[arjie]

This makes it sort of obvious how large the US welfare state is.

Medicaid: 10%

"Safety Net": 7.1%

Social Security: 22.6%

Medicare: 14.2%

53.9% of the federal budget is spent on welfare. That seems roughly in line with most Western nations.

[phillipcarter]

Unfortunately, much of that gets dispersed into an unfathomably complex web of private and profit-seeking interests, with much less actually going to individual beneficiaries.

[trollbridge]

Social Security almost entirely flows to beneficiaries, as do programs like SNAP, where overhead is around 6-7% (admittedly, fraud might be a good bit higher than that); likewise Medicare is one of the most efficient systems at getting money directly to medical providers (although fraud might be a problem there too, estimates range from 10%-25%).

[munk-a]

Yup, Medicaid and SNAP are extremely efficient. Social Security is almost completely disbursement charges but those disbursements aren't means tested so even quite wealthy individuals receive them. Additionally you mentioned that Medicare gets money to medical providers but I suspect that was meant to mean medical insurance providers - rather than health care providers (like doctors) since the system is partially direct payments but mostly runs through intermediary privatized companies and, of extreme note here, is that Medicare is famously barred from cost negotiations so while our Canadian healthcare system can talk to a pharma manufacturer and tell them "The price for this drug is unreasonable, we won't cover it unless it's cost competitive to biosimilars" Medicare just needs to roll over and accept whatever made up numbers it's given.

The benefits that are intended to go exclusively to the impoverished though, those are extremely means-tested and often have work requirements or other hoops to jump through.

[RhysU]

> Social Security is almost completely disbursement charges but those disbursements aren't means tested so even quite wealthy individuals receive them.

Only to those who paid into the system and far less than they personally could have earned on investing the same dollars.

[renewiltord]

Yeah, one of the problems I have with taxes is that if I pay $100 into taxes I don’t get $100 of value back. Everyone should get at least as much as they put in back. Also, some other people should get more back. But we shouldn’t spend more than we make as a government.

[RhysU]

Many people do get more back than they put in. High earners do not:

> Most American workers receive significantly more from Social Security over their lifetimes than they contribute through payroll taxes.

https://legalclarity.org/is-social-security-worth-it-contrib...

[Ntrails]

> Everyone should get at least as much as they put in back

I don't even understand the thought process here. Taxes are not being used for productive investments. Some spending is growth, but probably not half.

I could see expecting the median citizen to be flat over their lifetime as a goal.

[munk-a]

Assuming the presence of a sovereign wealth fund which does work somewhat logically for programs like social security - that would make sense. The government should sensibly invest money they're holding onto... however, it's unrealistic to ever expect the government to tolerate a level of risk and thus a rate of return above what you're personally comfortable with so it's unrealistic to assume that the government will be as efficient with money as you'd personally be if they'd never taken that money.

Additionally, a lot of these programs will pay out beyond what you've personally put in - programs like Medicaid are nearly entirely social subsidies to ease poverty and financial distress, so I'm not certain where you'd find the money to pay for them if not looking at either other people's taxes or debt.

As a taxpayer I expect the money I give to the government to be evident in some social projects but I don't personally expect that for each dollar I pay that I'd see a dollar in benefit to me personally. I have a belief that I indirectly benefit from the expenditure of charitable safety net programs even if I never expect to collect from them directly - the improvement in the lives of those around me is to my personal benefit by making society more just and egalitarian as well as reducing the incentive for crime which is a difficult to measure but observable direct benefit to myself.

The fact that so much of our budget goes to debt servicing is probably my personal biggest objection as it is effectively just a wealth extraction from our earn national budget to some select individuals.

[ch4s3]

A lot just gets sucked up by 3rd parties of all stripes. Only ~20% of hospitals are for profit institutions for example.

[tgrowazay]

My daughter’s classmate’s father is a head of a non-profit hospital.

They have a 6k sqft house with a basketball court, pool and a pool house in the prime location in West Los Angeles.

They had to join two lots to build to their liking.

[shipman05]

We call that "pulling an Altman" these days.

[ch4s3]

Would you expect that job to not pay well in a market where similar skills are directly transferable to running any mid sized corporation?

[airstrike]

Non-profit doesn't mean money-hating, though

[ch4s3]

No but it directly contradicts OP's claim of "profit-seeking interests".

[airstrike]

Individuals in such hospitals can still very much seek profit.

[ch4s3]

Care to explain what you mean specifically?

[cucumber3732842]

>Only ~20% of hospitals are for profit institutions for example.

And the other 80% are little to no more efficient in terms of dollars input vs services rendered.

[ch4s3]

I am merely commenting that profit seeking is not a sufficient explanation.

