[comnetxr]

Imagine if grocery stores forced us to choose one of a few dozen grocery "insurance" memberships to buy groceries, and negotiated directly with the insurers. No prices are labeled in store, they just detect whatever you take and send you a bill at the end of the month. (Differing brands of the same food product are not available in store of course.) Individuals are charged 3-100x more per product than negotiated rates, but can't find out until afterwards. Grocery "insurance" would then become a necessity. People would trade away disproportionate amounts of their salary to get good grocery benefits from their employers, i.e. to not get price-gouged by virtue of being an individual on the market. Stores would run discount programs for the very poor, which they could point to when people get outraged (as drug companies do now.) When politicians would threaten the system, grocery stores would fund ads about the "long lines" and limited food availability that would occur. Instead laws would get passed reinforcing the system by making sure everyone gets grocery insurance, as its a necessity (and it would _be_ a necessity).

I'm not saying that health care _could_ be exactly like grocery stores, with many alternatives, transparent pricing, and customers making the final decisions, but that it would have to be much _more_ like grocery stores to call it a free market. What we are working with now is just a system of pricing cartels supported by fear and lobbying. It needs to go.

[throwaway66920]

This is a good analogy because it highlights the important problem. Insurance companies are incentivized to have healthcare prices increase so long as they get a discount. Why? Because it increase their value to the consumer to the point of necessity.

[xivzgrev]

Also they are only allowed to make a certain profit margin: cost plus. One way to grow your profits is for the underlying cost to increase.

"The Affordable Care Act kept profit margins in check by requiring companies to use at least 80 percent of the premiums for medical care. That's good in theory, but it actually contributes to rising health care costs. If the insurance company has accurately built high costs into the premium, it can make more money. Here's how: Let's say administrative expenses eat up about 17 percent of each premium dollar and around 3 percent is profit. Making a 3 percent profit is better if the company spends more."

https://www.npr.org/sections/health-shots/2018/05/25/6136857...

[closeparen]

From the consumer perspective, calorie needs are stable and predictable, fundamentally different from what insurance is for.

From the supply chain’s perspective, there is a very sophisticated insurance system to smooth out issues with crop yields, weather, etc. called the commodity futures market.

[zwkrt]

Both of your points are true of healthcare. No, not everyone will break a leg or need major surgery, but everyone gets old and dies. Flu shots come out at the same time as pumpkin spice lattes. From an aggregate standpoint I would wager healthcare needs and costs are predictable and forecastable, just like commodities.

[kmjg88nvf8]

Can you explain to a Non-American what forces this system of employer insurance onto the US? Why don't independent insurance companies emerge that offer other models of insurance?

[dredmorbius]

There's both historical and insurance-business (underwriting) reasons.

The history: wage-price controls implemented during WWII as labour was taken up by the military and companies had to find some basis other than pay on which to differentiate. Benefits, including health care, were excluded from wage consideration.

Insurance itself is the business of assessing, managing, and sharing (or "pooling") risk. In the case of health care, the typical costs that a given population will face are predictable based on age, gender, and various exposures. Given a sufficiently large number of people, a group or policy cost can be assessed. Along with other groups, this results in pooled risk.

I'm not an actuary, but "large pool" risk is fairly low, I suspect it's on the order of 30 or so people. Smaller pools can be formed (or more likely: aggregated to form larger ones), down to a small number of members, as few as a handful or so.

The idea being that in any given pool, what's called "adverse selection" (people specifically looking for insurance due to high risks) are less likely -- you're dealing with the average population.

In individual markets, all of this becomes much less predictable, and/or the transaction and administrative costs of individual insurance simply add up.

Since a large share of the population works, or lives in a household with someone who does, allocating healthcare group insurance through employment has more-or-less stuck in the US.

The fact that it provides yet more leverage and control by employers over employees is another factor, of course.

Source: A long time ago in a galaxy far, far away, I studied this at uni. Plus more recent experiences / exploration.

