run into troubles here are regulary "integrated"/"bought" by bigger ones - and some "new" ones try their luck growing on streamlined procedures). - Those funny extras they throw at us to lure us into swaping are very secondary. - The docs have much less hassle cuz it is all one price (or two: "insured" vs. "privately insured"). Imagine a doc had to deal with dozens of prices, some insurances not covering certain stuff others do! Nightmare! And hell of extra-costs). - The docs love private (insured) patients, as they can charge them around 75% more plus for some less cost-efficient stuff. (Dermatolgists loved looking all over my skin when I was young and private. Nowadays ... - well thanks for letting me know I enjoy the best health care in the world. ) - Fun fact: many Germans with private insurance (self-employed or high salary) stay unmarried. As their partner+kids would be forced into theit contract and make it much more expensive.

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In the Germany system don’t you get stuck in the private system if you stay there too long?

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Kinda. And the premiums go up with age, of course. I got out by no longer being a Beamter (civil servant) - a fate I could not bear for more than a year. But it is complicated - wikipedia (and the book) should have more info.

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(And the government subsidises the basic premium for those on low incomes). However, for me this fits the category definition "Individuals use their own money to buy insurance from private companies" a la Switzerland. It certainly doesn't fit "the government pays 100% of your costs". You're going to pay 80-200/month for insurance - to a private company - plus probably some out of pocket expenses/deductible for usage. What is the distinction being drawn between these two systems? Is it saying that the government acts as a middle man - they pay the hospital/doctor, insurance reimburses government?

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It seems like it would only work if your politicians aren't already captured/corrupted. If they are, then the public system would suffer as Angus said. Arguably this wouldn't work in the US for this reason.

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I second that anecdote. I'm privately insured in Germany and it's GREAT (for me, that is. although I do subsidise the publicly insured people to a small extent, so not exclusively for me).

And I had that issue you describe in the UK - I didn't want to wait as long as I would've had to for a specialist whIle living in the UK, so I looked for private options (which my German insurance, under certain circumstances, like those I was in, would cover).

It was possible, but there was little choice, and it was a lot more expensive than in Germany.

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As it stands I'd say the only people with an actual stake in the healthcare system have that stake going in the direction of: "Make things more expensive" -- as much as the populace at large would like things to be cheaper their interest is diffuse.

If your moral or intellectual model of healthcare is that healthcare is perfectly inelastic then private options are unethical since it's more money chasing the same supply of goods, and the only ethical choice is to ration it at the lowest price point possible. Plenty of voters probably think this way subconsciously and plenty of economists will probably argue it explicitly.

If the supply is sufficiently elastic, and you combine private healthcare with a sort of sales tax that finances the public option, then the existence of

Everyone in the US with a concrete stake in the healthcare system would want something like a (legally instituted or not) perfectly inelastic supply of medical services plus a government that pays "The market price"

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Except healthcare isn't perfectly inelastic. I do software development for a living and volunteer in EMS. If pay in EMS was to outdo my software engineering job I'd do that for a living. And if doctors were paid more I'd go to medical school. (Opportunity cost is a bitch)

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I don't think HC is perfectly inelastic, but rationing it makes sense if it was.

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I think that's a real theoretical worry, but we can see how it has actually worked and it doesn't actually seem to work that way where it's been implemented. And you also have to say 'Compared to what?' In the Private US system, basically young(-ish) people with money just don't care at all that there even is a system available for people who may fall through the cracks.

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It has worked that way in plenty of places. Chile and India come to mind. Also Russia iirc. From my conversations with people from those countries, the public option is horrible and you essentially have to go to the private to get anything like reasonable care.

So maybe not in first world countries, or maybe just not yet, but saying "it doesn't happen" is not accurate.

Looking at incentives is so important because it shows you how the system is going to trend over time.

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Do the "people with money" ever have a stake in the public system? I mean, it sort of depends on how you define "people with money", but I suspect that in all of the surveyed countries the 1% are basically going to go to whatever doctor they like best and get whatever medical treatment they want (or that their doctor tells them to), and if the public system wants to pay for it, great, otherwise they'll just pay themselves because is there any better use for their money than (perceived) better health care?

So, they'll *prefer* the public system to be generous in paying for high-quality health care. But being in the 1%, they are almost by definition net taxpayers, particularly in health care. So they'll know that any plan that ends with "and the public system can now afford to provide €1,000 per capita additional high-quality health care", is going to start with >>€1,000 per year additional taxes from their 1%-er selves.

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There's an important difference between the top 51% being able to buy their way out, and the top 51%.

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“Also, one thing that makes the US system worse is its being tied to employment;”

This seems so obviously true that I was shocked that Obamacare went all in on entrenching it even further by MANDATING that most employers provide a particular level of insurance.

Portability from job to job, and state to state seems like a thing to definitely try.

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For many employers, paying the penalty is cheaper (and provides cheaper insurance) than paying for the employee's insurance. Too bad it's phrased as a penalty. When Biden increased the Obamacare benefits I kept wondering if the strategy was to just keep turning up the value of Obamacare over traditional employer health care until enough Accounting/HR wonks just decided to flip the switch and suddenly you have a bloodless healthcare revolution.

Too bad there aren't enough wonks out there and public image is still a cost consideration.

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My theory is that the nature of law being written in the US is - gather all the stakeholders [with lobbyists/organizations] - American Hospital Association, American Medical Association, Disabled Veterans' Groups, AARP, large health insurers or their representatives, and big pharma - and split the difference between all those interests, with tons of special carve-outs and special interests to go around. Hence you get gigantic unreadable bills that benefit specifically health insurance companies and heavily favor health system consolidation/monopoly formation, and increased bureaucracy. There aren't actually all the actual stakeholders - just the ones with institutional knowledge, but also resources to communicate that knowledge, connections, and political pull.

(This is also why I assume that US version of "Medicare for All" will be government-paid private plans and you pick one, run by insurance companies who are "at risk" for your costs and therefore with incentives to deny your claims and pay as little as possible - meaning it won't really improve quality or accessibility as much as proponents claim.

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Medicaid is government paid private plans where you pick one and they are run by an insurance company. The only information I see out there (5 minutes googling) about denied medicaid claims in Texas is on the provider's end, not the patient.

No, I'm not quite sure why there are several different private insurers to choose from under medicaid. Especially considering you can change them at any time and BACKDATE your change. It's weird.

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Perhaps the more accurate claim would be, that the incentives stack up and point towards denial, or reduction of care (or selection of patients). If the plan is at risk for all the costs, they will of course try to manage the costs (subject to regulations - they can't just deny every claim, because they get reviewed regularly by the relevant regulatory body on tons of metrics). They have whole "utilization management" and clinical review departments - "managed care" in a way that other countries definitely weren't doing, at least not recently.

I worked for a large managed care provider, they were all about "disease management" programs and value-based incentives, including capitation-based reimbursement to primary care where possible, diverting care to "high-value" practices, using various sorts of approaches to reduce expensive care, emergency department admissions, directing to more cost-effective post-acute facilities.... Some of these might significantly reduce costs without compromising quality of care, but it's hard for me to believe that something doesn't get cut somewhere - e.g., access to more expensive drugs, novel or additional treatments, out-of-network specialists, and so forth. I didn't delve into it too deeply, because that wasn't my direct job; but it seemed like the positive programs - data-based disease management programs, care coordination initiatives for high-claims individuals, community outreach, etc. appear high-touch and therefore expensive: great outcomes, but I don't know if cheap, necessarily (if they're to be done well). This is very different from "traditional Medicare", which basically covers most things that fall in its purview. Maybe someone who is an expert in managed care specifically can weigh in, but again my strong bias to believe that a company that's on the hook for certain costs - facing a fixed reimbursement rate per person (perhaps adjusted based on how sick the person is) - will seek to minimize those costs any way they legally can, balancing it against regulation and reputation, of course.

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Hey, would you be open to talking to me about your experience working for a managed care provider? I am researching the incentive landscape around psychiatric crisis care and am really lacking an understanding from the insurer/payer side. (if so, DM me on Twitter--I'm @utotranslucence)

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When I use "Medicare for All," it means just what I choose it to mean—neither more nor less."

