[curt]

How is this surprising? We've completely taken the free-market out of health care. The only way it will ever be solve is if we re-introduce market forces back into the mix. The other problem is all the government regulations that tie the hands of people that would do the innovating. That's one of the big reasons California is at the extreme. They continually add requirements to medical insurance that increase the cost. The solution is simple, let the free-market, ie us, decide what we want.

[danmaz74]

It's incredible how ideology can completely make you blind to facts. In most European nations hospitals are actually taken away from the free-market - they are State-run - and, guess what, health care is much less expensive and yet very effective by all metrics.

[untog]

You can't say that all government regulation of healthcare is a bad thing. It literally saves lives.

If healthcare was left as a completely free market I dread to think how many people would die as a result of cut corners and rushed diagnoses.

[wyager]

>It literally saves lives.

Authoritarianism does tend to save lives. That doesn't make it a good thing.

>If healthcare was left as a completely free market I dread to think how many people would die as a result of cut corners and rushed diagnoses.

As if that isn't the case in the most heavily bureaucratized healthcare systems today...

The free market doesn't result in "cut corners;" it results in optimal middle grounds between cost-saving and quality of service, tailored to individual market groups.

[curt]

You can still sue a doctor or hospital for malpractice.

EDIT (answering the responses):

- Overseas you can buy a cheap insurance policy to cover the cost of a lawsuit. The underwriter determines your likelihood of success and charges accordingly.

- You really think regulations stop that from happening now? People still get the wrong limbs operated on and amputated.

[untog]

You really think regulations stop that from happening now?

Should we stop sterilising surfaces because it only protects you from infection 98% of the time?

Regulations are far from 100% successful, but yes, I do believe they reduce the number of accidents.

[gte910h]

Case law is still law.

Libertarians who think "SUE SUE SUE" is the answer really frustrate me: It's random judges picking the law instead of elected reps

[rayiner]

I've always found it a bit strange that libertarians' solution to everything is always "sue!"

[dreamdu5t]

I would rather have judges, in a court case where parties get to represent themselves, applying common law, with a jury of my peers deciding the verdict... than random idiots elected by a bunch of other random idiots I don't know make laws without my input.

[bane]

Consider this:

You just died because, during treatment for an easily treatable medical problem, a lack of regulation allowed some part of that treatment to have a higher probability of complications.

Now go sue.

[burntsushi]

That just doesn't make any sense. That's a problem with and without regulation. First of all, some medical procedures have risks. That's just how it works. Second of all, someone could die in a world with a ton of regulations by a problem that could have been "solved" by a regulation. So you're emotional retort applies here too: "Now go elect a new representative to pass a different law."

[gte910h]

Judges create case law, over and over. Common law was created that way, and tons more is created that way every day.

I don't know why you assume this is better that popularly chosen law.

[dreamdu5t]

Common law is popularly chosen law created by the people. Statutory law (almost entirely with the exception of a few states and their referendums) isn't. Statutory laws applying to 350+ million people are crafted by 435 people.

[burntsushi]

People who think "throw more politicians at the problem" really frustrate me: they are a bunch of random people seeking more power for themselves.

[untog]

If you're still alive, yes. And even then, if you were paralysed from the neck down (for example), would you really be able to enjoy the millions you got in court? Financial compensation for crippling illness always struck me as quite strange.

[mseebach]

The point of financial compensation isn't really to compensate the victim (or their family), it's to push the cost of the externality created back onto the provider, giving an incentive to act sensibly.

[bane]

Good, the the incentive moves to kill the patient rather then try to save them from an accidental complication. Dead patients can't sue.

[kmfrk]

Lawsuits aren't free.

[wyager]

There are shitloads of lawyers who pick up malpractice lawsuits on contract, saying that they'll do the case for free if they get x% of the winnings.

[fancyketchup]

Just thinking out loud, not making a judgement: I wonder if the overhead from lawyer's fees would turn out to be any less than the overhead from government regulations.

[nawitus]

That's not the only way. Government based healthcare works very well in a number of European countries.

[curt]

Where does it work well? A small country with a homogenous population can pull it off but there isn't a single large country where it works. They keep their costs down by rationing coverage with wait-lists. I know a few people from the UK where their family members lived in daily pain and had to wait YEARS for their number to be called. They also limit the availability to the best medications and procedures to keep costs down. Also the quality is also quite poor, hundreds of people in the UK have died of dehydration in the hospital because the staff forgot to give them water.

[DanBC]

> had to wait YEARS for their number to be called.

They could have paid and gone privvate at any time. While wait lists were terrible some time ago they have got a lot better. Since year 2000 wait lists have been consistantly targetted for action by a variety of governments. There are some dodgy actions by some hospitals, but these are called out as dodgy and people take action to prevent it. Patients have maximum wait times listed in national documentation.

> They also limit the availability to the best medications and procedures to keep costs down.

I'm not sure what your point is. Imagine A and B, where A is shown to work effectively and B isn't. Which would you want? In this situation I'm glad that people have a responsibility to evaluate the research to weed out very expensive and inefficient medication and proceedures (and that's really what they're doing. They stop a small number of very expensive and ineffective meds; they don't just allow a small number of cheap meds.)

> Also the quality is also quite poor

How are you measuring quality?

> hundreds of people in the UK have died of dehydration in the hospital because the staff forgot to give them water.

Hundreds sounds too high. Do you have a cite for that please? (Note that the Mirror or the Mail will cause much mirth and laughter and people will then ignore anything else you say.)

While we're talking about deaths from incompetence: Yes, it happens. Yes, it kills distressing many people. It also happens in the US. Medical error is the 3rd biggest cause of death in the US. About 7,000 people die each year in the US because clinicians make a mistake with the medication. About 12,000 people die from unnecessary surgery. About 20,000 die from other errors. Nosocomial (Hospital aquired) infection kills another 80,000 people in the US. About 100,000 people get the right quantity of the right meds, but die from side-effect complications.

There are some things US health care does better. But the UK has better outcomes for some things. We also spend less money on our healthcare than the US.

(http://www.nursingtimes.net/a-comparison-of-british-and-us-m...)

[paulhauggis]

"They could have paid and gone privvate at any time."

