[bhupy]

It's a stat that requires a lot of contextualization. To your point, you're absolutely correct that the number of bankruptcies is important, because over the last couple decades, 1) bankruptcies in general have been falling, 2) medical bankruptcies have also been falling in absolute terms; but because the denominator has dramatically fallen relative to the numerator, the numerator looks larger than it actually is.

https://www.theatlantic.com/business/archive/2009/06/elizabe...

In other words, medical bankruptcies have fallen in absolute terms, but you wouldn't know that by just looking at the %age of bankruptcies.

[ddingus]

Why not simplify the medical bankruptcy discussion?

Fact is Americans have high personal cost and risk exposure relative to nearly all of the rest of the world.

Second, our system has making money as the priority, again in contrast to much of the world.

Finally, most of the world recognizes the inherent conflict of interest between for profit and sick/hurt people and both regulate that conflict to marginalize it, and make it so people have options that make sense.

My take, having been chewed up by our toxic healthcare system twice now (having a family does matter, lol), is the temporary dampening on cost and risk escalation starting the ACA brought to us is fading now, and issues are exceberated by the pandemic (demand for care crashing into variable supply), and shifted somewhat as large numbers of people fall into subsidy medicaid type programs due to job loss.

The honeymoon period is long over now, and the drive to "make the number" is going to be front and center and escalating from here.

TL;DR: We are not improving on this front at all. We need to.

I could go on at length about high student debt and it's impact on these discussions too.

The radiology control over labor, preserving income for it's members is totally real, and fron their point of view, necessary. They ask the legitimate question in the US: How can I afford to practice.

Most of the world does not put their medical people in positions to ask that question, with some exceptions, those being far more rare and easily discussed than most of the topic is here.

[bhupy]

Full disclosure: I work in healthcare pricing, so I have some first hand insight into all of this

> Fact is Americans have high personal cost and risk exposure relative to nearly all of the rest of the world.

This is only true for some Americans, and increasingly very few. I actually found this tweet by a health policy expert to perfectly capture the status quo: https://twitter.com/CPopeHC/status/1234510323425652737

"American healthcare in short: ~60% (in good employer plans, generous state Medicaid, or M.Adv/Medigap) have the best healthcare in the world. ~30% have insurance with gaps/risk of big bills. ~10% uninsured must rely on uncompensated care, go without treatment, or risk bankruptcy

The strength of M4A proposals is that they begin with an understanding that the 40% exist and need things fixed. Their weakness is that they pretend that the 60% don't, and threaten to take away what they have."

The fact of the matter is that the majority of Americans have excellent, world class health coverage. The problem is that there exists a small percentage of Americans that are totally screwed, and this is a higher percentage than most other comparable countries. There are a couple reasons why, which brings me to...

> Second, our system has making money as the priority, again in contrast to much of the world.

First of all, this is false insofar as not all health insurance in America is for-profit. Blue Cross Blue Shield, for example, are predominately 501 non-profits (with a few notable exceptions).

Second of all, while you're right that much of the world has public insurance companies that don't seek to "make money", there are a number of countries with world class healthcare that do have profit seeking insurance, many of them with purely private profit driven insurance companies: including Switzerland and the Netherlands. Some have a hybrid of public/private, including Germany (public/private mix), Singapore (public/private mix), etc. In fact, while many countries have a public insurance system, it is extraordinarily rare for countries to outright ban private insurance options.

Third of all, in America, health insurance is one of the most regulated industries in the country. After ACA was passed, there's a strict cap on profit margins that health insurers can enjoy. It's not too dissimilar from how private health insurance is regulated in Switzerland and the Netherlands, both of which have some of the best healthcare on the planet.

> Finally, most of the world recognizes the inherent conflict of interest between for profit and sick/hurt people and both regulate that conflict to marginalize it, and make it so people have options that make sense.

Again, as I mentioned above, this is not only not true, it's debatable if such an "inherent" conflict of interest even exists. By this logic, there should be an inherent conflict of interest between for profit food providers and "hungry/starving" people. The profit motive alone can't explain America's health outcomes, because there exists countries with fantastic healthcare systems (Switzerland, Netherlands) which are driven purely by private health insurance.

America actually has a pretty good apples-to-apples experiment of "profit seeking" vs "not profit seeking" insurance, ironically in Medicare Advantage. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare, also cover Part D prescription drug benefits, and often include supplemental benefits that Original Medicare doesn't already cover. There are some interesting findings so far:

- 39% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly, that we expect by 2025, more seniors to be on a private plan than the public one. There's also great variance by State. In Florida, Pennsylvania, Wisconsin, Michigan, Minnesota, Oregon, Alabama, Hawaii, and Connecticut — nearly 50% of beneficiaries are on Medicare Advantage. By 2022, we expect more seniors in those States to be on a private plan than a public one. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...