Most people have no idea what they're actually proposing, besides "fuck the current system."

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That's not a bug, it's a feature. Keeps people desperate for jobs, and unlikely to stand up to their employer/leave.

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It's a political feature: "If you like your insurance, you can keep it". A very large number of voters already have insurance that they want to keep.

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Yes, exactly -- mandatory employer-provided health insurance is the one clear and obvious way we are different from the other countries being studied. Almost no decision-maker has to bear the full cost -- not for care, not for premiums. And Medicare, which could be a disciplining influence, instead bases its formula on what insurance is paying. We have market power among hospitals, market power among insurers, and pharmacy benefit managers who do...what, exactly?

Come to think of it, considering how arbitrary and made-up the prices are for hospital services here, when we are able to find out what they even are, it's not surprising that alternative arbitrary budgeting methods actually work just fine.

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Jan 21, 2022·edited Jan 21, 2022

Well, that was the point of the public option, which was originally part of Obamacare but got killed by Joe Lieberman. Without a public option there wasn't much choice but to freeze the current system in place, or else you would risk there being no options at all for large swathes of the employed public if private insurers chose not to enter the market in a given state. I think had the public option passed, there's a good chance the employer mandate would not have been included (and I definitely would have taken that trade; I wonder whether Joe Lieberman would have).

At the time there was definitely political pressure to "save" employer health insurance too because many people didn't want disruption to their existing health plans even though they almost certainly would have had better options waiting for them if the employer-insurance link was broken. One of the biggest complaints about Obamacare right after it went into effect was people upset that their employer plans were being modified/replaced.

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There are two-tiered private systems where richer people get nicer things (eg Australia), but I don't think that's what's happening in Germany and the Netherlands.

My impression is that Germany and the Netherlands are like charter schools in the US, where the government pays for everybody but you can still choose which of several competing institutions you want to use.

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https://www.commonwealthfund.org/international-health-policy-center/countries/germany

This description describes the private option as follows, towards the end of the blurb:

"Germans earning more than $68,000 can opt out of SHI and choose private health insurance instead. There are no government subsidies for private insurance."

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Jan 19, 2022·edited Jan 19, 2022

The set of criteria is more complicated:

https://www.expatrio.com/living-germany/health-insurance-germany/private-health-insurance-germany

From what I've heard, it includes quite a lot of people because there are quite a lot of civil servants because Germany likes to class people as civil servants.

So there *is* a two-tier option, but there are choices within each tier. About 10% of people (see link) choose the more expensive tier, it comes with lower waiting times etc.

Edit: I should add that a friend of mine is a doctor in Germany, and told me that apparently they lose money on the non-private patients, and make money on the private patients because private patients pay a lot more. Nobody is really happy with this situation, but it has been this way for a while.

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Why do the doctors see non-private patients, then?

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Some don't.

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They often claim that, but it’s not true. Doctors can easily chose to accept only private patients, however, it is pretty rare to do so, because the number of patients with private insurance is too low to provide enough volume.

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Jan 21, 2022·edited Jan 21, 2022

May not be true for all (or even most) doctors? Could have also been exaggeration.

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I used to work in billing software for doctors in Germany. This claim is definitely not true.

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Jan 21, 2022·edited Jan 21, 2022

Maybe its true for some doctors with higher costs but not others.

Edit: comment below claims " Also, doctors are only paid for a certain number of mandatorily insured patients per quarter – they can treat more, but they won't get paid for it " so in terms of marginal cost once they've filled their quota, they make zero money on the non-private insured people.

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I'd guess that if this is true at all (which I'm skeptical of) they 'lose' money in the same way that McDonald's 'loses' money when someone buys something from the dollar menu, rather than one of the more expensive options: ie, if everyone used the lower cost option, the fixed costs wouldn't be covered, but it still brings in more money than the variable costs (obviously, since if they were losing money on the variable costs they wouldn't be doing it in the first place).

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I think that thinking of the German system as "ACA, but the mandate is enforced so nobody is ever uninsured" is a good approximation (the "single payer part" being the subsidies for lower income individuals that also exist with ACA). At least for white collar and unionized jobs, you get private health insurance from your employer that is significantly better than the basic public one much like in the US.

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That is a better approximation, but an important thing is missing: There are only two (mostly overlapping) „networks“. Doctors, hospitals and pharmacies all charge according to the rules of either public or private health insurance. Most accept both types of insurance. So „out-of-network“ issues are almost nonexistent. Pricing for one type of treatment is the same at every hospital for everyone with the same insurance type. Because of that Hospitals and doctors don’t compete on price, but on the quality of service.

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> Most accept both types of insurance

Yes. Though there are a number of specialists that only accept private insurance, this is communicated and checked very clearly and in advance so I've never heard of anyone ending up in the wrong category by mistake.

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Jan 20, 2022·edited Jan 20, 2022

Germany has two parallel systems. One is the single-payer-through-private-companies that you described. In that system (called something like "mandatory insurance" in Germany) you pay a certain percentage of your salary and get health care. The other is a "private" system but there are still lots of rules, I think. Doctors get more money when they treat these private patients but this is also capped at, I think, 2.5x the money they would get from a mandatorily insured patient. Also, doctors are only paid for a certain number of mandatorily insured patients per quarter – they can treat more, but they won't get paid for it – whereas they always get money for the privately insured patients. The result is obviously that doctors give preferential treatment to those with private insurance. But also that privately insured patients are subsidizing those with mandatory insurance in a way.

You are allowed to get private insurance if you earn more than a certain amount or if you are self-employed. The system is either-or: either you have the mandatory (single payer) insurance or you have the private one. Though, if you have the mandatory insurance, nothing stops you from telling your doctor you are privately insured so that they send you an invoice which you then have to pay for by yourself. It's just that most people can't afford that (or rather that it's risky).

(As a side note, if you look at this from the Hansonian perspective on healthcare, then it doesn't necessarily result in better outcomes for those with private insurance. It's true that those patients get _more treatment_ but a lot of it is useless and only happens so that the doctor can earn more money. As someone with only mandatory insurance, you will likely get less treatment but you should always be able to get the really life-saving care, so you might come out basically the same. My mother has private insurance because she is a teacher – who always have private insurance for historical reasons – and every time she goes to the doctor they find some treatment they could do, whereas my father who has mandatory insurance gets told to drink water and rest.)

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Just adding my two cents: The insurers in the German mandatory system aren't really private companies, but public (as in "delegated by the administration with public tasks") corporations. They are entities under public law and can't fall into insolvency for example. Comparing them with private insurers really underestimates the grade of socialization in the German economical system. This also explains their bargaining power, because all the public insurers negotiate as bloc with the manufacturers, representing >85% of the market.

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You are right about their legal status and that they got huge bargaining power, but not everything is negotiate as a bloc and there are many different public insurance companies. This is not the kind of „one-size-fits-everyone“ socialism.

They can also go into insolvency since 2010.

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I would argue that the segmentation in many different public insurers has mainly historical reasons and isn't a fundamental weakness or strength of the system, because by and large the indivual differences between the insureres are marginal.

The price of pharmaceuticals is bargained on the insurers' side by the collective umbrella corporation, the GKV-SV.

You are technically correct (the best kind of correct) on insolvencies, but the insolvency proceedings of public insurers differs so fundamentally from private companies that they aren't comparable, mainly because claims against public insureres are backed by a collective fond.

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The insolvency rules are different, but they still get an important job done: Inefficient players are removed from the market, which is also one of the reasons why the differences between the insurances are so small. While the large number (97, used by more than 1000) of insurances has historical reasons, and a much smaller number could work just as well, or even better, I argue that it is an important feature of the German system to not just have one large insurance. With multiple insurances, they will compete on the efficiency of the administration. Inefficient players have to improve or will be forced to leave the market. However, if all or most of the insurance providers struggle you know that the system needs more money. While if you had a single big insurance and it is struggling, you don’t know if this is due to inefficiency or because not enough money is available for the task.

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Another thing: the rate of the mandatory system is ca. 15% of your gross income (employers pay half the amount).

