[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.

[disabled]

Thank you. Like another poster suggested, I will try to be more considerate next time.

I am off disability, but I can theoretically keep Medicare for life. I was always on traditional Medicare, and my orphan drug (a blood product) was covered under Part D for my condition. I was also insured as a "disabled dependent" via employer-based insurance, through my deceased father's retiree benefit--so it was secondary insurance--which functioned like a supplemental plan.

I have 2 rare immune-mediated neurological diseases affecting my peripheral nervous system (one of them being very rare--which means an HMO from a Medicare Advantage plan is a huge problem if I want to stay alive long term in the US--and generally, you cannot go back to traditional Medicare), plus type 1 diabetes. The very rare neurological disease is believed to have caused the autoimmunity leading to my diabetes diagnosis at age 5.

Anyways, I can tell you that the way things were set up in the US (prior authorizations, prescription formulary restrictions, quantity limits, networks, etc.) were certainly harming my health. I studied electrical engineering for undergraduate, and it is not like I am cannot handle bureaucratic and logistical nightmares.

But, there is a baseline level of stress and anxiety that is present in the US, and you do not have the realistic expectation that you will be cared for there. Not only that, it is a part-time job just to deal with insurance matters. This feeling is basically non-existent within most of the EU, including in places like Croatia. Croatians probably do have the best lifestyle in all of Europe, too.

It's just not worth it.

[bhupy]

> generally, you cannot go back to traditional Medicare

You're always able to go back to traditional Medicare, you just have to wait until the next open enrollment. In fact, after the first trial run with MedAdv, you can switch back before open enrollment if you want. Traditional Medicare is always an option.

Great to hear that you're staying healthy otherwise.

[disabled]

Thank you! :-)

True, but the issue is that medical underwriting is allowed on Medigap (Part B supplemental plans). So, once you are on a Medicare Advantage Plan, you basically cannot effectively go back, due to being unable to obtain a Medigap plan (covering the 20% that part B does not cover), due to having pre-existing condtion(s). The financial consequences of not having a Medigap plan are quite severe for somebody who has a rare disease, if you know what I mean.

As you know, it is a loophole in the ACA. Because I was declared disabled before age 22 ("disabled adult child"), there is a way for me to get Medicaid, for life, effectively, through the Ticket-to-Work program, via the PASS (Plan to achieve self support). Even if I "make to much money to stay on Medicaid", at some point, the Pickle Amendment allows me to stay on it for life, due to the age I was declared disabled at.

But, there are issues with that too, since it is a form of "welfare". You can end up having to pay back the US government hardcore overall. You also get punished for being on Medicaid. For example, some states only allow you to have 4 medications covered by Medicaid. After the 4th active prescription, a type of "prior authorization" is sent to each and every doctor--for some government bureaucrat to make an arbitrary decision whether this medication is being "worthy of coverage".

[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?

[disabled]

This is fine. I will try being more thoughtful next time.

[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]

Feeding people isn't a priority!

World hunger anyone! It's a real thing.

We have it because making money is a higher priority than feeding people is.

Cheers, I have other things to do, and did enjoy this discussion!

[bhupy]

> Feeding people isn’t a priority!

Feeding people is 100% the priority, which is why the vast majority of people in the first world have access to food primarily produced by a predominately private food industry.

The US is in the top 5 in the world for food security: https://www.worldatlas.com/articles/the-world-s-best-countri...

To the extent that there exists poor people unable to afford food, that’s a problem solved by welfare and subsidies, not by nationalizing food supply chains.

Apply that to healthcare.

[cloudfifty]

> Feeding people is 100% the priority, which is why the vast majority of people in the first world have access to food primarily produced by a predominately private food industry.

This isn't true when feeding people is the _100% priority_, like in a big crisis, as a major war. The market flies out of the window and doesn't return before after the war is over since it just can't reliably produce goods in way that is appropriate for a crisis.

When the crisis is over however, the game of profit based production is restarted again.

[bhupy]

No disagreements re: crisis / war. That's typically when states of emergency are conventionally recommended.

[ddingus]

"Unable to afford food" = making money is a higher priority.

Unable to afford the doctor = making money is a higher priority.

Many food banks will give people who want food, food. Few questions, sometimes no questions asked.

It is rare to have similar access to health care.

Where did I mention nationalize?

I did not do that, and meant to not do that.

[bhupy]

> Many food banks will give people who want food, food. Few questions, sometimes no questions asked.

> It is rare to have similar access to health care.

No it’s not, you just described Medicaid. The Venn diagram of people that rely on food banks for food and people on Medicaid is basically a circle.

Also, it’s debatable if food banks are a superior way of getting food to poor people, vs expanding food stamps and/or a UBI which can then be used at grocery stores.

> Where did I mention nationalize?

You seem to be attacking the profit motive as a mechanism by which to provision goods and services for which there is highly inelastic demand. My point is that if you think that the way we provision food is workable, then the concept of private healthcare with subsidies (basically the Swiss model and MAdv) should be as well. In both of those models, profit and “making money” is still key.