Once you have government health care in place, private care costs get so high, only the rich can afford them.

[DanBC]

I'm not so sure that's true. I think prices compare pretty well with the US. Here's one website found pseudorandomly via a web search. (http://www.bmihealthcare.co.uk/paying-for-yourself)

Notice that they offer many surgeries "at a fixed price" and that all costs are known before surgery starts. I'm not sure what happens if there are complications; whether those are covered or not.

(I would have called them to get a quote, but they're not open yet.)

[chc]

The United States has had this situation for a long time, despite healthcare being almost entirely private.

[arethuza]

"private care costs get so high, only the rich can afford them"

That is most certainly not the case - private health care is a fairly common perk for senior positions in many companies (I get it and I'm two layers away from a CxO).

[microtonal]

Where does it work well? A small country with a homogenous population can pull it off but there isn't a single large country where it works.

The Netherlands has a heterogeneous population (I don't see why size matters) with strongly government regulated sector of private insurance companies and hospitals. The net result is that we pay far less per capita than citizens of the US, yet the healthcare system is judged to be much better:

http://www.reuters.nl/article/2010/06/23/us-usa-healthcare-l... http://www.commonwealthfund.org/Publications/Fund-Reports/20...

[femto]

I gather the NHS (UK) is similar to Medicare, in Australia, where I live.

Under Medicare, highest priority is given to life threatening conditions. For example, if you have a heart attack, you will be treated without delay and to the highest standard. Non-critical cases, such as a knee reconstruction go on a waiting list and it is relatively common for such operations to be postponed multiple times, as higher precedence emergencies arrive at short notice.

Basically, a person who might die will receive care over an uncomfortable person. It can suck if you have a painful, but not life threatening condition, but it is an attempt to give the best overall service within available resources. The public system will treat you if you're not going to die and normally do so well, but in the worst case (that typically makes the news) it can take a long time.

There is always the option of having an operation done privately, and either paying for it yourself, or having insurance to pay for it. Medicare has broad support within Australia.

[danbruc]

It works really well in Germany with about one quarter of the population of the states. You pay about 15% of your salary split roughly 50/50 between the employee and the employer and that's basically it. You have to pay some additional money for different things - drugs (10% of the price, maximum 10,- €), hospital stay (10,- € per day, maximum 28 days) and so on. If you are unemployed, the state will pay for you. Finally you are free to opt out and get private health insurance - this may be cheaper when you earn much and are healthy but it may also turn against you.

The price of this is a very large bureaucracy regulating all this and of course costing quite some money that does not go into actual medical treatment.

[jeltz]

> The price of this is a very large bureaucracy regulating all this and of course costing quite some money that does not go into actual medical treatment.

I still think it is smaller than the bureaucracy of the insurance companies in the US. I do not know about Germany specifically but the US has perhaps the largest administrative overhead in the world.

[arethuza]

"Also the quality is also quite poor"

If the quality of care is so poor presumably voters here in the UK would be falling over ourselves to get rid of the NHS and replace it with a more efficient and cheaper private system?

The NHS is far from perfect, but in my experience (and I have private health insurane through my employer - which I personally have never used, although my son has) is that the standard of care generally in the NHS is very high - my son was born in an NHS hospital, my wife has been treated for life threatening injuries more than once (e.g. climbing accident) and the standard of care and the attitude of the doctors and nurses was great.

Private health care in the UK is mostly about getting access to non-vital procedures more quickly than others (my son had his tonsils removed) and getting a nicer room.

[superuser2]

>I know a few people from the UK where their family members lived in daily pain and had to wait YEARS for their number to be called.

What about people "the market" doesn't find it profitable to treat? I'd rather be on a waiting list for pain medication than told it costs more than I make in a year.

[cpncrunch]

That is certainly not the norm. I lived in the UK for 3 decades, and it's definitely not like that. The level of care is very good, and the vast majority of the population are happy with it.

[mikeash]

There are incredibly powerful vested interests in the US who find it useful to convince as many people as possible that socialized medicine is awful and must be avoided at all costs. As a result, there's a huge amount of propaganda floating about, using techniques ranging from cherry-picking (it's bad because of these specific example cases) to outright lies (socialized medicine is why European states are bankrupt). A sadly large number of Americans believe it. Everyone then gets terribly confused when such a person bumps into a European who never noticed that the health care system they used all their life is actually a communist hellhole.

[princess3000]

You realize that every single thing you enumerated could easily be applied to for-profit insurance companies in America, right? Just checking.

[mistercow]

> there isn't a single large country where it works

The healthcare system in Canada seems to be working a lot better than the one here. Is that large enough?

[refurb]

You mean the one where the Supreme Court of Canada agreed that the delays in the treatment of cancer in combination with a ban on private insurance were violating Canadian citizens' rights?

http://en.wikipedia.org/wiki/Chaoulli_v._Quebec_(Attorney_Ge...

[mistercow]

Is the bar "works perfectly" or "works better than what we have in the US"?

[selectiveshift]

The population of Canada is approx 35 million, whereas population of the United States is over 300 million. Canada is not a large country population wise.

[nisse72]

And presumably, there are nearly 10 times as many taxpayers in the US to fund such a system. Why do the absolute numbers matter? In fact, shouldn't there be better economies of scale in the larger country?

[mistercow]

OK, Japan then. 125 million people, universal health coverage, ranked 10th in the world by WHO (the US is ranked 38).

[cmircea]

I hate to say it, but:

owned

[maxxxxx]

Why is this always used as an excuse why the US is different? The US has ten times more people, hence 10 time more tax payers. If anything I would expect things to be easier for the US because of its scale.

[AlexandrB]

Canada has significant costs associated with delivering health care service to remote areas because of its low population density. A US public system should be more efficient, not less.

[brazzy]

Nonsense. It works quite well pretty much everywhere in Europe. Better that in the USA, at any rate.

[rayiner]

People waiting is better than poor people not getting any health care at all.

[bane]

> They keep their costs down by rationing coverage with wait-lists. I know a few people from the UK where their family members lived in daily pain and had to wait YEARS for their number to be called. They also limit the availability to the best medications and procedures to keep costs down. Also the quality is also quite poor, hundreds of people in the UK have died of dehydration in the hospital because the staff forgot to give them water.

