[smgit]

Its the environment that compounds the complexity. Go down the list of Largest companies by revenue in the US and 8 in top 20 are related to "health" - are they running hospitals? are they pharma companies? No.

They run pharmacy benefits management, health insurance and drug distribution.

The estimate is 4-5 Trillion flows throw these firms. Which is larger than the GDP of India. So this gigantic structure has emerged that doesn't really make too much profit btw (very similar to Amazon Platform Economics) but is layer upon layer upon layer of cash flow passing through middlemen.

Drastic change requires new ideas about what do we do about all these middlemen who shape the environment on top of which everything exists.

[ethbr1]

The biggest problem with the US health system? Complexity.

It's impossible to fix overly complex systems.

Simplify, simplify, simplify, and then the fixes become trivial.

In the US case, that means banning most of the middle-layers.

[zdragnar]

Alas, independent middle layers have long been the US solution to avoiding monopolies. This is the whole reason car manufacturers can't sell directly to consumers, and micro breweries can't sell to consumers except for on-site purchases. Breweries in particular have to sell to distributors, who sell to stores.

Banning the middle layers here (absent other changes) just means that the companies that replace their spots in the top 20 will be vertically integrated conglomerates that manufacturer, distribute, prescribe and provide insurance (i.e. payment plans) for pharmaceutical drugs.

[vitus]

> Banning the middle layers here (absent other changes) just means that the companies that replace their spots in the top 20 will be vertically integrated conglomerates that manufacturer, distribute, prescribe and provide insurance (i.e. payment plans) for pharmaceutical drugs.

Except these companies are already vertically integrated, to a large degree. All the biggest insurers have their own in-house PBMs.

CVS (the parent company of Aetna) has Caremark.

Cigna has Express Scripts.

Anthem (fine, Elevance) has CarelonRx.

UnitedHealth Group has Optum.

[potato3732842]

I'll take a monopoly I can afford over a ton of entrenched middle men that I can't

[vineyardmike]

Revenue is an incomplete signal of the complexity and waste. It’s just a signal of the money flowing through. A “single payer” system would probably also show a huge revenue number even if the profit was <=0. There’s just a lot of money and a lot of people who are patients.

I don’t disagree that the system requires change and is extremely complex, however.

The real problem is that it’s nearly impossible to “scale” healthcare and keep it personalized, and people want personalized healthcare - because that’s shown to be more effective healthcare. Doctors can only see a limited number of patients a day, and they need to be paid some compensation commensurate with their skills and efforts. That alone makes it hard for everyone “healthy” to see a doctor often enough and for long enough to get deeply personal care. Most people realistically can pay out of pocket for preventative care. $100-200/yr for an American isn’t crazy. Even most drugs are super affordable out of pocket if the profit margins are kept low (which is started to be available, bits at a time).

The real complexity, of course, is the long-tail where a few people get cancer and car accidents and other serious conditions which swamp the costs of everything else.

[marbro]

I don't think $100-200 per year for preventative care is enough. I reckon $1000-$10,000 per year, depending on age, is more accurate. You should spend at least $500 per year on nutritional supplements like Vitamin D. Switzerland has a better medical system that's cheaper than our system, but it's still expensive.

[analog31]

Indeed, it may be the case that the middlemen aren't individually all that profitable, but if the money passes through several stages and each one skims off a few percent, you end up with the present situation where health care costs twice as much as it does in any civilized country.