[youknownothing]

As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK.

Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the slightest out of their parameters, tough luck. And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you. I could bore you with countless stories of doctors who have used tricks not to provide service and make it look like it was the patient's fault.

The problem with private healthcare is that profits corrupts it. The problem with public healthcare is that politics corrupts it. There is no good solution.

[nicoburns]

I think this is mostly a problem with state funded healthcare budgets being cut (relative to population demographics) in these countries. If the UK or Spain spent anywhere even close to what the US spends on healthcare (per capita), I have no doubt that it's healthcare provision would be just as good. In the UK, healthcare provision was notably dramatically better 20-30 years ago under the same system (except for less private finance).

[eitally]

I don't think so. With state funded healthcare you get rigid rulebooks and policies. In the capitalist-ish US model, if you are a successful advocate then you can get better than average care because there's enough flexibility in the system (in many cases, physicians can individually decide to over-extend for one patient if they choose to) to allow for this. Having a private payer market absolutely helps here.

[nicoburns]

Having care depend on "being a successful advocate" does not sound like a good thing to me! Albeit it's probably impossible to avoid entirely. We want good care for everyone.

I'm mostly familiar with the UK system, but medical professionals make pretty much all the decisions here, with a large degree of discretion according to their professional judgement (and they never have to adjust or delay their care based on whether you can pay). Except for some particularly expensive treatments (think CAR-T for cancer) which are not available at all in the state funded system. But you can still pay for those privately if you want to.

[fragmede]

> Having care depend on "being a successful advocate" does not sound like a good thing to me!

It's not. You have to become a horrible demanding person to get a decent level of care instead of things being nice.

[rexroad]

The data supports this. The AMA's 2024 Prior Authorization survey found 93% of physicians report PA requirements delay medically necessary care. Twenty-nine percent reported a PA delay causing a serious adverse event for a patient. Seven percent reported PA contributed to a patient death.

The requirement that patients fight for care isn't just a frustration. It's a documented cost driver: Health Affairs (2025) puts the total system-wide cost of prior authorization at $93.3B/year, including $35.8B borne directly by patients navigating the process. The persistence required to appeal a denial is unevenly distributed across income, education, and time availability. That is a structural equity problem as well as a cost problem. Issue #5 of this series covers the full mechanism.

[gopher_space]

> With state funded healthcare you get rigid rulebooks and policies.

We could just not do that. If you change the flow of control certain problems solve themselves. Think about a landscape where government funding multiplies the patient dollar, for example.

[LorenPechtel]

The problem is that it always happens. There's no such thing as comparable funding.

[gnz11]

I'm sure there is a lot of nuance but long term healthcare outcomes are generally lower in the US compared to other countries. https://www.healthsystemtracker.org/chart-collection/quality...

[alistairSH]

Personal anecdote... My uncle is an auto mechanic in Scotland (Scottish NHS) and my brother-in-law is an auto mechanic in WV, USA.

Both have similar health care outcomes - they have ready access to quality care, specialists, etc. ER/A&E is available. The biggest difference is the perceived cost and stress incurred by that cost. My uncle doesn't give much thought to health care - he can work, retire, whatever and be assured a reasonable level of care. My BIL will work to 65 or beyond, fighting red-tape the entire time, then retire and still have to deal with supplemental programs.

Looking at another uncle, who was a small business owner in Scotland vs my father (also small business owner), it's similar to above, just with more money at stake. Uncle also purchased additional insurance on top of NHS for faster access to selective care, still cost less than insurance in the US, even after accounting for tax differences.

American's kid themselves when they say the Western Europe has higher taxes. Once you account for medical care, college funding, and other similar things, it's pretty close.

[rexroad]

The RAND Round 5.1 study (2023) puts US commercial insurer payments at 254% of Medicare rates for identical procedures. That's the mechanism behind the international gaps — it's not complexity or quality, it's that commercial insurers negotiate against chargemaster list prices rather than against cost. The HCRIS cost-to-charge analysis (3,193 hospitals, FY2023) puts median markup at 2.6x actual costs.

[bandofthehawk]

I think this difference mostly disappears if you group Americans by wealth. So wealthy Americans have similar life expectancies to those in other countries. It's really the poor that are most affected by our dystopian healthcare system, which is probably a big part of why it never gets fixed.

[rexroad]

The obesity adjustment is worth quantifying. US adult obesity: 42% (CDC). UK: 28%, Australia: 31%, Germany: 22%. Those gaps are real, but they don't explain a 2.5x per-capita spending differential. The Commonwealth Fund's 2021 analysis controlled for age, income, and chronic condition burden; the US still spent roughly $5,000 more per capita than the next-highest spender (Switzerland).

Obesity also matters less than assumed in hospital pricing: a hip replacement costs $29,000 commercially in the US regardless of patient BMI, vs. $15,000 in Germany and $9,000 in Spain (iFHP 2024). The cost structure is in the pricing system. Johns Hopkins researchers estimated eliminating US obesity would reduce healthcare spending by about 12%, real but not 2.5x. Repo with methodology: https://github.com/rexrodeo/american-healthcare-conundrum

[dinkumthinkum]

Hvae you considered that America is a much larger and much more diverse country that these other countries and and it is very different social norms? Obesity is a major problem in America and it is not the fault of the doctors. I wonder if this has anything to do with it?