[tomp]

I don't think the size of the pool is that relevant. The pool from the perspective of insurance company is all insured people, so it doesn't matter whether it's a company of 5 or 5 individuals joining, it's still a huge pool.

Adverse selection is the big reason. An individual signing up for insurance can be used as a signal that means "individual is sick" or "individual is likely to need insurance soon". If a company policy covers all employees (or all employees above a certain level), the signal is "person works" which is orthogonal to "person will need insurance" (in fact, it's probably slightly anti-correlated, a.k.a. "person is fit enough to work").

[dredmorbius]

Adverse selection among groups is an issue, given adverse selection: individuals or small groups with high but non-evident risks may emerge.

"Small-group" coverage is generally 50 or fewer (in some states, 100) members:

https://www.healthinsurance.org/glossary/small-group-health-...

[kmjg88nvf8]

I think people who are already sick should be covered by a kind of charity (or social services). It doesn't make sense to ask insurance companies to insure people who are already sick.

[dredmorbius]

An alternative is to have random-lot assignments, at least so long as you care to preserve a private, for-profit, insurance sector. That is, members of a given population is assigned, at random, to a set of insurance providers, who have minimum performance and obligation standards.

Otherwise, the socialised version already exists, in most industrialised countries, in some form or another. Within the US, Medicare for the elderly, Medicaid for the poor and children, and in many states, "high risk pools" which are state managed.

More generally, a problem is that the bulk of health benefits do _not_ accrue from direct or acute medical treatment, but from public health and preventive measures, _especially_ well-mother, well-baby, early childhood, municipal sanitation and environmental measures, and general (workplace and elsewhere) safety provisions. Insurance companies of and by themselves don't address much of this.

[sokoloff]

Great comment. I’ll agree and add that the pool of people working full-time itself serves as a beneficial selection process for the insurance pool. It includes (expensive) births but excludes a lot of expensive debilitating conditions so long as that condition precludes someone working full-time.

[orborde]

One major factor in the US is that, from the perspective of an employee, employer plans have a massive tax advantage compared to anything the employee could buy outside their employer.

If your employer pays your insurance premiums, this doesn't count as taxable income for you. So you effectively have a choice that looks like:

- Your employer directly pays $200/mo for your insurance, or

- Your employer pays you $200/mo as cash, the government takes $40 (adjust as appropriate for tax bracket) out as income taxes, and you have $160/mo left over to pay for health insurance.

I can't really speak to the political forces that keep this subsidy in place, though.

https://www.taxpolicycenter.org/briefing-book/how-does-tax-e...

[kmjg88nvf8]

So if you insure yourself privately, you can not deduct it from taxes? That would be an issue then, but seems easy to fix. Why isn't that part of the health care discussion?

[orborde]

You can deduct it, but there are a couple of distinct minimums in the tax code for how much you have to spend before it starts reducing your taxable income. ( https://www.insurance.com/health-insurance/health-insurance-... )

Also, for simplicity, I left out payroll taxes, which are invisibly paid by your employer directly to the government ( https://squareup.com/us/en/townsquare/payroll-taxes-defined ).

So the choice from earlier is actually more correctly stated as:

- Your employer directly pays $220/mo for your insurance, or

- Your employer pays you $200/mo as cash and pays $20/mo directly to the government in payroll taxes, totaling $220/mo. Then the government takes $40 (adjust as appropriate for tax bracket) out of your paycheck as income taxes, and you have $160/mo left over to pay for health insurance.

The payroll tax issue would apply even if you could fully deduct the $200/mo from your personal taxable income.

> seems easy to fix. Why isn't that part of the health care discussion?

I am as mystified as you are.

[kmjg88nvf8]

If employers can deduct more for health insurance than private people, it seems unfair and rigged.

Payroll taxes are another matter to me, that's mostly window dressing. Either employer pays the tax to the government, or pays it to employees and they pay it to the government. The outcome is the same.

I think payroll taxes exist mostly to hide the amount of taxes they pay from the population.