Lowest income the assurances assume is about 1200€/month and if you earn more than 63000€/year the rate is capped, so you pay a maximal rate of 756€/month yourself and your employer pays the same amount.

So both companies and workers are interested in low rates.

Your insurance may ask for 1-2% or/and offer some additional treatments (some pay for homoeopathic "medication" e.g. LOL) People are allowed to change once per year, so this is not a monopoly but earnings are capped.

The good thing about the mandatory system: your family might be insured as well (kids until 25 resp. end of study/apprenticeship, your partner in a marriage if they have no income of their own) and they do not care about your health status.

Private insurances start often cheaper if you are young but get more expensive every year. Of course if you are disabled or have a condition, you smoke, are obese etc. the insurance is expensive immediately.

So the mandatory system has more people who are sick and the private ones the more healthy and rich.

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Just to be clear, the UK has a private medical system including hospitals totally separate from the NHS where you can buy top up medical insurance to the NHS, which allows you to see specialists and get treatment quickly. Emergency cases though are usually treated on NHS. About 10% of the population pay into this or get it through work. It doesn’t seem to cause much resentment. There is little regulation on the cost and content of these plans, though of course the medical care can’t deviate from UK standards. For a family of 4 annual costs are around £2,000. To me the UK system is a good compromise between looking after the less fortunate with some pretty good health care at a low cost for the country but allowing those who want a higher standard of care without too much regulation.

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Yes, I know that you can get private insurance in the UK, but you can't opt out of the NHS, right? I'm not completely sure whether that is a meaningful difference, but when you get private insurance in Germany, none of your money flows into the "single payer" system. Also, people with both kind of insurance go to the same doctor in Germany – I have never heard of a doctor or hospital that only takes one or the other kind of insurance. But in the UK there are private hospitals that only take private insurance (or rather, they send you an invoice and you have to pay the money somehow), right? And you couldn't just go to an NHS doctor and say you want to pay for yourself, right?

Note that I'm not making any sort of claim about which system is better, but they do seem clearly different to me.

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You can't not pay for the NHS.

sample size of 1 but my experience of the system is:

My work offered private (probably quite a cheap plan) - I turned it down as the main benefit was access to GPs quickly. I didn't have to pay for it but i did have to pay tax on the 'value' of the benefit and even that was too much. They would let you go to in network private hospitals and you might have shorter wait times but they were only covering stuff that you'd get on the NHS anyway and my experience with the NHS has been good.

My wife has given birth in NHS, I've had 2 ops and an ongoing blood condition. All times I've been pretty impressed at the level of service. A friend of ours got cancer at 30 and I was also impressed with his care.

Another friend has ongoing problems with something vaguely IBS shaped. He has been to his GP a bunch of times but they aren't showing much initiative. Another friend with mental health issues had a similar story.

I think my blood condition got a lot more traction because there was a binary test and if the test was positive there was a protocol to follow. Refer to this specialist, give this medication until this number is in this range. For more subjective stuff people tend to have worse experiences. Maybe going private in these cases would mean they would but more effort into finding what is actually going on.

If I wanted to see a GP I could:

* go through the NHS process and get a 10 min appointment. If it isn't 'urgent' (which has quite a low bar) it will take weeks to be seen. If I just give vague sysmtoms I feel its likely I'd be 'fobbed off' with something like 'drink more water, do some more exercise and come back in 3 months if its still an issue'

* go privately and see a GP immediately (who almost certainly does NHS work too). I could pay for just that visit or if i was part of a private scheme this would be covered by that. I've never done this but I would expect them to be a lot more proactive.

I've mentioned ages in all the previous examples because I'm aware of the level of service not being as good for retirement age people. My grandfather was in a hospital for about 3 month until he died recently and I can't say the quality of care was very good. From a completely dispassionate perspective I'm not sure spending money on better care for him would be cost effective.

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I think one of the benefits of the NHS is that it has to prioritise so minimising the number of unnecessary treatments, this is overall good for society but of course if your treatment is the one being deprioritised it sucks.

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Jan 20, 2022·edited Jan 20, 2022

I think it's worth noting that in Australia the private system only offers some services, with the most specialised procedures (transplants, major trauma, most paediatric specialties etc) only offered through the public system.

The private system we have, imo having worked as a doctor on both sides, is great for bulk surgical procedures like knee replacements but not very good at looking after people who are acutely unwell or have multisystem long term illnesses. Private medicine has very little oversight (you are treated by one attending/consultant who can basically do whatever they want) compared to the public system where departments and the presence of trainees act as a kind of peer review which I think leads to better medical care. If I was seriously sick I would rather be looked after in the public system.

I think there's a fair argument to be made that the private system skims off the healthiest and most straightforward cases and dumps the rest on the public system. I don't know whether this is cost effective or not - obviously there are efficiencies which come with higher throughput, but there is definitely overservicing and waste in the private system. It's a source of resentment.

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Much of what you say is true of the UK as well. I would come down on the place that there is a political limit on the amount of funding for a national health service so people who go private are releasing resources for those who do not. Like school systems. So it is a good thing. But I can see why communitarian leaning people don’t like people who have a limited stake in the success of the state system.

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Jan 20, 2022·edited Jan 20, 2022

That was my thought too - I spent a year working as a junior doctor in the UK and IMO the public systems are almost identical, we just spend a bit more in Australia.

My view is that on average private patients don't get significantly better medical care (just a nicer room and marginally better food), so while I think the communitarian argument has its merits I'm not sure how relevant it is here.

I think it would be fairer if the government ended subsidies for private insurance and let the companies/hospitals really fend for themselves. As it is they have negotiated a cosy niche where they are paid to provide the highest yield procedures but shift costs back to the state when it suits them.

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I don’t know about Australia but I don’t think there are any subsidies in UK for private medical. But of course overall the NHS is a regressive system, I am always amazed every time I get free medicines even though I could well afford it. A system that charged high earners more would be more fair, although I guess since most of the top decile has private maybe it works out.

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The system does charge high earners more. At least, assuming they pay tax.

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In the Netherlands individuals pay (order of 100euro per month) for insurance. If you have low income the government will subsidise this. The price for insurance is basically fixed by the government, and insurers can’t refuse people. And you are legally required to be insured.

I don’t know how true this is, but among people here I know the Dutch healthcare system has a bit of a reputation for just ignoring problems that would be treated in other countries. I’m slightly skeptics of satisfaction ratings, as they are relative to expectation (Dutch food being an example where this may play a significant role…).

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Jan 23, 2022·edited Jan 23, 2022

Actually, in the Netherlands, the government decides what will be covered in the basic plan, and every insurer then sets their price. Every 1th of January, consumers can switch healthcare insurers, and price is an important consideration (and prices are widely advertised in November/December). Some plans are cheaper because not all providers are covered, meaning that, for example, you might not be able to go to your hospital of choice. Still, I have a limited plan, and always could go to the providers I wanted.

GP's in Holland seem to be more reluctant than their colleagues abroad in prescribing drugs and treatment ("Let's see how it goes before we do something"). I think this is more a question of medical culture than to limit costs, and I like it, because in general, it is a good thing to be reticent in prescribing stuff.

Insurers bargain with providers over prices. The government bargains with pharma over drug prices.

Waiting lists for many procedures can be long, but I can't compare them with other countries.

Dental is included in the basic plan for children under 18.

Insurers and health providers are private entities, but government sets many rules limiting their behavior. Still, they can go broke (and sometimes hospitals do).

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My understanding is that the Dutch system also has the unique property (though it gets muddled in practice) of separating out short-term and long-term care. Where long-term is more fully socialized and short-term is more market oriented. I could imagine something similar in the US where you have the government provide something like catastrophic coverage on a universal basis, which would free-up insurance companies to have more competitive plans for the remaining (capped) coverage.

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The other big factor is that "Single Payer" is a massive stealth transfer of wealth, and so this appeals to the sort of people who want to do massive transfers of wealth.

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Thats technically true but for me at least isn't a useful lens.