- For most beneficiaries, Medicare Advantage costs about 39% less than Original Medicare. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...

- Medicare Advantage plans are, on average, of higher quality than the public Original Medicare. https://healthpayerintelligence.com/news/medicare-advantage-...

- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan. https://www.commonwealthfund.org/publications/issue-briefs/2...

So the reality is really more complicated than you're making it out to be.

From where I sit, the one thing that sets apart America from the rest of the world is not that health insurance can be profit driven (so do the Swiss and the Dutch, for example), it's that health insurance is coupled with employment. There's really no other peer nation for which this is the case, and a lot of the economics of health insurance look the way that they do because big employers buy most of the health insurance in today's market, and that has resulted in market distortions that hurt those that are unemployed. What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. Employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.

[disabled]

> The fact of the matter is that the majority of Americans have excellent, world class health coverage. The problem is that there exists a small percentage of Americans that are totally screwed, and this is a higher percentage than most other comparable countries. There are a couple reasons why, which brings me to...

Really? That is news to me, as a dual US|EU (Croatian) citizen, who is culturally American--but currently living in Croatia.

Even Croatia has a higher life expectancy than the United States. Yep, even those "eastern European countries" (that are within the European Union) that Americans refer to with derision, often have higher life expectancy than the United States.

See: https://www.reddit.com/r/croatia/comments/nuiyk1/hrvatska_sp...

Also, just in case you want to blame this on "lifestyle factors" (which means that this is a public health matter, which the United States has severely underfunded--locally, state, and nationally for more than a few decades now), the third leading cause of death is believed to be preventable medical errors. (The source I provide has been verified by several follow-up studies.)

See: https://www.bmj.com/content/353/bmj.i2139/rapid-responses

Also, you don't know what you are talking about here. I have studied healthcare systems worldwide for hundreds of hours.

Ironically the IMHE group that does the coronavirus projections is world renowned at producing this data. All of this data is open-access.

For starters (easy reading) this article is relevant: http://www.healthdata.org/news-release/how-healthy-will-we-b...

But, seriously, we have far from the best healthcare system in the world. That is not even remotely true. There are several countries where a woman can give birth and is less likely to die, compared to the US.

I wish you were joking.

[bhupy]

> Really? That is news to me, as a dual US|EU (Croatian) citizen, who is culturally American--but currently living in Croatia.

Yes, and just like that health policy analyst, I can attest to it. I've read more than enough plan documents, and work with health actuaries every day.

> Also, just in case you want to blame this on "lifestyle factors" (which means that this is a public health matter, which the United States has severely underfunded--locally, state, and nationally for more than a few decades now), the third leading cause of death is believed to be preventable medical errors. (The source I provide has been verified by several follow-up studies.)

Actually, there's a fantastic analysis that addresses this point head on, even analyzing the IHME data: https://randomcriticalanalysis.com/2017/05/16/the-explanator...

The vast majority of the variance in average life expectancy is attributable to lifestyle factors. As long as you stay away from drugs, you don't participate in a gang, or you take the bus (or any public transit), you're on roughly equal footing with the rest of the OECD.

"The data suggests motor vehicle accidents, homicides, and drug overdose deaths can explain a large fraction of the US life expectancy gap as compared to several highly developed countries. Obviously this does not account for obesity, diabetes, (historical) smoking, and related lifestyle differences that are likely to have a pronounced negative affects on US life expectancy as compared to most other developed countries and which statistically explains the vast majority of the very large spatial differences in the United States."

> Also, you don't know what you are talking about here. I have studied healthcare systems worldwide for hundreds of hours.

Um, so have I. I literally work on health pricing systems, and have studied health policy. "For hundreds of hours" even, for whatever that's worth (not a lot, I assure you).

> But, seriously, we have far from the best healthcare system in the world. That is not even remotely true. There are several countries where a woman can give birth and is less likely to die, compared to the US.

I don't think I ever said that we have the best healthcare in the world. I agree that US healthcare is broken. All I'm pointing out to you is that the "profit motive" has nothing to do with that, as evidenced by counterfactuals in Switerland, Singapore, and the Netherlands; the former two of which actually have the best healthcare in the world.

https://www.rd.com/article/switzerland-worlds-best-healthcar...

https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...

https://www.bloomberg.com/graphics/infographics/most-efficie...

In my opinion, the profit motive has nothing to do with America's healthcare ills (no pun intended). It's the fact that it's tied to employment and purchased by employers. No other country is set up that way.

[beaconstudios]

This is the most HN argument I've ever seen.

Personally, I defer to you, the person who actually understands the industry from the inside, in terms of having an opinion based in reality.

