[jiggawatts]

It’s so bizarre to me that this uniquely US phenomenon of for-profit-middlemen inserted into the healthcare system has resulted in an adverserial relationship between the sick person and the “healthcare provider”.

I put that air quotes because insurance companies don’t actually provide health care. They provide insurance. That’s a financial product, not a medical one.

[beezlebroxxxxxx]

> That’s a financial product, not a medical one.

It often goes unsaid, but America, on a cultural and political level, is really ideologically fixated on a distinction between working and non-working individuals, and, in a far deeper sense, whether an individual "deserves" healthcare or not. This makes access to healthcare intricately connected to class, wealth, and income, in America. That's why access to healthcare is seen as a product in and of itself. You can either afford it ("you've earned it"), or you go into debt for it ("you have to earn it"), or you simply have no expectation of ever paying for it ("you cheated the system").

The entire conversation is often dominated by these ideas in a way that often makes talking about healthcare with Americans baffling to people that come from many single-payer or universal systems.

[somerandomqaguy]

To a degree. You have to keep in mind that a hospital emergency room isn't legally permitted to turn you away even if you can't pay under the Emergency Medical Treatment and Active Labor Act.

So the wealthy and insured are covered. The lowest rungs and those that don't care and will just run away are covered. It's mostly lower / middle lower class that this really hurts, ironically.

[FireBeyond]

> The lowest rungs and those that don't care and will just run away are covered.

They're really not. They are only entitled to "stabilizing care".

I work as a paramedic. We have had situations with "frequent fliers" where when we've called the hospital to give a report as we are transporting, the hospital will say "let us know when you're here", and when we've done so, there's literally been a physician come out to the ambulance.

"Hey, X, what's happening?"

"I got a lot of fluid in my gut (he had ascites)."

"Okay, well, that's not new, and it looks like you have an appointment for having that fluid drawn in two days."

"Oh, okay."

"Anything else bothering you?"

"Nope."

"Alright, we're good then." Gives us a nod.

"We're going in then?"

"Uh, no. You have been by a physician, you're stable, you're good to go, you can jump off their gurney and head home now."

Which is harsh - but also this person at this point was being transported 4+ times _per day_.

But EMTALA only requires acute stabilizing care, not definitive management.

[coffeecat]

I think your premise is flawed. In America, the access-to-healthcare versus income curve is U-shaped.

If you have literally no income (or your income is entirely "off the books"), then you qualify for medicaid; everything is covered with no premiums, copays, or deductibles. At a middle-class level of income, you're probably looking at either a comparatively shitty ACA marketplace plan, or a comparatively shitty employer-provided HDHP plan. At an upper-class level of income, you can afford top-of-the-line healthcare.

[xdfgh1112]

I get this feeling a lot. For example the UK typically has unlimited paid sick days for salaried jobs, while I have heard of US employees pooling together and "donating" sick days to someone. The UK has a ton of benefits for the sick, unemployed, single mothers, carers etc. in the US I am sure those exist but I get the sense that charity is supposed to play more of a role.

[xp84]

FYI it’s not common to allow sick days to be transferable.

TBH I think in the US it’s more than anything about how much more competitive industries here are vs in the UK. If X company feels it’s worth the extra cost by allowing unlimited PTO and 2 years of parental leave, etc. the worry is that X will be trounced by Y Company, who is ruthless enough to not offer those things and as such has much cheaper labor costs.

If you take an industry like retail, those companies have a point - Walmart and Amazon offer low benefits compared to what companies once offered. Their lower prices are part of how they killed off most of the department stores and put the rest on life support.

And if you think about a highly paid job, even though our fringe benefits suck compared to Europe style, my impression is that US salaries are higher for equivalent jobs, enough that it makes up for it. So we value the money more than we would the benefits, apparently. Only problem is you can’t use all that money to buy more time with your family (except for by taking breaks between jobs, if you’re good at saving!)

[miki123211]

Be aware that in many single-payer systems, insurance is also tied to working (or unemployment / retirement / pensions).

In my opinion, this is actually the reason for why we have so little innovation in Europe.

Mandatory, single-payer insurance very significantly raises the cost to be self-employed / have a sole proprietorship, which you practically need to run any side project that you want to eventually make money from. This means that if you launch a startup, you either need it to be profitable on day one, or you're vasting significant amounts of your money, not just your time.

[tsimionescu]

> Be aware that in many single-payer systems, insurance is also tied to working (or unemployment / retirement / pensions).

This is true.

> This means that if you launch a startup, you either need it to be profitable on day one, or you're vasting significant amounts of your money, not just your time.

This is a false dichotomy. First of all, even ignoring health-care, you're still spending money on housing, food, electricity etc. If you're not employed and your startup is not profitable, you're paying money out of pocket to live.