I don't feel the same about:

* giving everyone access to a minimum standard of healthcare

* giving poor people the same amount of money it would cost to given them a minimum standard of healthcare.

Maybe its because I'm in the UK and we've already done the 'wealth transfer'. To transfer it back, and have less fortunate people be vulnerable to crippling medical bills for minor problems so I can save on national insurance, seems incredibly selfish

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In countries with private and public systems the private system can sometimes get you into surgery quicker for elective surgeries, or you get a nicer room, or sometimes more options - like cosmetic surgery. If you are hospitalised in those systems in an emergency then there’s no difference in care.

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Depends. There are absolutely countries where there's a two tier system and the public option is fucking atrocious.

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At least in Germany, comparing it to economy vs. business class might be a good comparison. Both tiers will get you from A to B, you won‘t be more likely to get into fatal accident if you travel coach rather than business, but the process can be much nicer in the more expensive tier.

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That's not what people mean by a two-tier system, though. What you're describing is fine - so long as everyone uses the same hospital and same doctors, and the only thing you can pay for is frills (private room, better food, whatever), then you're ok.

A two-tier system is you can take the government DC-3 that's held together with bailing wire and twine and one of the wheels is just a skid, or the the private 777 with proper maintenance and flight crew.

And in healthcare that looks like a public hospital where you have to bring your own bandages and medical supplies because it's so poorly supplied vs the private hospital that is, you know, a hospital.

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Hey! I wrote a longer comment below, but there's some good evidence that you can't just get better healthcare in the US by paying more money; in other words, the care that the richest Americans get is about equivalent to what average folks in other rich countries get: https://bit.ly/3nGRHL8. In other words, there is no reasonable change for you to have better things just by paying some money; in the US even if you have access to top tier healthcare what you're getting is something like average French or German healthcare.

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Even the "socialist" UK has a private option, often based on cash payment rather than insurance (thought that exists too.) Because it has to compete with free, it tends to be quite a lot cheaper than in the US, sometimes even less than the co-pay for insured patients in the US.

I am in favor of universal free healthcare, but I don't see a problem with people also paying privately if they want to. The alternative would be banning all health care outside the government system, which seems draconian. I think that paying for private healthcare when there's a free government alternative is a lot more justifiable than paying for private education, which seems much closer to zero-sum competition.

More money incentivizes more supply, and this is true even if the constraint is a fixed number of staff. For example, there are doctors who work full-time in the NHS and then see cash-pay patients on the side for a few hours a week. I guess in an ideal world, the NHS would have so much money that no-one would need to go private, but I'm not aware of any system that works this way.

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Canada works this way. Most Canadians would tell you they wouldn't want it any other way.

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Jan 19, 2022·edited Jan 19, 2022

Since I had no idea who Dr. Ezekiel Emanuel was, my immediate reaction was "He's either Jewish or African, I'm not sure which" 😀 So I had to look him up and went "Oh, *he's* your brother?"

"Emanuel thinks the UK is probably close to the cost-quality Pareto frontier and not making any stupid mistakes, but has made the political decision to not fund its health system very much."

That's... certainly one way to look at it. I think the view in the UK would be (a) various governments have and are trying their best to privatise chunks of the NHS - there is some concern that large American healthcare businesses are competing for contracts and buying up lots of healthcare provision which they run for-profit, funnelling British taxpayer money back to the shareholders:

https://www.ft.com/content/4f428fc8-fefe-11e9-b7bc-f3fa4e77dd47

https://www.theguardian.com/society/2021/feb/26/nhs-gp-practice-operator-with-500000-patients-passes-into-hands-of-us-health-insurer

(b) there is constant meddling with the structure of the health care system in Britain which ends up with layers of bureaucracy and lack of efficiency (c) health is one of the huge drains on the budget, along with social welfare and education; no matter how much money you put into it, it always requires more (d) various Health Secretaries have been very unpopular, see Jeremy Hunt (and the, um, rhyming slang version of his name)

https://en.wikipedia.org/wiki/Jeremy_Hunt%27s_tenure_as_Health_Secretary

https://www.thecanary.co/trending/2018/06/25/the-bbc-accidentally-referred-to-jeremy-hunt-in-rhyming-slang-again/

The NHS is doing its best but there are a lot of problems. Then again, compared with the Irish HSE, it's much better.

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Does this review and book not refute that the NHS is expensive and inefficient, at least compared to peers? The table shows it’s pretty much the cheapest option. To me that suggests:

A) bureaucracy exists In all systems - the NHS probably avoids a lot of bureaucracy by removing the insurer/claim dynamic, but instead gets the public sector bureaucracy cost add on

B) People hate taxes and perhaps paying for healthcare through a general tax (paying for everyone) makes people feel more negative about it than paying for your own insurance only (paying for me only). Bit the lesson from the review here is seems to be you can eat your dinner hot or cold, but you have to eat it.

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The theory I heard for why the NHS is cheap is that it was founded many decades ago when healthcare generally was cheap, and bureaucratic inflexibility meant it resisted changing its tightfisted ways for a long time (though it has more recently become less of an outlier as it got more expensive).

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Jan 20, 2022·edited Jan 20, 2022

I think that's a common argument Megan McArdle makes: it's much easier to *keep* costs low than to *lower* costs.

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Note that the NHS budget is a big political thing. Underfunding the NHS is one of the main accusations that Labour make against the Tories.

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Is there an argument for preventative care. Most developed countries don't want to just let people die so hospitals are obliged to get them stabilised before letting them go. Given their problem wasn't actually fixed how long will it be before they are back in the ER?

These visits are expensive and have to be subsidised by higher fees for paying customers. Maybe its just cheaper to give anyone treatment that needs treatment (from a menu of pre approved cost effective options)

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It's an idea people throw out, but I haven't seen evidence for that.

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I tried to find some numbers. The best I could do was that us spends roughly ~35B a year on 'uncompensated health care services' which is pretty small change compared to the $4.1T it spends on total health care.

So thats definitely not the main reason UK care is cheaper than US care

I feel that proactive care should do more than save us $100/capita. Maybe it isn't captured in these figures but does lead to a healthier more productive workforce...another nice idea I have no evidence for

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Lots of people have tried it before, since it seems like a free lunch. It rarely works out.

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It depends. Getting diabetics to be compliant with their medication could save tens of thousands of dollars per year. Most, in practice, will save little. The problem is that the people who are non-compliant are usually that way because they choose to be, rather than due to cost or anything else.

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Sort of - healthcare was cheap as the number of conditions that could be effectively treated, was really quite low - the NHS was created in '48 after the discovery of antibiotics and their initial use during the war.

The relative cheapness is the capital cost - the British Government anticipated really quite high, bordering upon truly massive, civilian casualties during the war, partially down to the expected use of poison gas, and over-estimating the effectiveness of aerial bombing. So, an awful lot of capacity got built out quickly, of varying, ah, quality.

Neither of those scenarios actually occurred as expected. So, a great wodge of stuff was there to be used after the war. F'rinstance, the hospital where I was born in '69, and had some broken bones sorted out (at age 7 and 16), was a building dating from around 1920 or something, and a whole load of Nissen huts. For all I know, those huts had been there, in use, since 1940.

The other part is that some number of hospitals had effectively been built/created much earlier, essentially in acts of Victorian (or possibly Edwardian) philanthropy. And they were operated as charities.

For those, there were no identifiable owners - so no compensation paid upon nationalisation.

This gave rise to a number of voters, in my grandparents generation, who utterly despised the Labour Party on the grounds that "they stole our 'ospitals".

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Zeke and Rahm have another brother, Ari, who's a Hollywood agent that I believe even had a TV show about him, called "Entourage": https://en.wikipedia.org/wiki/Ari_Emanuel

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I found out that Singapore has one of the more reasonable healthcare systems out there, with only 4% of GDP spent on world-class service. Basically, it requires the citizens to pay a small part of the healthcare costs out of pocket, and the rest is financed by taxes. There's a lot of interesting intricacies that make it work well, all detailed in this 16-minute video by a good economics youtube channel: https://youtu.be/sKjHvpiHk3s

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Singapore is not good for non Singaporeans ... Who are a fourth of the people.