So we don't have these problems in the U.S. under the current "free market" system?

Before you answer, I already know that the answer is "yes we do".

[_delirium]

Wouldn't a free-market system have to ration coverage in some way as well, unless infinite resources were put into medical treatment? The disagreement seems to be over how to ration it, e.g. do you do it based on wait-lists, or do you do it more auction-style, or some hybrid (like France), or something else entirely?

[dragonwriter]

> Wouldn't a free-market system have to ration coverage in some way as well

"Free market" is a rationing system that provides scarce goods/services to those willing and able to pay the most first.

[mseebach]

Generally it just works.

[runn1ng]

And, as a consequence, our doctors got paid much less and the state-owned insurance companies are still hemorrhaging money.

[stevewilhelm]

I would never make a personal health care decision based on price.

I don't want to live in a society where we would let people suffer or die if they can not afford health care.

Given these two conditions, free-market forces aren't very helpful.

[mdesq]

You already make personal health care decisions based on price. Did you get a complete physical and blood test today? If yes, will you do the exact same thing tomorrow?

[gordaco]

I'm guessing that those are a lot more based on the inconvenience of doing such things daily than their price.

[growse]

Price is about more than just cash.

[mikeash]

You can get the free market back in health care once you can convince society in general that it's acceptable to let poor people die of treatable diseases. Until then, it's simply a question of how it'll be heavily regulated, not if.

[anonymoushn]

This is a red herring. It is not surprising that the cost of care can vary wildly when the customer cannot possibly know the cost of care before purchasing it. Even a person with no immediate need for care cannot obtain the best price since no hospital will provide him or her with a price up front.

"Posting prices publicly" is not the same thing as "completely deregulating the industry" or "repealing EMTALA."

[flatline]

The customer generally cannot even know the cost of care after purchasing it. Not only is the issue muddled by insurance companies' negotiated rates, but the line item prices on doctors and insurance statements are almost complete nonsense. Really they just say what broad category the care fell under for record and insurance purposes, and there is no way to tell if you have, for instance, been double billed for a procedure. The only times I've been able to clearly tell what I paid for was when going to a specialist for a very specific procedure.

[grey-area]

It is not surprising that the cost of care can vary wildly when the customer cannot possibly know the cost of care before purchasing it.

Even the healthcare professionals can't estimate the price of care before providing it, because it depends on the outcome of things like surgery and reaction to treatments which cannot be predicted. So there's no way to tell the patient beforehand that their care will cost x amount. In addition to this the customer often doesn't know what they want and has no basis for making an informed choice before seeing a doctor. This is fundamentally different than (for example) selling products in a supermarket where costs are known up front, shops can vary prices and quality, and people can shop around. So the benefits of patient choice of hospital and treatment etc are questionable.

Other countries spend far less using a single-payer system with comparable or better outcomes than the US according to the statistics on life expectancy and expenditure per capita on healthcare, so IMHO the US should have more and better regulation of the healthcare market, not less. Cutting out the insurance companies completely would be a good start, as at present they run a racket extracting billions from the US tax payer for questionable results.

[wfunction]

> So there's no way to tell the patient beforehand that their care will cost x amount.

I call B.S. -- unless you're calling B.S. on the data.

There's something called "estimation" which comes in very handy when you don't know something with certainty.

If you have absolutely no idea, then you just guess the average cost for each patient with a similar background, with a disclaimer that it may not be accurate.

Problem solved, unless you don't want to do it because then it'll prevent you from ramping up the prices unnecessarily later.

[wpietri]

Problem definitely not solved. There's too much uncertainty, and comparisons are too hard.

This happens all the time in software. Non-techies put a project out for bid. They will get estimates from a variety of consulting companies. The estimates could easily vary by an order of magnitude. Do they go with the lowest, because they are the most efficient operation? Or is the low price a sign that they're the dumbest, and are underestimating? Do they go with the highest, because in a market economy price is correlated with value? Or are those guys just the gougers?

And medicine is worse, because things are so contingent. Complications get complicated indeed. And the person trying to make the decision is pretty likely to be sick. I tell you true: deciding what to do about cancer is hard enough without trying to organize and judge a multi-round competitive bidding process.

[wfunction]

Claiming something is "too hard" never got anyone anywhere.

[artsrc]

Alternatively just charge everyone the average cost, with no disclaimer.

In fact you can do that before the need for care is even known, and you can call it insurance.

[jaynos]

Tell me my surgery will cost $100,000 at hospital X and $200,000 at hospital Y (both of which are close to me and staffed with competent employees). It won't influence my decision as long as my insurance company doesn't care. I'll pick based on the doctor and the insurance company can negotiate either bill (down to a very similar level, I presume).

If I don't have insurance, I may be swayed by the $100,000 price, but either way they'll have to sue me to get all of the money that they ask for.

[DannoHung]

How shall emergency rooms operate? Also, how shall people make an initial determination on care when no diagnostics have yet to be performed?

[mseebach]

> How shall emergency rooms operate?

Not all emergency room decision-making happen with blood pumping out of your pulmonary artery. There are parents who take their babies to ERs, and through repeat business decide to like one better (maybe because it's cheaper, maybe because it's a bit more expensive, but never have any waiting time) than the other. There are consumer reporters who will look into why one hospital is cheaper than the other. Smart phone "Yelp for hospitals".

EDIT: Forgot the conclusion: This will drive down prices in the general case, which will also result in lower prices for the emergency case, even if in an emergency you don't have the luxury of calmly evaluating all the options.

> Also, how shall people make an initial determination on care when no diagnostics have yet to be performed?

The same way you decide which restaurant to go to before you know exactly which dish to have: Ranking by a general cost/quality scale.

[bicknergseng]

I wouldn't bank on free markets fixing emergency room problems. While anecdotally some parents may choose to take their children to one hospital or another, I doubt this is a statistical norm. I imagine most people choose the nearest emergency room for most emergencies, and hold off for an appointment with a doctor otherwise. Sometimes, it's just a baby with colic. But sometimes (increasingly in a country with a serious obesity problem) it's a heart attack, and no one is going to drive their dad 45 minutes to the cheap hospital when the one that will save his life is 10 minutes away. Because of this I don't think hospitals have any incentive to drive down ER costs.