[jimbokun]

I don’t think that’s true. US government services generally have very low overhead.

[phillipcarter]

It's quite true. Take Medicaid grants to states for example, which then goes out to 50 different systems of disbursement to private entities. Enrollees on plans are often done so through private insurers, many hospitals are run as for-profit including being owned by PE groups, etc.

[airstrike]

And the intermediaries? And admin?

[BurningFrog]

Not sure if this is comforting or distressing, but it's the same in all welfare states.

[K0nserv]

The US spends the most per capita[0] on healthcare in the world, all to receive a healthcare system that still requires lots of citizens to carry private insurance. I've never dug deep into why, but it sure is noteworthy.

0: https://www.statista.com/statistics/283221/per-capita-health...

[ch4s3]

The private insurance expenditure is part of that per capita number. US healthcare isn't "A system", its a number of interrelated systems that have lots of expensive hand-offs. We also spend a ton on lifestyles diseases because no one walks and culturally we eat like shit on average.

[phillipcarter]

> We also spend a ton on lifestyles diseases because no one walks and culturally we eat like shit on average.

And there's a pretty straight line between that and government subsidies for sugar and processed foods in general, not to mention car-based infrastructure, although the latter doesn't stop other countries from not having crippling obesity rates.

[ch4s3]

> And there's a pretty straight line between that and government subsidies for sugar and processed foods in general

No there isn't. Sugar subsidy accounts for 1.7 cents per 12-ounce can of soda. Soda in the US is generally inelastic, and research has shown that a 10% increase in price results in lessss than a 5% decrease in consumption. Americans just like sugar and sitting, culturally.

[TimorousBestie]

And acknowledging the very obvious instances of regulatory capture that directly harm quality of life is political suicide for anyone with even the smallest amount of access to power.

It’s hard getting normies to admit that if soft drinks weren’t so heavily subsidized by the government at every step of manufacture and distribution, there would be less overall obesity.

[ihumanable]

The graph shows both public and private expenditure. If you only consider the public per-capita expenditure it's more than every other nation on the graphs public + private per-capita spending.

[jltsiren]

The data behind the graph is probably from OECD, which does not use a public/private classification. Mostly because in many OECD countries, "public" healthcare is largely funded by private insurance.

According to OECD data, US healthcare spending in 2023 was 28% from government schemes, 55% from health insurance, 11% out-of-pocket, and 5% from other sources. For most countries, the health insurance category is further split into compulsory and voluntary categories, but that distinction does not really exist in the US.

All US health insurance spending is reported in the compulsory health insurance category. Probably because the bulk of the spending is from employment-based insurance, which is effectively mandatory. (You usually can't opt out and take cash instead.) Naive aggregators then combine government spending and compulsory insurance and report that as public spending.

[renewiltord]

That’s because we pay people well. A low level pharmacy benefits admin makes more than head of cybersecurity for the UK or a doctor in Germany. When you people well, your spending goes up. You can’t pay people a lot and have low spending.

[duped]

> I've never dug deep into why

The wealthy people that run insurance companies bribe our politicians to keep it that way.

[einpoklum]

The distribution itself does not tell you much; you have to normalize by the share of GDP (or some other measure of production/activity) that the federal budget constitutes.

Also, as other commenters mention, the specifics of how money is disbursed or spent, matters. If, say, pharmaceutical companies are allowed to massively over-charge, than the same level of care would mean a higher level of spending than in other world states.

[silentsea90]

Playing devil's advocate - the measure of success of welfare isn't in the budget spent on it but public outcomes. That said, it is true more taxes or expenditure aren't the panacea that the left might think it is.

[cidd]

If clinics and hospitals do not bill 1k dollars each visit, 100k+ for a simple surgery, and pharmacy does not sell medicine 10x the price, US gov't do not need that much allocation for healthcare.

[mekdoonggi]

They only bill that much because they need the average amount of money collected for a procedure to pencil.

They get that cash price amount from a tiny amount of people, 70% of that price from private insurers, 30-60% from Medicare, less from Medicaid. Even then, they have to basically litigate the bills through private insurance appeals.

If they had one payer which had a single reimbursement rate, they wouldn't have to do these shenanigans.

[mikepurvis]

Given that reality, I wonder why it is that spending in this category seems to be so much less effective in the US relative to other nations? Why is the US #22 in general quality of life [1], and the bottom of many rankings of health system performance [2]?

Speaking as a Canadian, I wonder if at least part of it is the attitude that investments in these areas are "welfare" and not simply a part of the portfolio of essential services that are delivered by the state to citizens?

[1]: https://www.usnews.com/news/best-countries/rankings/quality-...