[watertom]

Big business likes the level of control. Employees are limited in their job mobility, especially to small companies. It restricts competition, it also suppressed wages.

Big business in the U.S. gets what it wants, and if they didn’t want employer provided healthcare it would be gone, but it’s not gone so it means they like it.

If there was universal healthcare in the U.S. there would be an explosion of small business. Most small business can’t afford to provide healthcare, and if you have an existing health condition there is no guarantee that the plan from your new employer, if they have a plan, will include your doctor, or that they agree with the old doctor’s treatment plan.

[kmjg88nvf8]

How can "big business" prevent alternative insurance companies?

[kelnos]

Lobbying for preferred tax treatment.

If insurance costs $500/mo, either your company can pay the premium for you directly, with no taxable event for you; or, they can give you $500 more as a part of your salary, but the government will take $150 of that (or whatever, depending on your tax bracket), and then you have $350 to cover a $500 expense.

Individuals can deduct medical/insurance payments on their taxes every year, but: 1) the rules are complicated with some payment minimums that mean a lot of people couldn't take the deduction at all, and 2) you have to come up with the extra $150 every month for 12 months before you get that money back (since the US tax system is pay-as-you-go with per-paycheck withholding), which is a real burden for many Americans.

Alternatively, your company can give you $715 per month, the government will take $215 of that in taxes, and then you have $500 left over to pay your $500 insurance bill, but: 1) your company would very much rather pay $500 instead of give you $715, and 2) that $715 is actually not a hard number, but will vary depending on each employee's personal tax situation, which can change throughout the year, and your company likely doesn't care to deal with that (this is less of a big deal, since it could be outsourced to a piece of software written by a payroll company).

Why do Americans put up with this? Many of them (most?) just don't understand how this all works, and so don't even know they're getting screwed. Many have no concept of systems in other countries that handle this better, in part because they don't travel and don't have friends or family abroad, but more because of concerted misinformation campaigns around any kind of changes to our health care system that would threaten the incumbents.

I guess big business doesn't "prevent" alternative insurance companies; there are plenty of available options for insurance that individuals can purchase on their own. But it generally costs more (because you're not an HR benefits person negotiating on behalf of your 500-, 1000-, 50000-person company), and you end up with the bad tax consequences described above.

If you're an enterprising individual who wants to set up an alternative insurance company that charges very low premiums for great plans, you run into the problem of having no negotiating power with health care providers, who are used to charging high prices because the traditional insurers will pay them.

[sokoloff]

You can adjust your withholding amounts by filing form W-4 with payroll, so that in-year cashflow issue is largely a red herring. (It’s solvable now and would become standardized/automated if the overall system changed.)

Other (more concerning) items you itemize are the real blockers.

[kelnos]

In practice, most people do not actually understand how the boxes on W-4 translate into withholding amounts. There'd be a lot of trial and error involved if done manually.

Regardless, there's a reason why I marked that issue as "not a big deal" -- because it isn't -- the other issues I mention are the meat of it.

[leereeves]

Another factor that hasn't been mentioned yet is adverse selection.

Individual health insurance plans do exist, but few healthy people buy them, so the pool is sicker than average, so the insurance costs more, so even fewer healthy people buy the plans, and so on.

Employer group plans cost less in part because the pool is generally healthy.

[webninja]

Tax laws. When healthcare is paid out from payroll, it is FICA exempt which means you don’t have to pay Social Security or Medicare taxes on it.

[Apes]

Consumers using grocery insurance would have no real say or insensitive in what groceries they get - it doesn't matter if all they need is some chicken and a cheap wine. All the grocery store sells are filet mignon and Dom Perignon, and that's what everyone gets.

[souprock]

With healthcare, it goes the other way too.

When my kid gets a deep gash, disfiguring an eyebrow or messing with an important finger, I'd be willing to pay extra for a surgeon to sit there with a microscope putting all the little capillaries and nerves back together. I'm offered a staple, or some glue, or maybe a couple stitches. No, I really don't like zig-zag eyebrows and stiff numb fingers.