Second of all, even in the USA, you are still going to pay for health insurance even if you are currently founding a startup. You could argue you are allowed to gamble that our health is good enough that you don't need health insurance for a few years, but that's just tossing coins. You could just as well not pay your taxes in the EU for a year or two, and gamble that the authorities will not catch on right away.

[xp84]

I don’t get it, why is a self-employed person paying so much more than others for single payer healthcare where you are? That sounds exactly like the USA where those not employed as a normal full-time employee pay the most for equivalent insurance, so people here definitely do stay at their regular jobs instead of quitting to found a startup. Insurance outside of those group plans is even more expensive than the already shocking normal cost, and of course normal full time employment (what we call W-2 jobs) usually provides a generous healthcare subsidy.

[miki123211]

Because healthcare is often paid per "working relationship", so if you work for a company and are doing something on the side, you have to pay twice, and the second fee comes out of your pocket.

[thayne]

Living in America, I have never met anyone who doesn't think our health care system is a complete mess. That includes doctors, nurses, people who work in HR, and people on both sides of the political spectrum. There is however disagreement about how it should be fixed. But from what I've seen that disagreement isn't about whether people who don't get insurance from their employer "cheated the system", it's about whether the system should be controlled by the state or private companies.

[LtWorf]

You can praise/blame the puritans for this weird idea.

[rscho]

Not unique to the US. This develops to a certain extent everywhere private insurance is sold. It is a completely logical consequence of the insurance company raking in the most when selling you insurance for everything that won't happen, and deny you any coverage for stuff that will happen. At that point, it is a mystery to me why so many people still think free market theory works for healthcare.

[LtWorf]

It doesn't work at all for anything without strong regulations.

[nox101]

in Japan where the government sets the prices, dentists do things over 3 visits that dentists in other places would do in 1 because then they can bill the government set price 3 times instead of one

[josephg]

There are certainly problems in the healthcare systems in other countries. I don’t think there’s any perfect system. But if you ask me, “you have to go to the dentist 3 times” is a much better problem than “even people with health insurance go bankrupt regularly as a result of getting ill and needing medical care”.

The US government spends a similar amount of money per person on healthcare as other western countries do. But unlike Europe, Australia, Canada, Japan and so on, people don’t even get free healthcare in exchange for all that tax money. The system is deeply flawed. I don’t know anything about the Japanese healthcare system, but I’d still choose to be sick in Japan than America any day of the week.

[hattmall]

I'm sure you could offer the Japanese dentist 10% of what the procedure would cost in the US and they would do it in one trip.

It cost about 25% of US prices to fly to Costa Rica, stay at a resort, and get the procedure done in a top notch facility. And that's if you just need 1 root canal and crown. If you need even more done the savings move closer to 90%.

And that is a really nice places. You could drive to Mexico and get it done at a decent place for comparatively nothing.

[FireBeyond]

My dental work in Cancun was under $30K including flights from Seattle and 10 days at a higher end hotel (Westin), for work I was quoted up to $65K for in the US.

[hattmall]

Honestly that seems high but I can see Cancun being a lot more expensive because people are comfortable going there.

[FireBeyond]

The actual dental work was $23K, so about 35% of the US quotes.

[pilotneko]

Well, that seals the deal. If it doesn’t work for dentists in Japan, there is no point changing anything at all for US healthcare policy.

[throw16180339]

No system is perfect, but Japanese healthcare administrative costs are under 2% as compared to 30+% in the US.

[nightshift1]

that's crazy ! Do they at least schedule the 3 visits back to back in the same day ?

[crmd]

In my view, the root cause of the bizarreness is that medical care is one of a few enterprises that are inherently social in nature, and is therefore a prima facie exception to the common wisdom that free markets create the most positive outcomes for the largest number of people. Because in the US we are taught from a young age that private sector capitalism is "all there is", we end up tying ourselves into knots trying to solve medical care using the wrong toolset.

[superq]

True! Really, it's a three-way relationship:

customer - insurer: the govt (or, far more rarely, the employer) is the customer

insurer - recipient: the recipient is you. You're really just a necessary but unwelcome side-effect.

[wat10000]

Once AI is able to replace patients, the industry is really going to take off.

[saxonww]

I think the industry terminology separates the provider (a doctor) from the payer (or payor; an insurance company in this case).

[matheusmoreira]

Somebody is paying for it. If not insurance companies, then the people through the government.

As a citizen of a country with socialized health care, I will tell you the politicians promise the world but when the bill comes they can't seem to find their way out of the room fast enough.

The only way to avoid this adversarial relationship is to pay for it yourself. No insurance, no government, nothing. That means vast amounts of people will not be able to afford even a doctor's private practice.