[2]: https://www.commonwealthfund.org/publications/fund-reports/2...

[fhdkweig]

It may just be my cynicism talking, but it seems that it comes down to the power of lobbyists. In the US, the healthcare companies control the government. Elsewhere, the government controls the healthcare companies.

[mikepurvis]

The media narrative is a factor too. Like I have extended family, friends, and work colleagues in the US, many of whom are wealthy and well-traveled and even a lot of them will still loudly assert obviously disprovable untruths like "well at least we don't die in waiting rooms like in Canada" or "at least we don't have death panels deciding who gets to have life-saving treatment" or worst of all "ehh I mean I have good insurance, and outcomes are much better here for top-5%ers, so I don't really care about the rest of the system." All while decades of TV hospital dramas depict a well-oiled medical system delivering effective and efficient care to people with nary a whisper about how it's getting paid for.

It's got to be desperately frustrating trying to fight this kind of thinking when you've got whole communities who have never even thought to question it.

My main hope at this point is with bottom-up type efforts. Let Mamdani show people that an effective city government can fill potholes and operate a few at-cost supermarkets. Let that be the start of citizens expecting more than chainsaw-waving and twitter meltdowns for their tax dollars.

[ekjhgkejhgk]

> "at least we don't have death panels deciding who gets to have life-saving treatment"

They do, it's just that in the western world the death panels work for the government and optimize for "given a certain level of cost, how do we maximize lives saved", whereas in the USA the death panels work for insurance companies, and optimize for "reduce cost". The latter is a much easier job.

Maybe point your US friends to google "united healthcare denial rates" and check that it's 33%. That's the the death panel at work.

[zahlman]

> Speaking as a Canadian, I wonder if at least part of it is the attitude that investments in these areas are "welfare" and not simply a part of the portfolio of essential services that are delivered by the state to citizens?

Also speaking as a Canadian, I don't understand the distinction you're drawing.

[mikepurvis]

The distinction is in whether there's a value judgment. Is healthcare and welfare something we assume is part of the package living in a developed nation, or is it an indulgent extra, subject to suspicion and scrutiny above and beyond what essentials like military spending get?

I would say that the mainstream Canadian view is the opposite of this. We expect healthcare funding and many are supportive of the strikes when it gets cut, but we are much more likely to treat military budget as the purchase of a lot of unnecessary toys.

[insane_dreamer]

That depends on your definition of "welfare". For most Americans that means the government providing support for those who can't afford it (taking from the taxes of others).

Social Security isn't really welfare -- it's more like a nationwide retirement plan, whereby I'm getting X back in future dollars for Y paid in now.

Medicare isn't really welfare either -- it's medical insurance that I am paying for in advance.

(Now you can argue that a percentage of SS and Medicare is welfare because there is a floor on how much you receive regardless of what you put in, though you have to have paid in for at least 10 years to be eligible to receive anything.)

So that really just leaves Medicaid and Safety Net as true welfare: 17.1%.

[airstrike]

In line on price, but not on value.

If anything this speaks to the cost of welfare in America.

The corollary is that many suggestions to reduce welfare spending would lead to even less actual welfare being delivered, without addressing systemic cost problems.

[ekjhgkejhgk]

My (admitedly superficial) understanding is that in the USA because the welfare state is mostly private, it optimizes for profit. So just because you put a lot into it doesn't mean you get much out. I have no first hand experience of this, but the other day I stumbled upon an article explaining private equity buying up the "ambulance business" and costs balooning, so that tracks.

[yohannparis]

That is the sad part, your money is wasted. You guys pay roughly as much in welfare, but get a tenth of it back.

[ForHackernews]

A big chunk of the "defense" budget is also healthcare and benefits for veterans.

[Alupis]

Yet, people still meme how unsupportive the US is to its people.

The reality is the US operates the world's largest social services apparatus, including the world's largest public healthcare system.

[silentsea90]

Both can be true. US spends a ton but people feel the pain because the money is spent poorly

[jimbokun]

The problem is that our public health care system could cover the entire country at no additional cost…if our health care spending per capita was inline with other nations with better health outcomes.

[hyperhello]

The people paid for that welfare for themselves. Everything that helps people is a scare word. They’re too entitled to welfare!

[altruios]

What would you rather have the government spend it's money on if not on the wellbeing/welfare of its citizens?

[atoav]

Yes, if it was actually spent on welfare and not lost as friction in a system of cronies.

[trollbridge]

One of the most generous welfare states with one of the best safety nets. I' not really aware of any place better. Maybe one of the small countries like Lichtenstein.

[pennomi]

Except the US doesn’t have universal healthcare, and other nations do.