Anybody know how to get the good treatment?

[pmart123]

This isn't a bad analogy actually.

[plughs]

Then imagine that there are some people who can't afford the food they need in the grocery store and are going to die.

Alternatives and transparent pricing isn't going to make brain surgery affordable to the average consumer.

[Spivak]

Solving the problem of care that a person can’t afford is a completely different issue than fixing the problem of routine affordable care being exorbitantly expensive.

[kuzimoto]

According to Wikipedia, there are only .5% of all physicians in the US who can perform neurosurgery. So it's probably safe to say the demand for brain surgery is much higher than the supply.

This incentivises people to become doctors that perform such complecated procedures as it takes a lot of time and a lot of money to be able to do those things.

If you were to force doctors to perform work on people that can't afford it, then presumably they will earn less money. If they earn less money, there is less incentive to do that kind of work as they will pick something easier and more profitable.

You will end up with fewer people to do brain surgery.

[akhosravian]

There are two parts here that are not clear, and potentially misleading for folks unfamiliar with how doctors are minted in the US. The first is the cost to the individual to become a neurosurgeon. The second is around the supply side of the health market.

First, to become a practicing doctor of any sort one first completes med school then a residency and (depending on specialty) fellowship. The med school part is more or less the same for all physicians from your GP to brain surgeons to psychiatrists. Many folks take out loans to cover med school.

The residency and fellowship parts are paid. In practical terms this means a person becoming a neurosurgeon needs no more loans or upfront cash than a person becoming a GP. (I assume everyone is familiar with opportunity cost so will leave that part unsaid)

As an aside, much of the funding for these programs comes from the public (via Medicare).

All this means, the cost of becoming a neurosurgeon is about the same as any other specialty.

As for the supply side entry to med school and selection to residency programs are the big bottlenecks.

Med schools are accredited via doctors trade bodies. This means doctors (not market forces) decide how many new folks can become doctors.

As previously mentioned, residencies are largely funded via Medicare already. However, the number of residents has been capped since 1996. In that period of time the US population has grown by about 60 million (25%).

You may have been familiar with all this, but I think the context is important for discussing market solutions to healthcare — there are a lot of distortions around the US having anything resembling market behaviors.

[nine_k]

I suppose that the amount of doctors graduating each year is below the supply-demand equilibrium, and this us because the artificial supply-side limitation. Most doctors are overworked, despite their very high throughput and medical offices' efficiency.

This gives doctors a way to pay out their colossal student debt, though!

[ClumsyPilot]

How did you come to your concluding without looking at demand?

I don't need brain surgery every tuesday.

[kuzimoto]

This article suggests that there is a gap, and is widening. Only 1 to 61,000 people. It also mentions that they tend to be clustered in more populated areas, leaving some places without any coverage.

https://aansneurosurgeon.org/departments/neurosurgical-workf...

[rubidium]

If money were the only incentive to life no one would become a schoool teacher. Your summary is missing something.

[aianus]

Someone will still become a school teacher, they'll just be incompetent at it: https://www.thestar.com/yourtoronto/education/2016/05/13/for...

[Noumenon72]

If money were the only incentive tons of people would become school teachers because school teachers make significantly more than the average. Other incentives, like having to deal with kids and get a degree, is what keeps people out.

[Wh1skey]

Entry-level teachers earn over $40,000 according to Payscale. Median income for the lower class is about $25,000. Anecdotally, it's not unreasonable to become a millionaire in real estate by the time you retire on a teachers salary.

https://www.pewresearch.org/fact-tank/2014/12/17/wealth-gap-...

[kuzimoto]

That is true, but if you're the type of person that likes to help others it's much easier to become a teacher than doctor.

Also, if you are a doctor and your primary motivation is helping people, wouldn't you want to help many people with simple problems, than few people with highly complex problems (which most likely have a higher risk of failure)? There is already a shortage of doctors doing the easy stuff.