It's sad but the bitter truth is nobody really wants to pay for other people's health care either. They only say they do because it wins them votes or clients. They all can't leave the room fast enough when the bill actually comes. Politicians have other far grander things they'd rather do with all that taxpayer money, and that's when they're not corrupt and pocketing it. Insurers obviously want profit. They're all betting you won't actually need all that fancy schmancy health care they promised you. They're literally banking on it.

In my experience, people barely want to pay for their own health care. They "want" to but start appealing to the altruism of their fellow man the second the bill comes. In my country, doctors are shamed every day because of our "oath" to help others. People act like we are their slaves, not even entitled to payment for services rendered. The good doctor is the one who pursues medicine as a hobby, who walks the earth helping others in need, with no needs of his own to tend to. The good doctor somehow absorbs the costs of it all. Including the costs of the cures involved. Especially the opportunity costs.

People are not prepared for the soulless utilitarianism of public health care. The bitter truth is there aren't enough medical resources for everybody. You must pick and choose who gets that fancy MRI scan. If you pick right you kill people. If you pick wrong you kill even more people. You have hundreds of millions of citizens, how do you help as many as possible as much as possible with the resources available? Decentralization via hundreds of basic clinics and hospitals turns out to be better than centralizing everything into one well equipped giga hospital. It's not about any one guy. It's about saving costs now so that you can help more people later. That's what primary care is all about. Saving costs, by promoting healthy lifestyles which means less sick people later in life where treatment is more expensive. It's about money, about resources.

But people don't want that. Good lifestyles are hard to lead, they require sacrifices. They want to do whatever they want, then go to the doctors when they get sick, then they want others to pay for whatever's necessary to fix it, and they want it fixed good as new. They are like consumers who don't want to pay for the services they need. Nobody wants to pay for it, even the people who directly need the services.

[egypturnash]

Death panels.

[olddustytrail]

What about them?

[thephyber]

The political boogeyman was that government bureaucrats would be the members of “death panels” if we went full socialized healthcare industry, but in practice we already have death panels in health insurance claims adjusters and (less maliciously) doctors on transplant review boards.

[_DeadFred_]

My mother beat cancer. Insurance paid for follow up testing every 2 years. I tried to convince her to pay out of pocket and do it every year but she said 'they know best'. My mom did not beat cancer the second time when it came back and too much time elapsed between screenings.

I know 'pro status quo' people will say online anecdotes are all lies and not relevant, but there are a heck of a lot of people with a lot of animosity to the current system and it's 'for profit death panels'. I think it would be easier to swallow if it were societal chosen death panels over failed doctors (that can't make it so they go work for the insurance company) or random AIs doing the decision making.

[herewulf]

I'm sorry for your loss. I'm also sorry it now has to serve as a warning for others. Thank you for sharing.

[jopsen]

With a socialized healthcare system the system would have delays and you'd get the screening every 2.5 years, even if it was scheduled for every 2 years. Because of wait lists.

To be fair, it's impossible to know of it matters :)

I moved back to Europe from the US. And I can certainly feel that healthcare is slower, less eager to jump and investigate everything.

But on the other hand, in the US you most certainly risk talking your self into procedures you don't need!

[josephg]

I live in Australia, and I don’t pay for private health insurance. Last year after travelling to Egypt I ended up in hospital with some gut related issue. I was let straight in from the emergency room. The doctors were great. I stayed overnight in one of the wards hooked up to machines and all that.

I was discharged the next day. I didn’t pay a cent. I didn’t even see a bill. I don’t think they made one.

I keep hearing stories from Americans about wait times in other countries. I’m sure it happens, but I’ve never seen it myself. My experiences with the medical system here has been pretty universally excellent.

When I was in America I was very impressed with how proactive everything is. My insurer paid for yearly physical exams. I’d never done that before. It’s certainly possible I would have even better health outcomes in America. But, I’m way happier here. And I’m a lot less stressed than I was when I lived in the Bay Area. That counts for a lot.

[nick__m]

That is not my experience at all !

I live in Québec, Canada and my wife had breast cancer and her periodic scan happened at a 4 months interval. When they detected oligometastasis on her spine she had radiotherapy 2 weeks after the biopsy.

The only thing not covered by the gouvernement is a drugs called kisqali that sucessfully keep her alive (may it continue to works). If I did not had gold plated drugs insurances, the public alternative was weekly chemo (taxol or taxotere i dont remember).

[datavirtue]

People need to be reasonable and know when to DNR. 85 yrs old with massive health problems has a stroke and falls over...DNR. Not here. We jump them back to life, deny their claim and stick them in a facility. Now they are babling and drooling all day and the trust fails to kick in so the people grandma was taking care of financially wait patiently while someone with POA drains grandmas bank accounts and sells off her houses that said people were going to live in (all in violation of her wishes and planning) to pay medicare.