But maybe I'm projecting, since my experience with ERs tends to be "Oh shit... get me to a hospital now Google Maps" rather than "I should Yelp some reviews of hospitals, because I have time."

[mseebach]

Of course it's hard to predict what will happen. But right now, nobody has an incentive to even check, so obviously it doesn't happen.

Some people will live 10 minutes from one ER and 45 from the next. But some will live 25 from one and 30 from another. Or have three within 15 minutes (ie. short enough that they're equidistant for "the baby has colic"). Some will have more time than money and drive 45 minutes if it means saving $20.

But there's another factor in free markets you're not accounting for: new entrants. If an ER charges high rates because they're the only player in the area, someone could set up a competing ER and charge less.

[pfranz]

Doctors have no idea how much a procedure or test cost (and they don't care or want that burden)--that stuff is generally insulated by insurance. In my experience, they are vaguely aware of the price of different prescriptions (after insurance) because that directly affects the patient. The economic forces are all out of whack. I'm not blaming doctors--the information should be more easily available to them to provide to the patient.

I'm not in the medical industry (but my g/f was seeking out her own insurance recently), but I would guess that the ER would work similar to a car mechanic. Where the paperwork you're already signing upfront includes a flat price you're paying for diagnostics. Then after the diagnostics (or possibly at the same time you signed the diagnostic paperwork), you agree to a price range for treatment/tests. It would itemize the fixed costs and estimate the variables. If things go outside of that range, there's an amendment. You walk home with the bill.

[DanBC]

"Each blood test: cost $X" "Each x-ray: cost $Y"

etc etc.

That way patients can ask the doctors if the tests are actually needed.

You're right that emergency care becomes a lot more complicated.

[zecho]

In actuality, it would be: "Each blood test paid by insurance company $A costs $X, Each blood test paid by insurance company $B costs $Y." Etc.

I really think a big part of the problem in healthcare pricing is insurance company policies regarding networks and guaranteed volume. Your auto insurance doesn't demand you use a certain body shop, why should your health insurance?

Here's a practical example that recently came up for me. My wife is a nurse at a few clinics. At one clinic, she's got health insurance and that clinic provides IUDs via their hospital, which she wanted to get. At this clinic, the price billed to her insurance would be $4700.

At another clinic she works at, she could get the same IUD brand and procedure for $600.

When she asked her insurance about it, they said they would pay 100% of $4700 in-network but 60% of $600 out-of-network. Obviously, being selfish, she decided to let the company eat the $4100 they would otherwise save so that she would pay $0 instead of $240.

[tsotha]

Because that $4700 isn't the cost the insurance company is paying. The real reason you can't go without insurance in the US is they're negotiating steep discounts - where I live it's supposed to average 80%.

It may well be they paid less than $600 for a procedure that lists at $4100.

And of course the government numbers don't take this into account, so what they've published is pretty much worthless.

[tsotha]

>That way patients can ask the doctors if the tests are actually needed.

How does this work? If a doctor prescribes a blood test, he's already said it's needed. Put yourself in a doctor's shoes for a minute. You told the patient he needs a blood test. Then he asks you whether it's actually needed.

How can you possibly say "Nah, just kidding. We don't need that one"?

[DanBC]

One of the most important questions you can ask of a doctor is "what happens if we do nothing?"

[anonymoushn]

Overtesting is more or less a thing in the U.S. Many tests are not harmless, so even a person who carries an infinite amount of money around would do well to question the necessity of tests.

[wfunction]

need it != it would be useful

[warfangle]

Because a plumber from idaho can make better decisions about whether the hacking cough + bloody sputum requires a chest x-ray than his doctor.

Right.

[warfangle]

And why should healthcare cost money? That's pinning quality of health to how much money you make.

And that's just plain immoral.

[anonymoushn]

Well, let's look at the alternatives. If we don't want people to have to pay for the services they use, we can let people enslave doctors. Or, we can steal from every citizen in the whole country and use the resulting money to pay the doctor. This second option would be called "single payer," and it is my preferred policy, but it does not seem to be obviously morally different from enslaving doctors or obviously morally preferable to requiring people to pay for the services they use.

[wpietri]

Or, and I'm going out on a limb here, and we could have a thing called a "democracy", where we jointly decide to pay for health care for everybody. And then we could come up with some sort of system for sharing out the costs of the joint project in a more-or-less equitable fashion.

[anonymoushn]

Right, this is what I proposed. We should democratically agree to use the threat of violence to steal money from everyone to pay for medical services for everyone.

[tsotha]

"equitable"? That's a 100% subjective term. Of course if someone else is paying it's equitable. If you're paying for someone else, it's not.

[warfangle]

Which is the greater moral disservice - a set price, to be paid for by a non-profit, heavily regulated healthcare org -- or letting people die because they can't afford to go to a hospital that isn't overrun by MRSA?

[anonymoushn]

It's not clear to me what you are proposing. Particularly, the source of funding in your proposal seems to be something like "A miracle occurs, and then the healthcare org is sufficiently funded to pay for people's health care."

One could just as easily ask "Which is the greater moral disservice - a global food distribution network that ensures every person will have safe sustenance, or letting people starve because of regional droughts, tyrannical governments, and currency speculators?" but the question does not apparently lead to any actionable policy decisions.

[tsotha]

Why should food cost money? Why should shelter cost money? Why should heating oil cost money?

[artsrc]

Because those industries work better when they do*

Just like health care works better when it is provided by a single payer.

* In the case of shelter, temporary shelter for those who need it is also provided free of charge, but that is not the normal situation for most people.

[Vivtek]

No, it's not a red herring. It's two different problems with the same industry.

[mseebach]

He said reintroduce market forces, not remove all regulations.

I'm a pretty big fan of the swiss model, I think it contains the best of both worlds:

You're forced to buy a certified policy with a certain (broad) coverage. If the cost of such a policy exceeds 8% of your annual income, government makes up the rest.

Both insurers and providers are regulated heavily for quality control, but compete freely for their business.

The result is a generally consumer driver system, as opposed to an insurer driven (US) or state-bureaucracy driven (most of Europe) model.