So often, these hand-wavy solutions which boil down to "we must remove the bad people preventing our utopia" (ie scapegoating) are masking wicked problems (https://en.m.wikipedia.org/wiki/Wicked_problem) that cross multiple thresholds of responsibility, incentive and jurisdiction.

Declaring hard problems to be caused intentionally by evil people has led to some of the most despicable acts in history.

[disabled]

> I've read more than enough plan documents, and work with health actuaries every day.

So, part of your job is to analyze health benefits plans (health insurance plans) that Americans get. You also work daily with actuaries in the life sector, who assign dollar values to people's lives.

Yeah, like that really makes you a good source when it comes to the well-being and long-term outcomes of a country.

> In my opinion, the profit motive has nothing to do with America's healthcare ills (no pun intended). It's the fact that it's tied to employment and purchased by employers. No other country is set up that way.

Congratulations on coming up with that point. That is precisely why I left the US, as somebody with a rare disease that requires an orphan drug to survive.

I knew better than to stay in the US, in order to survive. In fact, there may be a major ACA Supreme Court decision coming soon. If not, it will be released in the next session. I refresh SCOTUSblog every morning, worrying for my fellow Americans, who could very well die from the outcome of the decision. Regardless, I never plan on living in the US ever again. It will never be "home" for me anymore.

[bhupy]

> So, part of your job is to analyze health benefits plans (health insurance plans) that Americans get. You also work daily with actuaries in the life sector, who assign dollar values to people's lives.

Yes, exactly like health insurance actuaries at publicly run health insurance providers. We don't sit around trying to figure out how to make people die, like cartoon villains. We try to figure out how to make healthcare sustainable.

If you read what I had written, it's clear that not only do the private sector insurance providers perform comparable with public sector ones like Original Medicare, they can even out-perform them. So we can't conclude the "privateness" as the root cause of our problems, we have to consider other confounding variables.

> Congratulations on coming up with that point. That is precisely why I left the US, as somebody with a rare disease that requires an orphan drug to survive.

Sorry to hear that, truly. In my opinion, the single most effective thing we can do to help folks like you is to decouple health insurance from employment, and I'm sticking around to try to make that happen. Hopefully you'll come back, and stay healthy.

[tptacek]

It feels like this is the point in the thread where you just got frustrated and started casting aspersions instead of making arguments. That happens to me a bunch too, and the strategy I've developed for it is to look at how many question marks I've managed to put in my comments, and try to fit more of them in. The person you're arguing with has some apparent domain knowledge; try extracting it?

[ddingus]

>All I'm pointing out to you is that the "profit motive" has nothing to do with that

You have not met that burden. Not even close.

The best case is a mixed environment, with a for profit portion that can address clear for profit cases well.

And those exist!

But, doing that sans a robust system that actually just delivers health care to sick people is crazy bad policy.

There is another argument in your favor out there, and that is consistent, transparent pricing. Or "Equal Pricing"

In Singapore, there are no real surprises and people have options that don't cause them to trade, homes for example, to get sick people they care about healthy again.

Here? Nothing but surprises!

And frankly, that being the case actually does support the difficult argument:

If making money is the priority, then making sick people healthy isn't.

On the other hand, if making sick people healthy is the top priority, and then we talk about money?

Very different scenarios.

The US is firmly entrenched in the former. Examples of the latter exist in the world and perform well.

The profit motive matters. How it's framed, what priority it has, and more all do contribute to the overall effectiveness and again that cost and risk exposure.

[bhupy]

> You have not met that burden. Not even close.

What? I absolutely have. I’m not sure what you’re on about. Switzerland is as close as it gets to a profit-driven purely private healthcare system. Indeed, the US was modeled off of it. The only difference between the two is that the former is based on a robust individual market while the latter is driven by group benefits.

> But doing that sans a robust system that actually just delivers health care to sick people is just bad policy

I don’t think anybody is suggesting not delivering health care to sick people. The question is whether the private sector can provide an actuarial product.

> In Singapore, there are no real surprises

Agree, Singapore’s healthcare system is excellent, and price transparency is very important. The reason the US system is devoid of price transparency is because the majority of Americans simply don’t care about prices, since they have little skin in the game. This is true for old people on Original Medicare, poor people on Medicaid, as well as employed people on generous group plans. If none of those describe you, then you’re unfortunately SOL. THAT’S the problem. Not the profit motive.

> If making money is the priority, then making sick people healthy isn’t

Again, it’s a cute pithy quote, but that’s not how the real world works. If making money is a priority, then feeding hungry people isn’t. If making money is a priority, then providing cheap clothing and shelter isn’t. It’s impossible to understand how the world works through such a simplistic lens.

As I showed you above, the Medicare A/B test is illuminating. Medicare Advantage payers are primarily in the business of making money, and yet their members are on average healthier, have higher quality plans, and at lower cost.