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Even granting that, it would remain true that 3/4 of the population gets very good healthcare for 1/4th the cost. Maybe there's an access issue but the core design is very good imo.

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The core design is decent except it still relies on private insurers, which is odd on an island of 5 million, and you can get denied for pre existing conditions. Additionally, the fact that foreigners are not part of it is a problem.

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in what way does it *rely* on private insurers? yes, people may choose to get supplemental insurance or to participate in private providers, but this is true in every country with nationalized healthcare. it would be insane to outright ban private insurance (as Bernie Sanders has suggested).

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Problem according to who?

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This is not a valid criticism of the efficacy of the Singaporean healthcare system. This is a criticism of their value system with respect to public spending.

(and imo, a meritless one; what's the issue with the Singaporean government restricting access to social programs to Singaporeans?)

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I think I agree with you, but it's interesting to consider that Singapore has such a large number of expats. Something about the place requires a lot of non-singaporeans to be there doing stuff. Not because the citizens don't work, but just becauese the culture has evolved to live off a supply flow of outside blood.

So Singapore is refusing to offer health care to a population that is a vital and organic part of it's fabric. I think that's morally fine, but it's still interesting.

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Any foreigners here, like me, are here of our own accord.

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Jan 21, 2022·edited Jan 21, 2022

You're there of your own accord, but the large majority of non-citizens in Singapore are lower-income, some even there for generations, and have much more limited options. Upper income non-citizens are clearly a different group and not really who is being discussed. This is a somewhat less extreme version of being the British banker in Dubai who says foreigners have it great there; true for British bankers, perhaps, but absolutely not true for Indian manual laborers, who far outnumber the British bankers. It's hard to take any policy advice too seriously from places like Singapore or Dubai that rely so heavily on low-wage foreign workers who are always excluded from public benefits to make their economies run.

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Well, the construction labourers from Bangladesh and India are here because their other options are less enticing. Even low wage in Singapore is good by their local standards.

Similarly, I am in Singapore because my other options are worse.

You seem to imply that it is bad of Singapore to let poorer people work here? Countries like the UK which don't let poor people from India work there are even worse for poor people from India.. Alas, out of sight is out of mind.

I do agree that it would be better for humanity if Singapore, and other countries, opened themselves more to (economic) migration.

If the UK could let more people in to work, and somehow use that to make the NHS cheaper and better for locals, that would be great! Even if they don't open the NHS to the foreign workers.

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That is the standard argument for extending national coverage to non-nationals (ie, that they contribute to society so they should be included). But as alluded to by Matthias, I think freedom of exit satisfactorily addresses this point.

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I'm a non-Singaporean living in Singapore. It's great here, not sure what you have to complain about?

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How do non-Singaporeans access medical care? Do they pay doctors out of pocket every time they go for a visit? Or are there insurance options available for them?

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Different people do different things.

I often pay out of pocket, but there are also insurance options available.

Many expat white collar professionals get medical care through their employer as a benefit. But that's not mandatory to offer.

If you employ a foreign domestic worker in your household, the government mandates some insurance; and there are multiple competing private insurance providers for that.

I don't know about foreign blue collar workers. Though in general, the government is more paternalistic for poorer people, than for richer people or richer expats.

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I've also heard that singapore has good+efficient healthcare. althrough I have not look into it. More info on Healthcare triage:

https://www.youtube.com/watch?v=WtuXrrEZsAg

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Lived in Singapore for 5 years, doctors were good, if expensive, but the biggest issue was that as a foreign resident, you don't get to take part in all of the parts of it that keep costs down. Foreigners don't get the HSAs and they don't get the basic government Medishield coverage. So, as a foreigner, you are in the same boat as the US system where you pay for expensive private insurance on your own, or you are reliant on your employer to do it.

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Jan 20, 2022·edited Jan 20, 2022

Paying out of pocket as a foreigner here isn't all that bad.

For example at least you get a good estimate of costs upfront.

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yes! everyone benefits from having a system that centers price-sensitive consumers and provider competition. even those not covered by the system.

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A big part of it seems to be the compulsory savings accounts that can only be withdrawn from for healthcare expenditures. I'm not American, but I do not think most Americans would agree that this is a "reasonable healthcare system".

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They might see the light of reason, if you passed the savings of the system on to them?

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Maybe. But enough Americans seem to place a high enough premium on freedom that I think this would be a hard sell.

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Not sure. A mandatory savings account sounds like more freedom than eg taxes.

They can probably come up with a better name, too.

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HSAs are very popular for higher income americans due to the invective of tax savings. There probably is a way to scale them down, but it gets problematic once you have people living paycheck-to-paychecks with savings available (even if you pay a penalty to remove it).

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In Singapore you can't remove money from your health savings account for non health expenses, as far as I know. Not even with a penalty.

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we literally have compulsory retirement/health "savings" in the form of payroll taxes, although we do not get to keep the premiums (nor earn a guaranteed return). I would much prefer my 6% of income to go to a 401k and an HSA than to the pyramid schemes known as Social Security and Medicare.

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it's actually 12% of income... (employer and employee each pay 6%)

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Singapore is a strange omission here, given that it a) is unusually cheap, b) works well enough, in that it hasn't kept Singapore from consistently being near the top of the life expectancy rankings, and c) actually is very different from the others; among other qualities it has a very high proportion of out-of-pocket spending.

That said, the cheapness of Singapore's health care system is probably overstated due to its GDP being inflated by Singapore's finance industry.

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High GDP might be a part of the explanation. In absolute numbers, healthcare spending in Singapore is $4,439 per capita. Quite expensive with #20 spot globally, but still below most of the countries analysed here, save for China and Taiwan.

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> People talk about how the US system is “privatized” and the Canadian system “socialized”, but a lot of this comes down to whether your payments for the same basic package are marked “paycheck deductions” vs. “taxes”.

Having compared what is for sale in America to what is provided under OHIP, this is very much not the case. OHIP provides far more comprehensive insurance and greater peace of mind than any insurance I was able to find for sale in the US. You quite literally cannot buy the kind of insurance I have in Ontario in America.

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Could you clarify? I'm very interested to know about it. In the US I can buy a plan with no (apparent) limits where I pay $6,000 at minimum and $14,000 at maximum ($0 at minimum and $8,000 at maximum after subsidies). Or I could spend a few hundred more and get a different selection of doctors.

What actual content for the insurance ("more comprehensive") is different in Canada?

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Maybe things are different now? When I looked I couldn't find anything this good.

OHIP offers:

- no deductible

- no limits of any kind

- any specialist, any diagnostic covered

- hospital stay, surgeries, etc. fully covered

- no gotchas

- no having to sift through options (honestly this is huge for me, ymmv, but I don't think you can underestimate the importance of knowing that your coverage is good with no effort)

- no "out of network" BS, I can go to any doctor or clinic or hospital without any restriction

- no signups (e.g. I'm trying to find American insurance plans to compare, and I'm seeing "Open Enrollment for 2022 health insurance has passed", what the fuck is that lol)

I just spent some time trying to find a provider, and holy shit that was a nightmare. Best I could fine before getting too aggravated was $6000 US/year with all kinds of caveats, deductibles, copays, in-network-out-of-network bullshit... Copays on every kind of diagnostic into the hundreds of dollars. Like, what exactly am I even paying for at that point?

I would call that $6000 for a very much worse plan.

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So basically what US employer-based insurance used to be like 25 years ago.

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Except I don't need to be employed to get it.

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Deductible: it's a pro, not a con to me. In years I don't have medical bills I pay less, in years I have medical bills I pay more. If you consider the top number in the plan the "price" for the plan and then end up spending less, then you have the peace of mind that the most you can spend is X and if you get a little back into your retirement account then that's nice.

No limits: there's no dollar limit in the US. I suppose there might be some weird loophole where they decide spending one billion dollars on you to extend your life 30 minutes isn't kosher, but I imagine Canada has the same setup.

Any specialist, any diagnostic: Yeah, under the maximum price anything and everything that's legally medicine is covered.

