[weinzierl]

I understand you, but health care is expensive everywhere. The difference between the US and many other countries is in the distribution of this cost.

So, for example, if a young person from the US or elsewhere comes to Germany to study they will get health care basically for free.

I think (and I might be wrong) if you move to Germany as retiree the public health care system would not be open to you. You could choose a private insurance but, very much like in the US, the premiums depend on age and existing preconditions. I cannot tell if this would be cheaper than in the US, but I doubt that it could be much cheaper. Also, I think it would be similar in most other EU countries.

Of course you could move to a country with significantly lower living standards to save on medical cost, but then you would increase your likelihood of medical issues and not really gain any real advantage.

[gcanyon]

> health care is expensive everywhere

That's simply not true: per capita spending on healthcare (regardless of how that spending happens) is dramatically higher in the U.S. than anywhere else on the planet. For example, Germany spends 60% Per Capita compared to the U.S. https://www.pgpf.org/chart-archive/0006_health-care-oecd Spain spends just over 30% compared to the U.S.

And I've paid for/received healthcare in Portugal, Thailand, Nepal, and England. It's more cost effective (I started to say cheaper and better, but "better" is a loaded word) pretty much everywhere else.

[weinzierl]

Out of interest: Did you receive public healthcare or did you take out a private insurance in those countries you mentioned? I'm especially curious if you were able to receive NHS health care as (I assume) a foreigner?

When you say cheaper do you mean (private) health insurance or directly paying for medical services, or both?

[gcanyon]

Portugal: paid out of pocket, no insurance. A trip to the ER to refill a prescription (it's what our landlord told us to do) took about twenty minutes and cost under $30. Filling that prescription cost less than the copay in the U.S.

Thailand: paid out of pocket, no insurance. A trip to the ER for digestive issues took under an hour and the visit plus antibiotics cost under $200. This was at Bumrungrad, one of the best hospitals in Thailand.

I'll double-check, but I'm pretty confident my wife's care in the UK was under the NHS. Nepal was also her, I think it was out of pocket, but I'll check.

[weinzierl]

Thanks, that's insightful. I take your point from above.

[gcanyon]

I checked with my wife:

Nepal: she had some form of insurance. She doesn't know how much it cost, but presumably not much (she was volunteering for a non-profit) and her out-of-pocket costs were zero for a multi-day stay at a hospital.

UK: she doesn't remember having insurance, but thinks she must have (she was a student at the time). She used the NHS, again with no out-of-pocket expenses.

[weinzierl]

Thanks!

[nikolay]

That's absolutely false. For example, I buy a brand medication in Europe without insurance for price many times lower than the generic drug in the State's copay! There numerous examples, but most recent example is my wife's Levothyroxine. I buy a German-made medication for $1 in Bulgaria. In the States, a generic version made by noname Indian company has a $10 copay. Same with the Metformin I buy. The original brand medication (Glucophage) I get at around $2/month supply. And this is just meds.

The most advanced MRI in Bulgaria costs without insurance cost a fraction of the copay in the States.

Same for labs. I recently got a comprehensive labs including advanced lipid profile (with lipoprotein(A) and ApoB, cholesterol fractions, etc.) for less than $20 out of pocket with no insurance. Same with my wife's thyroid test - full picture, not just TSH for less than $15. All self-ordered by the way! No need for intermediary companies to authorize it - you just go directly to a lab, which keeps the costs low as there's fierce competition for your business unlike in America where Labcorp and Quest keep the prices ultrahigh!

An quantified American (by Abbott) COVID-19 IgM + IgG antibody test in Bulgaria was less than $20 - here a yes/no test starts at $75.

Again, I'm talking about paying pure cost plus hefty private companies' margins here - no subsidy, no insurance, all up-to-date technology and materials.

The margins in America are unimaginable for any humane organization anywhere in the world. Healthcare should never be a business!

[weinzierl]

That's from your privileged position but for the majority of Bulgarians an MRI is equally expensive than an MRI for the average American - simply unaffordable.

For most people health care is expensive no matter where they are.

[nikolay]

I am talking about absolute costs not affordability. MRI costs might be mostly salaries, but it's not the same for drugs, labs, etc. Given the much bigger purchasing power in the US, prices should be lower, not higher. Why the economics of consumer electronics don't apply to health care? TVs and laptops are much more expensive in Bulgaria, but drugs are way, way cheaper and not subsidized - and these are commodities. Levothyroxine is a commodity available around the globe. Why it's so expensive in the States?! Why are American pharmacies buying generics from India, which so often have recalls due to contamination, and don't buy European drugs (such as from BERLIN-CHEMIE [0])? Because they want much bigger margins - I have no other explanation.

[0]: https://www.berlin-chemie.de/en-us/about-us/our-history

[weinzierl]

I take your point and learned something, thank you.

[ploxiln]

> No need for intermediary companies to authorize it - you just go directly to a lab, which keeps the costs low as there's fierce competition for your business unlike in America

> Healthcare should never be a business!