[saalweachter]

Didn't the US basically go with the Swiss model with the ACA?

We've still got all of our previous healthcare systems (Medicare, Medicaid), but the ACA added mandatory insurance with specified minimum coverage, and helps pay for the insurance of the poorest people.

[mseebach]

There seems to be elements, but hardly the important ones (making insurance and provisioning consumer facing).

[specialist]

What's your definition of "best"?

There are only two measures of effectiveness.

Per capita costs and life expectancy.

How does Switzerland rate?

[mseebach]

> There are only two measures of effectiveness. Per capita costs and life expectancy.

Uh, no. Health care is a lot more than keeping people alive.

Cost: More expensive than the European average, quite a bit cheaper than the US.

Life expectancy: second in the world, at 81.81.

https://en.wikipedia.org/wiki/Healthcare_in_Switzerland

https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

EDIT: And, since it apparently wasn't clear from context, by "best of both worlds", I mean that it manages to get a competitive, consumer oriented system without sacrificing universal coverage and regulation of quality.

[specialist]

Life expectancy correlates nicely with wellness.

Adopt the phrase "patient oriented system" and I'm totally on board.

[vidarh]

> Life expectancy correlates nicely with wellness.

It may correlate reasonably well, but there are plenty of ways life expectancy can be the same for systems with very different level of "wellness". For a long time, Sweden had special wards for people in persistent vegetative states because there was no provision for ending care, for example, resulting in people being kept alive for years long than they otherwise would. I believe they loosened the requirements for ending care quite a while ago. But there are plenty of other ways that life expectancy can correlate badly with "wellness", e.g. poor treatment of patents with long term conditions such as dementia where patients can often easily survive for a decade or more but where quality of life can be massively different depending on treatment.

[adventured]

Switzerland is likely first in the world. Japan's number is bogus, it's artificially inflated by rampant benefits fraud.

[dhimes]

There are only two measures of effectiveness

In the free market you could argue that 'customer satisfaction' is the only measure of effectiveness you need to consider. Equating customer satisfaction with best solution fails in everything from automobile ratings to elections.

[artsrc]

The most important contributors to those two things are likely to be something other than the health care system.

For example if you increase the tax on cigarettes you increase life expectancy.

And if you increase immigration, and therefore decrease the average age of your population, you will decrease per capita costs.

[tsotha]

>There are only two measures of effectiveness.

>Per capita costs and life expectancy.

This is laughably wrong. The biggest influence on life expectancy isn't the medical system at all - it's the lifestyle habits of the populace. Genetics play a big role as well.

[wwweston]

Sounds quite a bit like PP/ACA.

[mikeash]

If everyone has insurance, what makes providers compete on price?

[vidarh]

The UK healthcare system is 96% or so publicly funded. Yet I choose my private GP. If they don't treat me well, I go somewhere else. So while they can't compete for me by price, they need to be efficient enough to be able to afford to provide care their patients are happy with, or they loose their patients, and with it their funding.

They also need to keep their cost under control, as their cost determines their profitability: The rate they get paid to take NHS patients is set across the board.

And if/when the NHS sees the cost of providing certain care drops across the board, they can and do push the price they are willing to pay for it down.

The UK incidentally has a healthcare system that is substantially cheaper than the US, yet ranked substantially higher by the WHO.

[linker3000]

I spent 5 weeks in hospital last year for Pulmonary Edema (fluid on the lungs) related to diabetic-induced heart problems. Two ops and 5 stents later I can't fault the UK NHS model. It's not perfect, but it does a great job without bankrupting the patient.

[jusben1369]

Think of car insurance, which is mandatory (agree some people still ignore it) yet is super competitive. And they don't compete on price. They just differentiate in the market around price and services.

[pyre]

To get more customers from 'the other guy?' If they all cost the same, then no one will switch, but if Insurance Company A is cheaper, then maybe someone will switch from Insurance Company B.

[ I'm assuming that you mean 'insurance providers' and not 'medical care providers.' ]

[mikeash]

Odd how three people all responded to me with the interpretation that I was being a moron rather than the interpretation that I was asking a tough question.

[dragonwriter]

> If everyone has insurance, what makes providers compete on price?

Strictly speaking, they don't.

But they have a strong incentive to limit costs because of insurance company reimbursement policies and the conditions for getting "in network" for HMO-style plans.

[mseebach]

I don't understand, they compete like any other business? The same for less money or a better product for the same (or more) money (a poor product for even less money, of course, is not an option).

[mikeash]

The people choosing who to patronize aren't the people paying, so where's the incentive to compete on price?

[mseebach]

Providers, dammit, not insurers. Makes sense now. Sorry.

Good question, I don't actually know. Surely the insurers will make them compete, but that should also happen in the US, and obviously not fixing the problem.

[mikecane]

>>>that it's acceptable to let poor people die of treatable diseases

This already happens if you have poor dental health.

For Want of a Dentist http://www.washingtonpost.com/wp-dyn/content/article/2007/02...

Man Dies From Toothache, Couldn't Afford Meds http://abcnews.go.com/Health/insurance-24-year-dies-toothach...

Obamacare, AFAIK, excludes dental care. Dental care is somehow considered "vanity" medicine, even if prosthodontics are medically valid.

[curt]

The United States is the most charitable country in the world. On top of that I never said to deny coverage to those that can't afford it. There are other ways. How about the giving them an annual voucher for $X, whatever they don't spend gets rolled over into the next year. Just like a HSA.

[jmathai]

Not sure what charity really has to do with it. Americans aren't going to willingly give money to "help the poor" to the extent that medicare does.

I would imagine that the US is also among the greediest countries in the world.

Odd how it can work out that way with percentages.

[edit: grammar]

[caseysoftware]

Why would you assume or imagine when you have the single biggest source of information in the world at your fingertips?

From http://www.charitynavigator.org/index.cfm?bay=content.view&#... we learn that:

- Total giving to charitable organizations was $298.42 billion in 2011 (about 2% of GDP). This is an increase of 4% from 2010.

- Giving by individuals (which includes bequests and family foundations) is critically important as it represents nearly 9 out of every 10 dollars donated.