Hospital stay, surgeries: yup, same

No gotchas: Ugh, we had a weird loophole gotcha a couple of years ago here where these hospitals would be "in network" but the people that worked at them wouldn't be, and they'd bill you beyond your cap. We closed that loophole one way or another in all the states (AFAIK, maybe one or two is lagging), but honestly that was something we should have raked the hospitals over the coals on. This whole "we just rent out the stage to the performers" setup is terrible.

No having to sift through options: I like choices. I like being able to find the setup that's right for me. I understand that others don't and just want someone to take care of it for them, but that's not exactly impossible to find at any price. Just pick the most expensive or cheapest plan (as your heuristic demands) and go for it.

No out of network: Yeah, that's still there in order to give teeth to negotiation. I don't think it's that big of a burden. I go to brand X doctors. If I really wanted brand Y I change insurers. If I wanted X+Y I would just pay more and get a more expensive insurance company. In Canada how much choice do you have over what doctor to go to? In the US I just pick any one that's on my plan (or change insurers and pick any one on theirs).

No signups: Once a year you pick your insurer/plan. Or you just ride with whatever you had last year.

If the argument is "It's impossible to pay for the same thing" the answer is no, you can pay for the same thing. You can also choose to pay less and get less (my preference). The cost is that you do have to actually make that choice instead of just being told you're getting what you are getting.

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Deductible: you're paying money, I'm not. Keep in mind that you pay the same in taxes on healthcare as I do, AND you get to pay for private insurance. That's how bad the US system is.

No limits: I think that's new with the ACA, pretty sure there used to be limits. But sure.

No gotchas: yeah until the next one...

No out of network: I can literally go to any doctor in the country. You say you like choice, but apparently not that much lol.

I was not able to find a plan that offers no deductible, no out of network BS, no copay. Maybe it exists, but I picked a nearby state (Pennsylvania), and nothing like that was offered on the State clearinghouse. Not for any price. Happy to change my tune if you can find that plan, but the fact that it's not a) easy to find and b) the default that's included in your taxes, is a complete and abject failure of the system.

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Shifting goalposts. You said for any price. What is the difference between a plan that costs 14k and a plan that costs 6k with an 8k deductible/out of pocket max.

Where do you get that we pay the same on healthcare taxes? I honestly have no clue what Canadians pay. Toronto Sun says about 9k if you make around 90k. Don't know how accurate that is but I make about thay much and would only pay that much if I maxxed out the plan that year.

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Jan 20, 2022·edited Jan 20, 2022

I wasn't able to find such a plan. Doesn't mean it doesn't exist, but it does mean it's not readily available.

You can look it up, but Americans pay the same in tax for your shockingly efficiency Medicare system which covers a few people as we pay for our system which covers everything for everyone with no deductible...

Show me a link to a plan that has no deductibles and no copays for anything, no out of network nonsense, and so on. And is also included in your taxes lol.

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No out of network is a huge downside.

People have to change doctors because of it. This causes tangible harm to plenty of people.

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You're misundering. They're saying there's *no such thing* as an out of network doctor, no that there's no access to out of network doctors. Out of network simply isn't a thing up there.

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Jan 20, 2022·edited Jan 20, 2022

I meant to reply (thought I did) to etheric42, who was saying that it's not that much of a difference between the two systems. I agree with Angus.

Specifically I understand and agree that not having to deal with out of network is a great plus of the Canadian system.

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I've been thinking about this response for awhile. I assume that there are some cases where this would be a problem but... for the circumstance I'm talking about (US insurance not attached to your job, bought through the marketplace), this seems very minor.

1) When you choose your plan you choose the plan with the doctor in network you have been seeing.

2) If your doctor drops the plan because of failed negotiations, that's generally limited to the end-of-year period, which is when you are free to change plans to follow them.

3) There is a chance that maybe you want to see both doctor A and doctor B and no plan has both A and B in their network. That would be a problem, although I suppose the "at any cost" at the root of my comment comes up, in which case you sign up for both plans.

4) There is a chance that mid-year you discover you need to start seeing a doctor, and you only want to see a doctor that isn't on your plan. That would be a problem, but only until the end of the year. If it's a chronic problem then I can understand wanting to make sure you are with a doctor you can form a connection with, but for one-offs it seems like you should be able to find someone on your plan that does a good enough job.

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I have personally known people who have had their lives negatively impacted in large meaningful ways because of having to change providers. It's not really a hypothetical so much as a real thing that happens.

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Jan 20, 2022·edited Jan 20, 2022

> Deductible: it's a pro, not a con to me. In years I don't have medical bills I pay less, in years I have medical bills I pay more.

You mean, in years when you might have trouble maintaining employment to pay those medical bills, you pay more. Sounds like a nightmare.

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Don't know what you're talking about. My insurance isn't attached to my employer. If you have a choice between spending 8k and having everything covered and spending 0k and having everything but the first 8k covered, the latter is strictly a better deal.

And again: the original comment was about not being able to buy the same thing for any price.

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Jan 20, 2022·edited Jan 20, 2022

> If you have a choice between spending 8k and having everything covered and spending 0k and having everything but the first 8k covered, the latter is strictly a better deal.

Sure, if you have to pay for health coverage regardless of your employment status. However, you were replying to a post that listed OHIP's coverage where there is no deductible, and you replied saying that a deductible is a feature, but it's not in that context.

Under OHIP you end up paying into the healthcare system while employed and don't have to pay a deductible, but if you become *unemployed*, say because of a serious medical problem, then you *don't* pay for health coverage *and* you don't have to pay a deductible. In principle, it's absurd on its face to expect people who can't be employed due to medical issues to pay deductibles to get the help they need.

So like I said, a deductible is not strictly a pro, and definitely not a pro for a system like OHIP.

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I have an option everything except for the signup problem. Open season is necessary, otherwise you wouldn't have health insurance until you're diagnosed with cancer or something. The option that has all that is more $6,000. It was $7,500 with my employer paying 70% on top of that. But they are available, just expensive.

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founding

There is SOME level of out-of-network issue. Move between provinces and you can end up in a very nasty game of pass-the-parcel where each province tries to claim they don't have to cover you. And medical care on vacation is often a similar situation.

Those are exceptions, though.

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As someone who grew up in Ontario and now lives in the US: thank goodness!

The experience in Ontario was terrible. Long, long lines. Multi-month waits to see your doctor. Unless you want to see the doctor on-call at which point you are still waiting hours. A continual lack of specialists. And unconscionable waiting times for things like hip replacements.

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So you are saying "You quite literally cannot buy the kind of insurance I have in" <America> "in" <Ontario>?

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Our experiences are completely different.

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It might help to put healthcare within the context what the "public health" system is for each of these counties. Listen to Zeynep Tufekci's recent interview with Ezra Klein. She has an ability to put healthcare for individuals (whether public or private) within the context of the public health infrastructure of different counties. This begins to show why the US has done so poorly with Covid. Even countries like Vietnam have dealt with Covid better than the US. She doesn't say this but I do, if the concept/mindset that the government can't do anything right and we shouldn't invest in public institutions, then we won't be prepared for health emergencies. This seems obscene for the richest country in the world.

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author

Disagree, US had fewer COVID deaths per capita than UK (most socialized health system in the developed world) up until the vaccines came out. US COVID problems relative to most other countries are mostly vaccine refusal problems.

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That sounds a little bit like special pleading. The point about *public health* is that it has a heavy political and cultural element. If America is less healthy because of X, then X is part of the public health equation.

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Jan 20, 2022·edited Jan 20, 2022

The discussion seems to be about "Which Country Has The World's Best Health Care?". Even the parent post specified "within the context of the public health INFRASTRUCTURE of different countries" [my emphasis]. I do not see how it's at all special pleading to point out that "cultural elements" (ie, personal decision to not get vaccinated), ie NOT healthcare design, was primarily responsible for the different outcomes.

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This honestly seems like it might be a partial answer to Scott's entire question of why US healthcare sucks so much when it's similar to systems that don't. Maybe Americans are just less healthy and it's harder and more expensive to provide care to people with worse health habits and lifestyles. The only developed nation I can think of with similar lifestyle/obesity habits is Kuwait. What lifespan outcomes do they get for dollars per capita?