I just don't see the incentive for doing difficult procedures other than with money.

[tanr54ok]

> Also, if you are a doctor and your primary motivation is helping people, wouldn't you want to help many people with simple problems, than few people with highly complex problems (which most likely have a higher risk of failure)?

Your analysis completely falls flat here. Not all doctors are motivated by the same things and yet most of them would consider their primary motivation helping people.

Neurosurgeons are a prime example. They would very much prefer few complex cases (not everyone gets a brain tumor thankfully) as their way to maximize benefit rather than manage cholesterol meds for 100s.

Speciality surgeons by their nature are motivated by a certain degree of risk.

The incentive for doing difficult procedures is often because they are challenging. Compensation for doctors in the US isn’t fully correlated with difficulty either... with no offense to my dermatology colleagues making more than most general surgery sub specialists.

[kuzimoto]

> Not all doctors are motivated by the same things and yet most of them would consider their primary motivation helping people.

That's fair. I probably over-emphasized the money part of it.

> The incentive for doing difficult procedures is often because they are challenging.

We can assume that since doctors aren't doing this for free or at least cheap already, that they require at least some amount of compensation. To return to my original point, if you force doctors to perform procedures on people that can't afford them, and the amount they receive is less than they want, then there be a greater shortage of such doctors.

> Compensation for doctors in the US isn’t fully correlated with difficulty either... with no offense to my dermatology colleagues making more than most general surgery sub specialists.

Not directly anyway, it's probably more supply/demand. Low supply of neurosurgeon means high cost. Whether that's from artificially suppressing the supply of these doctors or because it's very challenging is up for debate.

I'd guess dermatologists make so much because people are more willing to spend money on that sort of work.

[maerF0x0]

No, but alternatives and transparent pricing allow us to weigh alternatives and to have an adult conversation about all of us will die someday (save singularity). Then we get to negotiate about what it's worth to extend that date of death forward 1, 2 .. N days for $N .

Next we look to that "scorecard" (bank account) which is the value provided but not called upon and get to see if we can call in enough "favors" to afford the healthcare

[adrianN]

As I see it, there are two solutions. Either all medical costs are "free" for the consumer and paid for via a tax, or you have a proper insurance system where consumers participate in a transparent market for non-urgent medical care and buy insurance only for things they can't afford. The latter needs some extra regulations for emergency care where you can't compare prices.

[bigtunacan]

Then imagine there is a government aid program to help those people. For the sake of argument we'll use the term "food stamps".

[kbutler]

There are people who can't afford groceries now - we don't fund that by having the government pay for all groceries for everyone.

[sabujp]

universal healthcare is sort of the equivalent of free food. What if your medical condition is malnourishment?

[bhupy]

Food stamps (or the equivalent value in cash).

Now s/food/health

[nextstep]

This would be great if health choices were being made by rational consumers. But when I break my leg, I want services quickly and I don’t have time or energy to price compare ambulances. Healthcare is not a marketplace that will have compassionate outcomes if we allow deregulation.

[mosselman]

Yes, because in countries where health care prices are 3-100x lower it is total anarchy. People lie on the streets for hours, browsing price comparison websites while bleeding out.

[baq]

in most countries you don't get billed your quarterly wage when an ambulance picks you up for a 10 min drive to the hospital.

[doctorpangloss]

This isn’t a very good analogy.

In a just world, nobody would go hungry, nor would anyone die prematurely or suffer needlessly due to lack of care. We can obviously afford both, in this country, just like they can everywhere else in Europe or Canada. So this entire argument about insurance is a straw man.

It’s not the doctors who set up this world. It’s people who want to pay less taxes, but blame doctors.

[throwawaytoday5]

Why shouldn't doctors and the medical industry take the blame in the US? They artificially limit the supply of Doctors in the US and have the audacity to claim that building more medical schools will ruin their already lucrative careers.

The whole industry is a shame.