- 32% of all donations, or $95.88 billion, went to religious organizations (down 1.7%). Much of these contributions can be attributed to people giving to their local place of worship. The next largest sector was education with $38.87 billion (up 4%).

- Donations were up to health charities (2.7%), to public benefit charities (4%), to arts, culture, humanities charities (4.1%), to International charities (7.6%), to human services charities (2.5%), to environmental and animal charities (4.6%).

For comparisons to Europe, check out: http://www.american.com/archive/2008/march-april-magazine-co...

- Per capita, Americans give 3.5x than the French, 7x Germans, 14x Italians.

- Americans are 15% more likely to volunteer than the Dutch, 21% more than the Swiss, 32% more likely than the Germans.

The pattern holds true across many demographics (education, age, income).

[rayiner]

So if the $298.42 billion donated world wide, almost half ($135 billion) went to fairly self-serving purposes (e.g. me donating to my alma mater to improve the stature of the school).

[caseysoftware]

First, those numbers were US exclusively as that was the situation you referred to.

Second, while many of the donations were to religious organizations, many food banks, shelters, etc are run by the same institutions. Assuming those categories are mutually exclusive is risky at best.

[jmathai]

I don't think data really helps you get to an answer. I can only go by my experience living in America.

My observations are that Americans definitely look out for themselves. People tend to give (as you stated) in ways that directly or indirectly benefit themselves.

These are broad generalizations but having lived here for 30 years I'd not consider our society to be generous by any stretch of the imagination.

[saraid216]

Charity is an excuse to keep the poor around in order to look good pretending to help them. As a stopgap in the immediate future? They're good things. As a long term strategy? It's intentionally ineffectual.

No charity has, or ever will, end major problems like hunger or poverty.

[rayiner]

Also, on a dollar per dollar basis, the government is vastly more efficient than nearly any charity. The Social Security Administration's overhead was 0.8-1.4% (depending on how you count) last year. Find me a private charity that efficient.

Make a Wish Foundation crows about spending 76% of funds on programs. If the SSA were as efficient as Make a Wish Foundation, it would have an overhead of an additional $185 billion a year (i.e. approximately equal to all federal payroll expenditures).

[kareemm]

The bulk of charitable spending is on programs and fundraising, usually in that order. The SSA doesn't have to worry about fundraising, hence the disparity in admin expenses.

[nazgulnarsil]

overhead is not the best measure of charity, QALYs saved is. If one charity has 50% overhead but saves 10 times the QALYs as one with 0% overhead you want the one with the overhead.

[refurb]

What a ridiculous statement. Most of the charities' overhead is money spent on fundraising. The SSA doesn't have to fund raise since it's illegal to not pay into it.

[tsotha]

>Not sure what charity really has to do with it. Americans aren't going to willingly give money to "help the poor" to the extent that medicare does.

"Medicaid" is the program you're looking for, not Medicare. Anyway, Americans did willing give money to "help the poor" get medical treatment. There were various organizations that operated charity hospitals (Shriners and the Catholic Church come to mind) where you paid what you could pay, and Americans donated generously to keep those hospitals running. It was normal for doctors to put in some amount of unpaid time in charity clinics because that was considered the right thing to do.

But the government crowded all that out, and since it's been a few generations people don't remember.

>I would imagine that the US is also among the greediest countries in the world.

This isn't even close to being right.

[cma]

Most of that "charity" is for religious brainwashing. Sending kids on thousand dollar flights to work on a cinder block indoctrination center and also get a beach vacation out of it.

Don't remember where I read it, but someone had a good line about youth pastors essentially playing the role of cruise ship activities coordinators.

[sp332]

Hospitals generally won't deny life-saving treatment. But they would deny anything less. Even, paradoxically, providing cheaper preventive care to avoid expensive emergencies later.

[fnordfnordfnord]

>Hospitals generally won't deny life-saving treatment. But they would deny anything less.

That's right, they will let you get sick enough to need intervention, and if you can't pay, they'll try in the meantime to find a gov't program to foot the bill.

[_delirium]

Isn't that just rationing in a different form? If someone has $X to spend on treatment, and the best treatment costs 10*$X, then they will not be able to receive that treatment.

[anonymoushn]

Do we expect that our medical professionals and facilities have the capability of providing the best treatment to everyone all the time? If they do not, how should we decide how to allocate the medical care?

[_delirium]

I agree, that's exactly the question. Well, unless we get to a situation where literally every person can receive the best treatment for every ailment, at high-quality facilities with no waiting. If we're not in that situation, then some people can't receive the best treatment for their condition, and the question is who and when.

[danielweber]

how should we decide how to allocate the medical care?

Our current method of deciding is to stick our fingers in our ears and pretend it doesn't matter. Anything has to be better than this.

[anonymoushn]

Actually, we are using money to allocate it, which seems pretty reasonable. This will be an even better idea if we can bring costs down substantially.

[mikeash]

People with serious diseases will outspend their voucher, and then many of them will die unnecessarily.

Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind. I've yet to see one, though. Not being allowed to refuse treatment screws up too much.

[burntsushi]

> Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind.

No such proposal exists. Any proposal that does requires a third party to intervene as either an angel to donate whatever resources are needed or as an agent enforcing policy that one group of people must provide services to another group of people regardless of means.

Both of the aforementioned scenarios do not exist within the realm of market forces because market forces cannot make guarantees.

People will always die because they don't have the resources to fix what ails them. We can only hope to lower the amount of resources to get treatment, and "market forces" are absolutely a legitimate solution to that.

But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely.

[mikeash]

"But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely."

We are in agreement. My point is that society is stuck on this (note that I have made no value judgment in these comments myself) and until and unless that changes, market forces are implicitly ruled out.

[beagle3]

Actually, the Israeli system does sort-of stop people from dying yet still lets market forces do some magic. It is single payer (gov) through taxes, every person chooses their HMO. The HMOs get paid per member (so they compete for the members) and they are also allowed to offer extra services to their members (which they also compete on). And finally - and I think this is also crucial - the government has a special fund for expensive life saving treatments that the HMOs tap into when needed - so they do not have an incentive to avoid those treatments.