It's analogous to why do we have so much more gun violence than Canada even though our laws are similar? We seem to just be culturally more violent.

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Along similar lines, what about credential systems? Is it easier to become a doctor in other countries? What about other levels of providers, such as nurse-practitioners or PAs. What about pharmacies that can diagnose and proscribe to address a limited range of ailments? What about the prevalence of parallel traditional-medicine systems?

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According to this graph

https://ourworldindata.org/covid-deaths

there is not much in it. The UK and US trade places a few time before vaccines.

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UK is also older and more densely populated on average.

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I think vaccine accessibility was a big part of the problem in the US, due to the piecemeal healthcare system. People were building third-party tools to share vaccine availability data, since the official ones were so lacking or awful: https://www.technologyreview.com/2021/02/01/1016725/people-are-building-their-own-vaccine-appointment-tools/ By contrast, the NHS really shone here: we all waited until our age-prioritised blue envelopes arrived through the post with our vaccine appointment details, then went along to GP surgeries or newly-created mass vaccination clinics in village halls and conference centres and got jabbed. It worked great until they got to the under-30s, who are much less likely to have stable addresses or to be registered with a GP (and thus harder for the NHS to get in contact with).

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You got a blue envelope? I got text messages.

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Not just vaccine refusal issues, but also issues that many people can’t afford to stay at home and isolate.

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Jan 23, 2022·edited Jan 23, 2022

I don't think you can put COVID deaths down to the NHS vs Medicare though. COVID deaths are mostly down how fast/far COVID, which is not something hospitals have much control over.

If the UK had stayed locked down during the winter of 2020 rather than the start/stop thing they did deaths would be a lot lower. That's entirely unrelated to how doctors are funded.

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I think that two things: the US style and culture of government, specifically, means that I inherently don't trust its government programs to be implemented as effectively other countries, even if the initial design is similar.

Two, I wonder if the ethnic makeup of the US vs. other countries had an impact on the Covid outcomes? COVID was very bad for Hispanics and African Americans, at least based on acquaintances on the ground e.g. in NYC hospitals. Did other developed countries have worse outcomes among their minority/indigenous populations? Is that just a factor of people being sicker (e.g. overweight, diabetic), more exposed (e.g., more crowded living conditions), or inherent predispositions? I've heard it argued that these factors are contributory to how Asian vs. non-Asian countries did with COVID, and how US vs. other European countries did with COVID, but I haven't really checked the numbers myself.

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My impression is that in Sweden covid incidence and bad outcomes were *much* higher among immigrant populations.

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Is there any official data to reflect that?

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This seems a similar argument to that made in this long read https://www.newyorker.com/magazine/2021/08/30/costa-ricans-live-longer-than-we-do-whats-the-secret that the kind of healthcare we normally think if that happens in hospitals is less important than widely available preventative steps, public health campaigns and easily accessible primary care

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COVID vaccine distribution seems like something the US actually did better than most other countries (with a few exceptions like Israel). Both initial shots and boosters were widely available sooner than elsewhere. The vaccines are also given away free without any need for health insurance, and the problem quickly became limited demand rather than supply.

This doesn't excuse the slowness of the CDC and FDA in approving vaccines and boosters, of course. It just means that other countries were even worse, or perhaps that the US was able to outbid them.

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founding

Whatever may be ailing the US government, it sure ain't lack of money.

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Jan 19, 2022·edited Jan 19, 2022

I read the comment "No country except the US pays anything like a market price for drugs[,]" and had to ask myself, "What does 'market price for drugs even mean?"

As I understand this section, in some countries, the price is set by government fiat. In other countries, the government or an entity indistinguishable from government negotiates the price. Neither of those seem like they could define “market price.”

The United States is different. But it seems suspect to say that the price paid in the US is the “market price,” since the combination of all of the other countries is (I suspect) a larger population and therefore a larger “market.”

And in the United States, the vast majority of consumers are not negotiating the price, their insurance is. I differ from Scott in as much as he says “Consumer’s don’t for drugs directly.” A small subset do, and they are paying a higher amount than those with access to insurance. So is the market price the price paid by the smallest, weakest part of the market?

I’m an economics near-illiterate, to say that almost everyone is paying below market price seems backwards.

ETA: I should say, can some explain this to me as if I am five, because my inability to figure this out indicates to me that I missing something. What would the proper measure of the "market price" of a drug be?

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It's hard to say what the market price would be, since many drugs are monopolies. Out-of-patent generics tend to be quite cheap, monopoly-produced new drugs tend to be quite expensive. That suggests that the actual "reserve price" of most drugs is quite low (i.e. the price below which it makes no sense to sell it as you're not making money), and it's only monopoly power that makes the drug expensive.

That further suggests that in a competitive environment where anyone could produce the monopolized drug, its market price would probably be fairly low. And that for monopolized drugs, the idea of a "market price" is kind of nonsensical.

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Indeed. As far as I understand, after a drug has been deemed useful and safe the actual cost of producing, distributing, and marketing is usually not particularly high. The problem is that getting from the idea for a new drug to the point where it can be prescribed or used is incredibly hard, expensive, and annoying, at least in the USA. And furthermore it fails for some non-negligible percentage of drugs. So the saying goes that pharma companies won't even try to do that work unless they get free reign to set the price for 20 years or so. But then what is happening in these countries where drug prices are low? Is it that getting drugs approved is easier or cheaper? Is it that they import all of their drugs and don't need to incentivize any pharma company? Something else?

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It varies from country to country usually some combination of

a) They don't get the drug

b) They don't get the drug for a long time (maybe 20 years)

c) They don't get the drug for a short time (maybe 6 months after first to market)

d) They only get a limited supply of the drug and then have to decide who in their country gets to use it (similar to how COVID vaccines were for the first 6 months or so)

e) They get as much of the drug as they want at a lower price than what is paid in the wealthier countries

Option e is great when it happens but it doesn't always happen...

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Option e often happens, as long as it is a sufficiently big market and the offered price is still way above cost. If you can manufacture and distribute a drug for $10 and you want $100, but you get offered $20, it would be stupid to not accept that offer, because that still offers you a $10 profit. Withholding the drug to get a better offer, only works, if your drug is really much better than everything else on the market, which is usually not true.

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Wouldn't that tend to imply that the amount of money a country spends on a drug isn't really the cost of the drug, but instead effectively the amount the country is willing to invest in the development of drugs?

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Yes, precisely. You can save money on drug prices by free riding on everyone else paying development costs.

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And by everyone else, you mean the USA. Per Cato, "the United States accounts for approximately 78% of worldwide drug industry profits". Since most profits are re-invested in research, America is basically saving the world.

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It seems that this claim is disputed. See e.g. 'Debunking The Pharmaceutical Research ‘Free Rider’ Myth' (https://www.healthaffairs.org/do/10.1377/forefront.20170602.060376/full/).

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This debunks nothing. It merely asserts without any backing data at all.

For an article with actual facts, please see https://www.cato.org/regulation/winter-2021/2022/why-are-some-us-drug-prices-so-high#

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You need to distinguish the price at which it pays to produce and sell a drug that is already discovered and approved from the much higher price at which it pays to bear the cost of developing a drug and getting it through the FDA approval process. Hold the price down to the former and you get no new drugs.

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Did you get your "n" back?! Did Scott find it on his honeymoon?

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Scott also fixed his blog title anagram when he moved to Substack. Together, this is what psychologists refer to as 'dual-n-back'.

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AFAIK whatever price anyone is willing to pay for a drug, is the market price 𝐢𝐧 𝐭𝐡𝐚𝐭 𝐦𝐚𝐫𝐤𝐞𝐭. Since it is illegal* for me to import a cheaper drug from another country, whatever the price for the identical drug is in Canada is irrelevant here in the U.S.

* https://www.fda.gov/about-fda/fda-basics/it-legal-me-personally-import-drugs

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That article is a bit weird - it starts from an assumption that those drugs "often have not been approved by FDA" and discusses the consequences, limitations and exceptions of that scenario while absolutely ignoring the very reasonable case where the drug is actually identical and *has* been approved by FDA, choosing (IMHO intentionally) to not give any answer whether that is legal or not.