[ddingus]

I agree with you on decoupling the insurance from employment. Great move! This would immediately clarify what cost and risk exposure means to people too. Bonus!

I disagree on cost and risk exposure. Ask around both employer and employee about cost growth this last decade, for example... not getting lower, often are digit increases.

Regulation?

Well, the cap that limits margin dollars is easily dealt with by owning more of the chain of care. Opponents of this tepid method of cost control predicted it and it has happened. They can do billing with themselves and it works like tax shelters do and film studio accounting do to show compliant profit numbers.

From where I sit, being one of the really screwed set, I found some of what you put here clarifying, but did not find myself sold on the idea we are improving at all.

In fact, one way to differentiate the US profit motive from the rest of the developed world, is our continuing move toward market based care despite a lot of information

[bhupy]

> did not find myself sold on the idea we are improving at all.

I don't think we're improving either; as long as we have an employer mandate and privileged tax treatment for group health insurance plans, I don't see this changing any time soon. All I'm saying is that the market/private nature of it has little to do with it. It's the "employer sponsored" nature of it that has everything to do with it.

> In fact, one way to differentiate the US profit motive from the rest of the developed world, is our continuing move toward market based care despite a lot of information

That the US is somehow undifferentiated in its pursuit of market based healthcare is not true at all; see Switzerland and the Netherlands. Both have purely private health insurance systems, and there's no sign of that changing any time soon, and both enjoy excellent health outcomes with broad approval of their respective healthcare systems. They're almost exactly as regulated as the US health insurance market, except with one glaring difference: the private health insurance is predominately purchased on the individual market. (https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...)

Not only that, Singapore has one of the most market-driven healthcare systems on the planet, and enjoys the status of being the most efficient healthcare system with some of the best outcomes:

https://www.bloomberg.com/graphics/infographics/most-efficie...

[ddingus]

>I'm saying is that the market/private nature of it has little to do with it.

I appreciate that. And still do not agree.

Either the goal is fixing sick people, delivering care, or it is not.

If the US were to improve DRAMATICALLY on labor policy, among many areas needing improvement, perhaps we could show for profit being able to work.

Fair enough.

[bhupy]

> Either the goal is fixing sick people, delivering care, or it is not.

That's an odd dichotomy. You could apply this to literally any good or service. With food, either your goal is nourishing hungry people, or it is not; and yet the private sector provides food just fine.

At the end of the day, price signals and market forces ensure that producers meet the needs of consumers. There are certainly instances of market failures, especially in the case of externalities. But with healthcare, there's really no evidence that markets and the private sector cannot deliver world class healthcare, and in fact we see evidence to the contrary, both domestically (in Medicare Advantage) as well as globally (in Switzerland and the Netherlands).

[aksss]

This is great info but I would add that when you talk about the unemployed left out in the cold, you also need to consider the self-employed. Having insurance tied to discrete employer risk pools makes insurance on the private market very expensive for all of those who cannot get subsidies (ACA/Medicaid). It really discourages people from taking the risks to start new ventures. When I started my business I went years without medical coverage.

[bhupy]

Yes, agreed. A big part of why that's the case is that the individual market is one huge adverse sample, in its current form. Because most healthy people in the US are employed, they tend to receive their health insurance through employer sponsored group plans, which by design pools risk only within that group.

What ends up happening is that anyone left over has to participate in risky markets with higher premiums in general, resulting in the mostly broken state of the US individual market.

In contrast, you have countries like Switzerland where pretty much all health insurance is purchased on the individual market, and risk is pooled across larger and more diverse populations.

[sam537]

Do you have any insight into how a Medicare eligible person choosing Medicare advantage lose most of their funding for extended care facilities or SAR/AR days (in exchange for subpar vision/dental)? That 39% does not evaporate into savings.

[bhupy]

Yes, Medicare traditionally never covered long term care. This was true for both Original Medicare, as well as for Medicare Advantage. Only Medicaid covered long term care, but as you may know that’s only for those with low income.

However, this is beginning to change. The Centers for Medicare and Medicaid Services has begun to allow private Medicare Part C insurers expand into long term care. Notably, to this day the public Medicare still doesn’t cover long term care, whereas M.Adv plans are beginning to.

If you’re talking about SNFs, Medicare Advantage is basically at parity with OM. I’ve seen Advantage plans by big payers like Humana with SNF benefit periods of 100 days. The 39% savings figure is on average, but if you require long term SNF stay, you’ll probably cost roughly the same to a private insurer as you do to Original Medicare. None of that stops private insurers from offering the benefit, since the actuarial math works out to the kind of savings that we’re mentioned above, across a whole benefit population.

> in exchange for subpar vision/dental

I’m not sure what data you’re looking at, but from where I sit, Medicare Advantage almost always includes vision/dental, whereas Original Medicare does not (which is why some seniors go for Medigap).