[adrianN]

Obesity is a problem in lots of countries.

[LorenPechtel]

So we do better at actually delivering care, they do better at getting it delivered to everyone.

[avhception]

Yet, living in Germany, the problems I hear about our healthcare system from friends or in the media are an absolute far cry from the insanity that I hear about the US system. Maybe some of it is sensationalism, but I very much doubt that would account for the whole story.

[9x39]

What's usually missing from anecdotes is class cohorts - so, US working class with Medicaid or a crappy marketplace plan vs working professional with an amazing plan vs retiree with Medicare vs...

Nothing's perfect, but the plan differences seem stark. For example, my wife had a crappy marketplace plan and I had a plan through my employer. For her, an MRI was denied, denied, then finally approved with many calls. For me, it was approved immediately. For her, pre-auth to a specialist was denied until her doctor went and tried a different referral strategy. For me...well, I haven't been denied yet. It goes on - same city, same hospital, some of the same referrals, etc.

I've come to think the price discrimination really does mean we have class-based care which seems to allow for the sensationalism. Combine a dire scenario with a working or indigent class American, and they don't have to exaggerate much at all.

[titzer]

Having lived in both Germany and the US, my experience with the German system is that there are a lot more, smaller hospitals and private practices, the care is good, and all I ever paid for out of pocket was prescription medications. I didn't have to wait long for an MRI (two weeks) versus months in the US. I had a number of things that would have been hundreds or thousands of dollars in the US that I never paid a penny for in Germany. I'll also say that hospitals are absolutely crazy about sending bill collectors after you. I had a handful of small charges--like $10 or $20 things--that I hadn't realized were even there and two months later they freaking inundated me with bill collector notices.

It does make a big difference exactly where you are in the US, however. Some places have a glut of healthcare providers and other places don't.

[matwood]

> I didn't have to wait long for an MRI (two weeks) versus months in the US.

Where in the US did you have to wait months? There seems to be an MRI/imaging location in every other shopping center in the US right now. I've never had a problem getting a same day MRI when needed. Perhaps you were waiting for the 'free' one your insurance would accept?

[pnutjam]

Why wouldn't you wait for one your insurance would approve? You're probably paying them thousands every month.

[titzer]

Pittsburgh / UPMC.

Now try to schedule a colonoscopy. It'll probably take two or three months.

[rexroad]

Personal experience with specific interventions reflects something real: US cancer survival rates, cardiac procedure outcomes, and access to cutting-edge treatments are genuinely strong for people with good coverage. That's not disputed.

The cost-outcome tradeoff shows up at the population level. US life expectancy: 77.5 years. Spain: 83.6. UK: 81.6. Infant mortality: US 5.4 per 1,000 vs. Spain 3.4, UK 3.7 (OECD 2023). The US spends $14,570 per capita. Spain spends $3,300, UK $4,100. If the premium were buying 10 extra years of life expectancy and half the infant mortality, it might be worth the argument. The data shows the opposite at population scale.

The newsletter's framing isn't that US clinical quality is poor. It's that the US is paying $3T more per year than Japan (same life expectancy, lowest infant mortality in OECD) for aggregate outcomes that are worse.

[youknownothing]

The cost and life expectancy differences are indisputable, but the rationale may need more nuanced: that's not necessarily a problem with the healthcare industry, but with lifestyles, safety regulations, food standards, and a long et cetera of reasons. For instance Spanish people, on average, have more balanced diets and are more active than American people. They also lead much less stressful lives. That's a big factor.

[pnutjam]

"And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you."

This happened to us with private healthcare. There is basically one specialty group for the procedure my family member needed so any 2nd opinion request just got routed back to the same doctor, "Oh, your Dr X's patient". Also, we could barely afford the procedure so we missed out on some follow up testing that would have verified things worked properly and basically got blacklisted from that practice so hopefully it's resolved...

[biophysboy]

There are other public healthcare models besides Beveridge though. Some countries do the payment & financing via gov, but the actual service is a mix of public/private. Not a perfect solution, but in my opinion better than what we have now. Maybe more achievable than Beveridge too.

[ninalanyon]

Norway funds health care through taxation, seems to work pretty well here. But we don't have PFI, instead there are fully private healthcare companies that act as suppliers of services such as MRI, CAT scans, etc. So if your GP orders an X-ray or MRI you will most likely get it done by a private company rather than the local hospital. The patient doesn't really see any difference most of the cost is borne by the state, the patient pays a small egenandel (like copay in the US, excess in UK insurance terms) wherever it is done.

I'm not sure how the other Nordic countries do it but I think it's probably similar.

[cherryteastain]

You can also get private medical insurance in the UK. The cost is usually much lower than the US and quality is decent. NHS acts as an anchor keeping down premiums.