[nine_k]

Regarding Europe, which I happen to have friends all over: it's not exactly as rosy.

European countries do have more doctors per capita, which is good.

They don't have nearly as much resources in the system, though. Come to a doctor with a bad cough, get a prescription for Paracetamol. You got to have a pretty bad infection to get a prescription for an antibiotic. Endure a long discussion with a doctor to renew an antidepressant prescription made in another country.

Lines are pretty long, too. Wait for two weeks to get an appointment about your coughing and sneezing. Have a deteriorating chronic condition and be prescribed painkillers and be told to wait for a year. You're not yet feeling so bad as the people who are currently being treated and who take up the capacity; these people also waited a long time.

All are examples from my friends dealing with the health systems of Netherlands, Sweden, Germany.

The US system has a ton of issues, but I still take it over these European systems. Have I been floored by medical bills? Yes, from my dentist, from my wife's heart surgery. But I somehow managed — and we both received instant, high-quality help.

Even the Russian system is better, or used to be back in the day. You could buy local insurance, and the choice was reasonably wide. You could pay upfront in cash, and the sums were manageable — Moscow definitely not being a cheap city, more expensive than many EU capitals.

Of course, I'm talking from a perspective of a well-earning software engineer who lives in metropolises, not in countryside. Still I think that either system has downsides, and the European systems are not superior, but just suck differently.

[mschuetz]

I'll chime in with my experience in Austria:

* If I have a cold, I go to a doctor without appointment and if I'm unlucky, I have to wait for 2 hours. Usually it's 30-60 minutes.

* If I have a specific thing that requires a specialist, I may or may not have to get a referral from a general practitioner first. Most specialist don't really need it, but for an allergy test I needed to get one. This puts me at 2 x 60 minutes wait time.

* Costs are close to nothing. Drugs will cost a little, up to around 6€ for a pack of meds. I have to pay 2€ for a doctors visit due to the specific insurance provider I have, which is okay. I needed to pay 12€ for an x-ray because it wasn't an emergency.

* My austrian insurance provider payed more than half of a hospital trip I had to take during vacation in Taiwan. Total cost of the trip to the hospital without insurance was 130€, which included check by the doctor, pain medications and some medical equipment. I had travel insurance, but I didn't use it because I was left with a bill of just 60€.

* A few times I was angry because a doctor only took 5 minutes time, prescribed some pain meds and sent me on my way. Told me all I can do right now is wait until it gets better. Turns out, that was the case.

* If it's an emergency, you get treated immediately.

I wouldn't trade our system for anything. It's not perfect, but it's perfectly fine.

[unionpivo]

Can confirm. I am from Slovenia, which just copy pasted this system (mostly), and it works decently.

we are not as ritch as Austria and that shows, so if you don't have emergency wait lists for certain things are longer.

[ddnb]

Exactly the same experience here in Belgium, only the doctor visit costs are way higher. Instead of €2 it's more like €25 per visit or I think €35 for home visits. I don't have experience with costs abroad so can't comment on that.

What is correct is that in Belgium you also don't get antibiotics because you ask for them. Only when the doctor deems it necessary you will get it.

[greggman2]

In the USA, at least in my experience. If I have a cold I still had to make an appointment which would be 2 to 3 days later. I got around this by joining a doctor in a clinic and they'd let me see any doctor if my doctor wasn't avaiable but i'd have to sit in the waiting room for 1 - 2 hrs.

In Japan I have had mixed experiences:

Good:

* It's relatively cheap. Apprently the government sets prices. The government offers medical insurence. It costs based on previous year's income. i've paid as little as $15 a month and as high as $300. I don't know the range. It only covers 70%. My employeers have provided insurance that covered more.

* Fast. There are no appointments or a least I've never made one. Just walk in, usually no more than a 20 minute wait. Did have one long wait 1998.

* Some pretty good tech. Had back problems once. Got an MRI immediately (Japan has/had ?x more MRI machines than USA). Last week had an unusual pain in neck, went in, got immediate endoscope pictures inside neck.