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Perhaps Americans pay enough for drugs for the companies to recover the research and FDA-approval expense, plus the profit their shareholders require. Prices in other countries can be as low as the marginal cost of production.

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Other countries do drugs research too though.

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Sure, but where the research happens isn't a factor in what Steve said. If the drugs developed in other countries are priced similarly to the drugs developed in America, it's plausible that the higher American price is subsidizing development of new drugs in those other countries as well.

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founding

Researchers in countries around the world develop new drugs in the expectation that US insurance companies will pay them enough to make it retroactively worth their while, yes. US insurance companies have deep pockets and don't care where the drug is developed.

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Typically the market-price is the level that people are willing to pay for the benefit.

If we had a government-run health-care system except that it issued prizes to people who could provide cures [1] for diseases, the government would rationally offer $1 less than NPV of all their future expenses on that disease. Tee company spends some fraction, gets a profit on the rest, the government saves a buck, and the citizens are cured of the disease.

[1] just to keep the model simple, assume that complete cures are on the table and we can recognize them as complete cures

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Jan 20, 2022·edited Jan 20, 2022

Exactly. The markets are just different. The seller is typically a single monopolist drug company. The buyer can either be A) a collection of smallish independent actors (insurances), or B) a single committee acting for the whole country.

In both cases, the buyer is pretty desperate to buy (access to) the drug. But in the second case, the buyer has still much more negotiation power, because the seller is much more desperate to sell the drug. For two reasons: it is a higher chunk of the market that the drug company would lose. But also because denying a drug to a country is a PR desaster, but denying the drug to one out of 50 insurances is not so bad. (In that case, it would obviously the fault of the insurance, right? Because the others do get the drug. Stupid insurance!)

So the market price in B is lower than the market price in A.

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It seems like the size of the administrative body might play a role here. I don’t know how to make the connection or if I’m just restating a prior, but it’s easier to imagine 50 US states, some being well managed, some not so much, as opposed to the single US regulatory agency outperforming.

Maybe the summary is “picking a spot on the Pareto frontier involved value tradeoffs and the more people you have knocked, the more likely you’ll end up further from the frontier , since this lowers the number of pissed off stakeholders.”

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This is a good point. And the size of the country's population too!

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Reading between the lines here, there are (presumably fascinating, enraging, etc) reasons for the differences in pricing, but the author didn’t have access to the driving forces behind the negotiations.

Ex post, the different systems have a story about why good X is costing them price Y. But that’s a justification, not an explanation.

It’s a bit like saying the border between these two European countries follows the river; the fact that it follows the river is the outcome of the forces one really wants to understand.

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A river is a good Schelling point.

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But why the Rhine and not the Moselle?

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The Schelling point mechanism already does a lot of work:

It suggests why the lines aren't totally arbitrary. Or why, unless something big and important happened, the border will stick to the river, instead of deviating with little bumps and detours.

You are right that it doesn't tell you which river or which watershed gets picked. You need more contingent information for that.

But the Schelling point mechanism (or simplicity in general) does account for the vast majority of bytes in the border specification.

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Life expectancy is a poor metric for healthcare outcomes, and varies a lot based on how countries calculated it. In particular, the US tries to save babies born very very prematurely, many of whom die, and this really brings down the average life expectancy by putting in a bunch of extra zeros that most of the world calls “miscarriages”.

Secondly, satisfaction with healthcare is a function of the PR and patriotism ala NHS as the UK’s National religion, not actual quality of care delivered. I remember seeing this “study” that purported to find the NHS as the best healthcare across a dozen western countries which seemed odd until you realized most of their survey was fuzzy metrics like “do you feel it’s affordable” or “how much do you like it” and not “what are your chances of not dying from cancer and can you even get a surgery for it scheduled”. Health outcomes were only 1/11 of the survey metrics and NHS did quite poorly on that.

There’s a reason the rich of the world come to US hospitals to get their serious procedures done.

https://www.fragiledeal.com/t/coping-with-medicare-for-all/3107/33

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author

I don't think the life expectancy infant mortality thing holds up. The US ranks about the same place in "life expectancy at age 65" as "life expectancy at birth", see eg https://www.oecd-ilibrary.org/sites/037c3a2d-en/index.html .

I think you're right that life expectancy is a poor health care measure as it includes things like diet, exercise, and maybe even genetics, but it seemed fairer than using any more specific statistic when there's so much noise in all of them.

I agree the top levels of US healthcare are able to offer excellent service to the rich.

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“I agree the top levels of US healthcare are able to offer excellent service to the rich.”

Is it really just “the rich”, or is it like 90% of the professional class? How many people are dissatisfied with US healthcare because of objective reasons that are actually better, vs checking the “no”box because that’s the Blue Tribe thing to do?

How confident are you that you aren’t suffering from a grass-is-greener problem where you live the worst parts of US healthcare every day and only hear about the German system from advocates?

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author

I'm mostly going off of the statistics I find at https://www.commonwealthfund.org/international-health-policy-center/system-stats, the Emanuel book, the patient satisfaction ratings, and my own experience as a healthcare provider and patient in US and Ireland. I agree it's possible all of those are deceiving me, but at some point I've just got to go with my best estimate.

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That’s fair. I think the “personal experience as a provider” (without corresponding experience in a different system) and “public satisfaction” are highly likely to bias you in a negative direction. The first because you see how the sausage gets made (but only in the US), the second because griping about how terrible the backward US healthcare system is compared to our enlightened Euro betters is what all the cool kids do.

In light of that, and statistics which are very real but require some interpretation, might you be susceptible to confirmation bias? I certainly trust you more than most to have considered this though, so this is maybe unjustified quibbling on my part.

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You misunderstand: Scott has worked as a healthcare provider in both the US and Ireland.

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Jan 20, 2022·edited Jan 20, 2022

Commonwealth fund is quite biased tho, full of anti racist healthcare for All and similar rhetoric. Here’s the article pointing out how they ranked the UK the best (since they scored high on equity and affordability) while scoring poorly on 5 year survival rates conditional on stroke, cancer, etc.

https://mises.org/wire/does-britain-have-worlds-best-health-system-only-if-you-ignore-outcomes

As I said elsewhere, you can die for free without a fancy system. What you should be paying for is one that actually keeps you alive when bad things happen. The US system is really good at that, which is why when the global elite get old and need procedures, the top US hospitals are often their choice.

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Small differences in lethal condition survival rates are not really totality of the healthcare system. It is really small part of it.

"As I said elsewhere, you can die for free without a fancy system." - yes, because NHS does absolutely nothing for your survival rates, you could have just stayed home ? That is a pretty bad argument.

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I have a lot of problems with Commonwealth's methodology (basically they're similar to my critiques of Emmanuel's comparisons as well, I just don't think most of the things that differentiate systems in quality are easily quantifiable KPIs or macro level things like private vs public), but this Mises critique is substantially more biased than anything Commonwealth has ever put out.

FWIW, the 2021 Commonwealth report had the NHS drop by 4 places, with Norway, Australia, and the Netherlands now as their top picks. I don't think that's because their methodology suddenly got better, but I do think that's closer to accurate even if accidentally.

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The five year survival rates are misleading.

See https://youtu.be/yNzQ_sLGIuA for the argument.

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I think the broken link in your post might want to be this one

https://www.oecd-ilibrary.org/sites/037c3a2d-en/index.html?itemId=/content/component/037c3a2d-en

Which shows the US is the middle of OECD by age 65 conditional life expectancy. But the US has way more obesity and diabetes than a lot of the rest of the OECD, so in some sense our life expectancy is a testament to our healthcare system, and we achieve it in spite of our poor diet, exercise, etc. how many Big Macs per day did those Japanese get to eat if they want to make it 22 years from 65 instead of just 19? :)

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"I agree the top levels of US healthcare are able to offer excellent service to the rich." <---This might not be true! I'm posting this link all over the comments: https://bit.ly/3nGRHL8. It's a paper (by Zeke himself, publishe