[baddox]

People with sufficiently serious diseases will die, period, even if they're the wealthiest people on Earth. I don't see how the inevitability of death caused by disease is a useful argument. If there was some disease that one person had, and that could be cured only by pooling the entire wealth of the Earth, should we forcefully take that wealth to cure that one person?

[wpietri]

That would be an interesting hypothetical if anybody sensible had ever suggested anything close to that.

[mseebach]

> Give me a proposal that stops poor people from dying of treatable diseases while preserving market forces, and I'll change my mind.

See my comment elsewhere on the swiss model.

[sp332]

Death isn't preventable, you can only delay it. Should the people pay for someone's heart surgery if their kidneys are on track to fail in a few months anyway?

[Klinky]

Life expectancy estimates are often all over the board and wrong. Imagine it's a close relative who is having the heart surgery. Would you actively try to persuade them to not do the surgery to possibly extend their life because their kidneys might fail later, so they might as well die now because they're not worth the money that would go into the surgery?

It's easy to say a Big Mac isn't worth the cost on the menu, it's harder to say that your mom's life isn't worth the cost.

Keep in mind we're talking purely about economics here, as that is what your post is about. We're not talking about quality of life.

[sp332]

Economically speaking, I think it's fine for a person to spend huge amounts of their own money that way if they want. Also, it's fine if they ask around for friends, family, or even total strangers to finance their health. But forcing people to pay (via taxes) for an operation seems outrageous to me.

[mikeash]

I don't know, but people in general seem to think the answer is "yes". Until and unless that changes, market forces won't really work in health care.

[Shivetya]

poor people might find better services locally if the Federal government allowed insurance across state lines. This would increase competition and bring costs down. With lower costs more money would be freed up to service those who cannot pay.

I have not heard of my local hospitals refusing care. If anything the ER seems to be majority sniffles or need a ride people.

[maxharris]

"Letting" someone not get treated because they can't afford it is no different in terms of my obligation than "letting" someone not have a new car, a new TV, an education, clothing, food, or anything else they need to live.

None of us are born in hock to the needs of others. If we were, that would be moral slavery.

[wpietri]

You need a new TV to live?

All of us are born incredibly dependent on others. After a long period of investment, we can function on our own. (Well, if by "on our own" you mean "without being directly dependent, but requiring a rich and complicated society where other people take care of most things for us".) Most of us choose to pay that forward by contributing to the maintenance of society and the species.

If you don't want to, godspeed. There is no law preventing you from being a selfish ingrate. You are allowed to opt out at any time and move to a country that is less interested in, say establishing justice, promoting the general welfare, or securing the blessings of liberty for the citizenry current and future.

For example, I hear that the tax rates in Somalia are very reasonable. Do start a blog! And maybe we can start a pool on how long you'll last in a place where helping others to survive is seen as optional as having a new TV.

[maxharris]

All of us are born incredibly dependent on others.

"Others" as you use it is far too imprecise. A person is born dependent on his parents, who have an obligation to raise him once they've chosen to carry a child to term. That obligation does not extend to people that didn't make the choice to bring the child into the world.

Also, you're attacking a straw man. I'm not an anarchist.

Sustaining a rich and complicated society requires that people act as traders. That entails producing things that are valuable to others, in exchange for things that are valuable to you, quid pro quo. And that requires a government, whose sole duty is to retaliate against people that try to bypass that process by force or fraud. A market cannot exist without an objective arbiter that keeps the peace (which can only be accomplished by having a monopoly on force - private armies, courts, police forces would lead to war) and enforces laws.

[wpietri]

Yes, that's the fundamentalist libertarian perspective. Like most fundamentalisms, it is hermetically sealed: you can never convince a Freudian it isn't all about sex, or a bible thumper that it isn't all about God's word.

I always find that a little depressing with libertarianism, as there's enough useful material there that I hate to see fanatics turning people off to it. There's a giant difference between "an important function of government is" and "government's sole duty is". The latter is appealing to people looking for simple answers to complicated problems, but is actively off-putting to everybody else.

I understand you don't think you're an anarchist, and, for a different reason, I'd even agree. I think the step-over-the-dying school of libertarianism would turn out, in practice, to be indistinguishable from the sort of chaos that people who don't know any actual anarchists think when they say "anarchy". (The interesting sorts of anarchism, like what the anarcho-syndicalists were pursuing, depend upon a human moral sense. Which, bringing this back, include compassion for the ill.)

The reason things will fall apart lies in another gap in your thinking. Parents are the most obvious thing a child depends upon. But try telling a teacher or a grandparent or a cop or a social worker or a neighbor or an aunt that they don't matter, that they don't have an impact on the kids they deal with. It takes, as they say, a village. Or, if you'd like a richer society, a lot more than that. You'll of course wave that away as inconsistent with your chosen theoretical framework. But that you can't perceive the value in something doesn't prove that it's valueless. It only shows you haven't bothered to really understand it.

[anonymoushn]

Why is "If you don't like it, get out" perceived as a reasonable response to only a very narrow set of ideas? It seems very strange to me. Nobody says "If you don't like your neighbor owning guns, move to Canada," "If you don't like the small size of your future social security payouts, naturalize in some country with larger entitlements," or "If you want to sell cars directly to consumers rather than to dealerships, just do it in Europe," because of course it would be completely unreasonable to say these things. Instead, for most ideas, people will bother to agree or disagree, knowing that both society and the law tend to change over time based on the views of people.

[wpietri]

I think if somebody is saying, "I fundamentally disagree with the foundation of our society", then "try someplace else" is a reasonable answer.

In this case, though, I'm not expecting anybody to move to Somalia. I'm pointing out that places with no effective social contract or taxation system are hellholes. It's not a literal recommendation; it's a reductio ad absurdum to show that the poster's views aren't thought through.

[maxharris]

You need a new TV to live?

You're making the mistake of defining "life" as only the things you need to for physiological/material functioning. But there's more to life than metabolism!

A human life also includes art, music, fine cuisine, fresh cut flowers, travel, and an almost endless number of other things, depending on whose particular life you're talking about.

Think of someone that loves movies. He definitely needs a new TV to live, and he's got a right to it as long as he's earned it.