Note that in Japan, unlike the USA, hospitals are a place you can just walk in for a cold. (you can also go to small clinics and private doctors). The advantage of going to a hospital is they have more specialists and equipmnent. The disadvantage is sometimes longer waits and probably not as close. I only bring that up as a contrast to USA where a hospital is someplace you don't go unless it's an emergency or surgery or something else really serious.

Bad:

* Bar to be a doctor much lower. Have had several very quack doctor expeiences in Japan. Have not yet had a quack doctor experience in USA

* Unclean. Have been to several facilities that seemed unclean to me. Machines that looked like people had coughed on them for years and had never been cleaned. Not all places but enough the experience has stuck out. No idea what that's about but just surprised since my experience in the USA was that medical services are or at least appear spotless.

Unknown:

* Nurses require no training (or so I was told by a nurse). You just go apply for job like a fast food job. Is that better (lower cost) or worse (less training).

[Aeolun]

> Unclean. Have been to several facilities that seemed unclean to me.

The thing I like about it is that you can just leave the unclean facilities behind and find a new doctor, and it will cost you exactly the same as the old one.

[deepaksurti]

>> In Japan I have had mixed experiences:

Replace ‘Japan’ with ‘metro cities in India’ and its almost the same. I can’t still fathom why there would be no walk in facilities for ailments like cold.

I still remember my shock when in US I realised from a colleague that for my cold I need to wait because I can’t walk in and need to take an appointment.

[greggman2]

I noticed recently in the USA places like Walgreens you can see a doctor for colds. That seems like a great idea to me. I guess that's similar in Thailand and maybe Malaysia.

[desas]

What does a doctor do for a cold? In the UK and I wouldn't dream of going to the doctor's for a cold. You just wait it out don't you?

[kelnos]

I don't get this either. If I have a cold, I just take acetaminophen a couple times a day to suppress the symptoms until it goes away. Sure, if you're elderly or have an autoimmune deficiency, you may want to see a doc for everything, but that's not that common.

(Amusingly, I was in London a few years ago and came down with a cold. One of my local colleagues told me about this amazing thing called paracetamol that was just magic and would make me feel better. I was astounded that we didn't have it back home in the US... until I looked it up and realized it's just acetaminophen under a different name.)

[jacobush]

YES?! What the hell? Especially considering, the kind of sinus clearing pills which are forbidden (classed as a narcotic) in Sweden, they handed out in jars like candy at the US office.

[beefalo]

Walk in facilities do exist in the US, but wait times can be 2+ hours because the supply is so constrained.

[broknbottle]

There's no reason to visit a doctor for the common cold. Stay home and get some rest.. Do you take your car to the dealer or local mechanic to put air and washer fluid in your car?

[g4omingron]

>There's no reason to visit a doctor for the common cold.

That's such an american thing to say. A flu can be swine flu and fever can be Malaria or Dangue and one day delay can mean losing your life, so people in many parts of the world take fever and flu seriously.

[twobat]

I live in Eastern Europe so it's a bit like a third world country compared to Germany or Sweden. But let me tell you, it's not like you describe it at all. First of all, you don't get antibiotics just because you think you need antibiotics. And then, there's the private sector which has normal prices. And they treat you like a VIP.

[noobermin]

>The US system has a ton of issues, but I still take it over these European systems. Have I been floored by medical bills? Yes, from my dentist, from my wife's heart surgery. But I somehow managed — and we both received instant, high-quality help.

You are not the norm.

[tails4e]

I think you are mis- characterizing the European systems. I say systems as each country is different - some better than others for sure, but from what I've seen from both the US and European systems, I prefer the ones where my family going bankrupt does not depend on one of us getting seriously sick or not. The cost of healthcare per capita is way higher in the US, and outcomes generally poorer (see infant mortality rates for example).

