[mgh95]

Realistically, the big cost differential in absolute terms in healthcare are borne in the elder group (65+). See this:https://pmc.ncbi.nlm.nih.gov/articles/PMC7411536/. This is exactly where the "government social safety net" takes effect (medicare and medicaid) and, in my opinion, the real spending bazooka of US subsidies take effect.

I say this as someone who wound up owning one business in this area (health insurance agency/producer) and was looking at expanding directly to the insurance providing aspect. I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.

[vundercind]

Yes, we pay more per-capita for our public healthcare system than some countries do for universal coverage, but we don’t cover everyone. Just for the public parts.

Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.

What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.

[mgh95]

> Yes, we pay more per-capita for our public healthcare system than some countries do for universal coverage, but we don’t cover everyone. Just for the public parts.

Yes, because the US is currently experiencing an adverse selection bias where healthy avoid enrolling until an issue occurs. See this: https://www.aeaweb.org/articles?id=10.1257/app.20170117

> Once you actually tally up how many people are having their healthcare paid for by public dollars—local, state, and federal workers plus retired; the military, active and retired; Medicare (old people); Medicaid (poor and disabled); CHIP (poor kids); the families of some of those categories; et c—it’s really not the case that moving to entirely public-funded would even be as big a leap as one might suppose. A whole lot of people already have government-funded healthcare.

Government funded but it's not a social safety net or mandate in a conventionally sense: it's an insurance subsidy. It effectively incentivizes depressing your own personal income to achieve high-subsidy plans (namely, the silver plan in most if not all states) resulting in abnormally high subsidies. It's just a form of tax planning today. See people taking "early retirement" with substantial assets (>1mm, which isn't much for HN but substantial in much of the country) at 40, reducing disbursements, and effectively costing the taxpayer ~36k/year in subsidies.

In an idea world, your assets would be subject to seizure under means testing on assets, not just income, before subsidies are provided. Seriously, go check out reddit /r/fire. They talk about it (and how a reduction in ACA subsidies in 2025 will force them out of retirement at the advanced age of 45).

> What we really lack, that every single other OECD state I’ve looked at has as a feature of their healthcare systems, is more-aggressive price controls, either set directly or via partial or complete monopsony. We’ve sniffed around at it, but never taken a full bite.

I'm going to be real: this is just wrong. Price controls only works in two circumstances:

* You are willing to tolerate reduced availability of goods and services * You are actively willing to prohibit others from purchasing goods and services with their own money

1 is complete anathema to the US consumer market. If price controls were to be implemented, the elderly would likely get care first, which is unlikely to yield practically the needed result relative to current costs curves -- keeping the working population working with preventative and minimizing the cost on the elder bracket. In my opinion, this mispricing is in part due to the ACA, but that's neither here nor there.

2 would require Norway style controls of Ozembic and similar. I don't think Americans would ever tolerate "your money, you aren't allowed to buy it". Prices are high because Americans can pay in dollars more than other nations and are willing to do so.

There is a very real perception that medicine can fix poor health choices and we should spend arbitrarily large amounts of money to fix it. It's a fantastic business to be in -- people insist "healthcare is a human right" and are willing to tax others to pay it.

[amanaplanacanal]

Look at the ratios though. US spending is about double in every age bracket. The really isn't anything special about the over 65 group.

[mgh95]

Age 65+ is roughly 17% of pop and accounts for 37% of all spending. It's quite literally the place to focus on cost savings.

[vineyardmike]

You can't genuinely believe that the reason that the 65+yo group costs more is the social safety net?

As you get older, you start to experience more adverse health affects. You start to need medical attention more. Especially if you've been denied healthcare for the first 65 years.

> I really think people underestimate just how generous (high cost) the "social safety net" is, and have a grass-is-greener view towards other countries healthcare systems for people currently working.

Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.

In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?

At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.

[mgh95]

> As you get older, you start to experience more adverse health affects. You start to need medical attention more. Especially if you've been denied healthcare for the first 65 years.

Sort of: as you get older, time catches up to you. In the USA for, heart disease kills 1015/100k for both genders (see: https://usafacts.org/articles/what-are-the-top-causes-of-dea... in Germany, it is just 673/100k for just men alone. We have an obesity problem, not a healthcare problem, when it comes to life expectancy.

> Well I think you misrepresent that greener grass is greener. Other countries literally live longer and healthier when they have socialized healthcare. It's a pretty easy metric to track, and pretty straightforward. Do you want the general population to live longer? Do you want the general population to be healthier? Do you want the general population to be saddled with crippling medical debt? Sometimes the grass is greener. And we have the data to prove it.

The question here is QALYS. We quite literally avoid this discussion in the US at all (see this: https://pubmed.ncbi.nlm.nih.gov/19738253/). The issue isn't that we disagree about the issues: it's that the issues are not addressed and Americans pretty much always say "spend more".

Europe has already begun rationing, by the way (see this: https://pmc.ncbi.nlm.nih.gov/articles/PMC1831659/#:~:text=Be....) It's not as though it doesn't already occur; we simply choose to blame insurance companies instead of a national system.

> In the link you shared, other social-safety-net countries had lower spend per capita. They have a better social safety net. So how can that be the issue?

Healthier populations. Americans make awful health choices.

> At least you're honest that you own a health-insurance business and you're biased. A single-payer system would destroy your income, and I guess that's pretty scary, so it's in your best interest to fear-monger.

Not really. Margin shifts along value chains; it's rarely destroyed. All that would happen is the profits would shift to another location. Then the game becomes how to get there.