[wpietri]

This seems like a further attempt to muddy the waters. There is a vast difference between "let's make sure people don't die from easily treatable disease" and "let's give everybody free TVs". I understand why, rhetorically, it's convenient for you to pretend they're the same, but the approach mainly persuades me that you're not serious.

[bane]

Let me know how that works for you the next time you don't pay your taxes that fund the Interstate I take to get to work.

[maxharris]

This does nothing to answer me. I was making an ethical point, not a political one (although it does have political ramifications).

I don't advocate that people not pay taxes. That's just a good way to get fined and/or go to jail. But I do advocate that people fight to abolish taxation, and especially the ethical ideas that support it.

[bane]

Oh, I get it, you're one of those guys that thinks all roads should be toll roads and you should only be protected by the police and the military if you can personally pay for that protection and all schools should be private -- wanna learn? gotta pay.

Yuck. Never mind I'd rather not debate this with you.

[maxharris]

No, that's not what I'm saying at all.

I'm not an anarchist. We need a government! Without creating the conditions necessary for a market, that market cannot exist. What are those conditions? The only fundamental one is to retaliate against anyone that initiates physical force against another. (Examples of this include murder, theft, fraud, assault, etc.)

[cpursley]

The thing is, poor people are still dying of treatable diseases. Many of them by choice (McDonalds, smoking, etc)

[mikeash]

Sure, but the system is still bent by the attempt not to let this happen, and serious market forces won't be allowed to do their thing as long as people continue to insist that this attempt be made.

[nazgulnarsil]

I hope you're not trying to imply that it is unacceptable to let poor people die of treatable diseases. Spending 1 million in other people's money to save one life when that money could also save 1 thousand lives elsewhere (givewell cost per life calculations) is morally inexcusable.

[mikeash]

No, I'm implying that society in general appears to find this to be unacceptable. Whether or not you or I agree with that is basically irrelevant.

[skylan_q]

Only the government can take care of poor people?

[wpietri]

That's a surprising conclusion given that countries who have the free market much less involved in health care have a much lower cost of care.

[psaintla]

It's really not that simple and I say this as someone who works in health care. Doctors control how many new doctors there will be in any given medical discipline and they do this via accreditation, residencies and fellowships. You can introduce all of the free market forces and relaxed regulations you want but until doctors no longer control the supply of doctors you're wasting your time.

[mseebach]

Doctors only have this control because regulation says so. But as long as there are such steep price differences across state borders, it seems that there are, in fact, lower hanging fruit than busting the doctors' monopoly.

[psaintla]

Strictly speaking this is not controlled by any regulation You simply aren't going to get the experience necessary to perform certain surgeries with any proficiency without the aide of the gatekeepers. Also the reason for the steep price differences from state to state is partly due to a lack of a supply of doctors with a booming population of people who are seeking more medical care so I would argue decreasing the barrier to entry into the medical field while not decreasing standards should be a part of the plan.

[mseebach]

I'm not familiar with the system, but I find it extremely unlikely if >600,000 doctors are able to organise to form a watertight gate without any help from regulation. Surely they control licensing or something?

[psaintla]

If you aren't familiar with the system why make the claim that doctors have control because regulation says so?

[mseebach]

Because of what your describe in your original post: That scenario is completely implausible, except where enforced by regulation. I don't know what the exact mechanism is, I can just tell that it must be there. It's a game of prisoner's dilemma with 600,000 participants.

[anonymoushn]

Are you saying that I can practice medicine without a relevant degree, or that the supply of the relevant degree is not controlled by the government?

[hippich]

from my personal anecdote - i had appendectomy 2 years ago. total for all bills i received during couple month after discharging was about 28k. Out of these $700 for surgery itself and $900 for anesthesia. There were some other bills where my doctor was involved, like follow up visits, but these did not get over $500 aggregated.

So looks like doctor's cost is not that big of a part of the total bill anyway.

[anon292929]

Free market doesn't really apply for emergency medicine. "Oh excuse me sir I am having a heart attack and dying please bring me to the hospital 30 minutes away because its 10 times cheaper"

[nnnnni]

You do realize that the regulations are in place to try to prevent quacks from killing people, right?

You sound like one of those Tea Party idiots. You have no credibility.

[rb2k_]

How come all the other countries that have regulated healthcare have costs that are usually at a fraction of the US? (http://www.pbs.org/newshour/rundown/2012/10/health-costs-how...)

[dragonwriter]

> How is this surprising? We've completely taken the free-market out of health care. The only way it will ever be solve is if we re-introduce market forces back into the mix.

The theory of free market efficiency is based on low-entry-barrier wide-open competition, and perfect advance knowledge of costs and realized utilities by both buyers and sellers. There's lots of goods and services for which this is close enough to reality for the theory to mostly hold, but there's not much reason to think that healthcare is among them (and comparative quality and cost measures among real world healthcare systems don't support the idea that its a market where more "market forces" equals more efficiency.)

[Spooky23]

Not really.

You're mixing up insurance costs with service costs.

California is more expensive because all ratepayers are bearing the costs for people who do not participate in the insurance system or pay. We have this crazy system where we want cheap workers to build things and farm, but we don't want to provide them with the benefits of legitimate status.

So, when a day laborer being paid off the books falls off a scaffold and requires hospitalization, that care turns into an unpaid debt. Because he gets kicked out of the hospital as soon as possible, he doesn't recover well and ends up back in the emergency room in a few weeks.

[rooker]

Why apply free market tactics to a service that is almost certainly necessary for everyone in their lifetimes? If anything, I feel like that would make things more expensive because this is a resource that people can frequently NOT decline (at the risk of losing their life) because the cost is too high. People are essentially a captive audience, so that's where regulation should ideally step in to keep costs down. Obviously that's not working, though..hmm..

[lucidrains]

healthcare is only a free market to an extent. unlike consumer products, people are willing to pay any price for life or a guarantee of good health. and given care is so hard to quantify and there is so much uncertainty in comparing care, people will always simply trust the physician to pick whatever he/she thinks is best, with total disregard to the 'free market'. just my take on it.

[BenoitEssiambre]

You can only get true free market in health care if people have the choice of when, where and how they fall ill and can evaluate quality of care themselves before buying it. Unfortunately getting sick is not like buying a TV.