The state of insurance for health in the US has far reach ing, society altering negative effects too which are often not considered. My sister in law would like to stay at home for a few years woth her young kids taking a career break - but cannot as she'd loose her insurance, despite her husband's income being enough to support them, it's the insurance holding her back. This absolutely would not be an issue anywhere in Europe I can think of.

[nine_k]

I agree that the "cost disease" is bad enough.

It's strange to hear about not getting an insurance if staying at home. That's exactly what my wife did when our child was small. She had the same insurance as me, because I was able to add her to my employer-sponsored insurance policy.

What really sucks is to be a small-scale entrepreneur, a garage-stage startup founder. You're cash-constrained, and there's no employer to give you a cheaper insurance plan. Obamacare is said to have helped recently.

[tails4e]

In this case she is a teacher in CT with very good benefits, but her husband, while on a decent salary has pretty terrible benefits, so she could not switch to his insurance is she stayed at home. Crazy situation when you think about it

[onion2k]

Wait for two weeks to get an appointment about your coughing and sneezing.

Here in the UK you can get an appointment to see your GP the following day most of the time, and we have walk-in clinics for same day check ups if you don't care which doctor you see. Availability varies a lot around the country but its mostly good.

[nixgeek]

This was not the case in Bristol when my GP took 2+ weeks to see me for the first time, then upon arrival, pawned me off on a nursing assistant rather than a doctor, then happily prescribed antibiotics for an “STI”, and then ignored my asks for a follow-up appointment for 2+ more weeks.

It turned out to be cancer. Original complaint stated when trying to book the appointment was “I have a testicle the size and hardness of a golf ball”.

Through that now, but the NHS is dysfunctional compared with U.S. healthcare. I have several relatives with bad hips or knees in U.K. who got prescribed stronger and stronger painkillers for >6 months because the waiting list for surgical intervention in their cases was so long.

[desas]

> You got to have a pretty bad infection to get a prescription for an antibiotic

That's because of antibiotic resistance. Increased use of antibiotics means they're less effective in the long term.

[ceejayoz]

> Come to a doctor with a bad cough, get a prescription for Paracetamol.

Good. Most coughs are viral, and that's the appropriate treatment.

[BrainInAJar]

> but that it would have to be much _more_ like grocery stores to call it a free market.

Except not really. If I'm poor I can choose to eat nothing but ramen. I might not like it, it might not be the best for me, but it'll keep me alive. If I'm poor and have a heart attack I can't choose to just take tylenol, I do need that bypass surgery.

The ability to walk away from a transaction entirely is what makes the market free, and because health care is life or death there is simply no way to make it a free market, you are compelled by your life to make (many? most?) of the transactions.

[kelnos]

I don't think that's a great analogy.

There are plenty of medical conditions where there are several options for how to manage it. With insurance, people usually choose based on risk of failure or complications, recovery time, etc. Without insurance, someone might choose primarily based on price, and a poor person might go for the cheapest option. For some non-life-threatening issues, a poor person might refuse treatment if the cost for even the most minimal intervention is too high.

This is obviously not what we want -- ideally, we want some reasonably-high minimum level of care so people don't have to choose between, say, starvation and permanent disfigurement -- so, as the parent says, we don't want health care to be exactly like a grocery store, but this kind of thing would be more like a free market for health care.

(And even in your example, you still have to buy and eat that ramen. Sure, you don't have to pay for steak, but you have to buy something. You can't just walk away from the transaction entirely.)

[mattkrause]

Have you ever actually tried to do this? It is hard.

A family friend, a smart guy with excellent insurance, was recently diagnosed with Parkinson’s Disease. Since I’m a neuroscience researcher, he asked me for advice. Despite working in an immediately adjacent field, at a Parkinson’s Centre of Excellence, with access to experts and tons of relevant training and literature, I found it very difficult to make a recommendation, even between the options his doctors had already laid out. I can only imagine how hard this would be if I had to consider the price of these treatments too.

[kelnos]

No one said it was easy. Regardless, I'm not sure this particular example is relevant: you cherry-picked something that actually _is_ hard to decide about.