... seems to me like Healthcare should actually be a normal business. Instead of whatever it is in the US - which as you explain, really makes no sense.

[nikolay]

Yeah, because it's already a business but non-competitive like in the States. Pharmacies can still sell me medications without an Rx - it's not allowed, but they still do it, because why do I need to schedule a doctor's visit get a medication thats for life (like my wife's Levothyroxine).

[maxerickson]

The cash price will often be lower than the copay (which isn't a good thing, but it signals that the issue is benefit design rather than cost of provision).

For example, Walmart sells a month supply of levothyroxine for $4 if you don't get your PBM involved.

[nikolay]

Yeah, but Walmart generics are made in India by companies known for recalls due to carcinogen contamination. Not that recalls in Europe don't happen, but I'd rather purchase from a pharmaceutical company in business from the 19th century. If US regulators believe that India has more stringent pharmaceutical standards than Germany, then something is fishy! And there's so much corruption in generics [0]!

[0]: https://www.washingtonpost.com/business/2023/04/04/big-pharm...

[microtherion]

I'm not German myself, but I'm pretty sure the public health care system is open to all legal residents, no matter what age they move there. But like most countries, there are significant hurdles to immigration, and they would be even higher for somebody in retirement age.

[weinzierl]

I am indeed German and to the best of my knowledge our health care system is not open to all legal residents. I worded it carefully above, because it is complicated and there might be loopholes, but in general a person older than 55 that has never been in the German health system will not get in.

[microtherion]

So correct me if I'm wrong, but:

* Germany has an Obamacare-like system: Insurance is private, but mandatory.

* You can choose and change your insurance provider freely, and they cannot reject you

So if that is true, health insurance companies have the risk of older residents joining, whether or not the previously resided in Germany, and it's not like they benefited from their contributions before.

So how exactly would this exclusion work? Is insurance not mandatory for immigrants after a certain age? Do insurance companies have a right to reject them?

I was not able to find a direct discussion of the question, but this page discussing the health problems of older immigrants (including "access to the health care system") does not mention the possibility that they would be excluded from the health care system altogether: https://heimatkunde.boell.de/de/2013/11/18/ältere-migrantinn...

[Agingcoder]

I think it’s public, not private.

[microtherion]

Ah, I was mistaken. I was correct in that insurance is mandatory, but most people get the insurance from a state-run insurance company:

https://www.informedhealth.org/the-german-health-care-system...

https://www.ssa.gov/policy/docs/progdesc/ssptw/2018-2019/eur...

[Corrected to admit my error]

[weinzierl]

First of all, it is not mandatory for everyone. Anyone with an income above an entry level IT job is exempt, but there are other exceptions as well.

Secondly it is not open to anyone. If you opted out of it at a young age you usually cannot come back (it's a bit more complicated). If you were not in the system for a couple of years and are over 55 you are out. So the US retiree will not get in, but the migrant with a low-incone that worked a couple of years in Germany has mandatory health care forever.

Thirdly, it is not a single state-run insurance company. There are many companies that provide mandatory health care and you can choose freely but you have to choose one if health insurance is mandatory for you. The companies differ in premiums and benefits but usually not by much. They also cannot refuse you if (and usually only if) health care is mandatory for you. The biggest ones are AOK, Barmer and maybe Tk. Bigger companies like BMW run their own ones for their employees.

Of course there are many companies that provide private health care. You can have private insurance in addition or, if you are exempt from mandatory health care, instead of the mandatory providers.

Everything is more complicated, but that is the rough idea.

[weinzierl]

The insurance companies are private but of course mostly financed by public money.

I think health insurance for civil servants (who are in a completely separate system) is state-run, but regular health insurance is private.

[mongol]

What if they are EU citizens?

[weinzierl]

Doesn't matter. Even if you are a German citizen and by 55 you've never been in the health system you're out of luck.

[lfittl]

In the above described scenario (US-based retiree moving to Germany), its likely the social security totalization treaty applies, giving them access to the health system: https://www.ssa.gov/international/Agreement_Pamphlets/german...

[weinzierl]

This is about social security and has nothing to with health care.

In fact it says:

"Although the agreement between the United States and Germany allows the Social Security Administration to count your German credits to help you qualify for U.S. retirement, disability or survivor benefits, the agreement doesn’t cover Medicare benefits. As a result, we cannot count your credits in Germany to establish entitlement to free Medicare hospital insurance."

There might be other loopholes though.

[microtherion]

It appears that if an immigrant was previously in a public health care system in their country of origin, they would qualify:

https://www.tk.de/firmenkunden/versicherung/tk-service-ausla...

https://www.krankenkassen.de/incoming/leben/nicht-erwerbstae...

That would cover most EU countries, though probably not the US (assuming that "private, but mandatory" does not qualify as "public").

[flir]

I quite like this graph (https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...) on the expense of health care.

One of those things is not like the others.

[throwawayapples]

Extortionist medical insurers coupled with regulatory capture.