The greatest healthcare improvements in the US could be brought about by:
- Dismantling the insurance/big hospital complex that milks the US population for the enrichment of c-suite executives.
- Removing the capacity for lobbying by insurance companies, large hospital groups, device and pharma companies (so they're less able to price gouge consumers).
- Price transparency on all links of the chain of healthcare delivery.
- Changing the incentives for physicians and other providers towards expensive, often harmful and unnecessary interventions.
- Facilitating improved therapeutic relationships between providers and patients (More time spent, more communication, more incentives for harm reduction).
- Social changes including less stigma for things like drug use, greater emphasis on community cohesion and care.
- Demilitarization (Not only are absurd amounts of money spent on the military that could be redirected to better community health services; but innumerable veterans (not to mention foreign and local civilians) are injured psychologically and physically annually in the absurd pursuit of 'global security'.
- Better end of life care. I think something around 40% of healthcare expenditure is on patients in the last 2 years of life. Patients and families would benefit from earlier access to hospice care and less aggressive therapies that only prolong suffering.
- A greater emphasis on preventative health and lifestyle choices (better diet, exercise and sleep regimes - ideally within the context of a long term health care provider relationship).
Its very typical of modernism (especially in the US) to think that the way to address everything is a nice app with a better UI. This also facilitates the corporate narrative of marketing the shiny new thing to throw money at (make money for the company) to solve everything whilst digging the hole even deeper (and letting society absorb the collateral damage).
EDIT* Thanks for the feedback, I have added some of the points made by others to the list above.
This probably also is the hardest part. And the most alien to the whole American model of which lobbying is an integral part. IMHO you can only counter lobbying by allocating more to fact checking so it would be harder for them lobby things which are objectively wrong.
We had such a congressional fact check organization. It was called the OTA (Office of Technology Assessment). Sadly it stood in the way of institutionalized lobbying (The K Street Project), so the Republicans eliminated it shortly after they came to power in congress in 1994.
It was on borrowed time anyway. The OTA was a threat to the fiefdom of literally every other agency. Their job was to butt in and ruin everyone's gravy trains of "not quite graft".
Imagine the OTA weighing in on the recent net neutrality shitshow. Wouldn't have made the FCC look to smart would it have? That same threat existed for every agency and congress and the executive. Literally everyone wanted them gone.
Why would fact checking have an influence on lobbying? Everyone knows what is going on. It isn't like the politicians, lobbyists, technical experts or public are in the dark about what is happening.
If anything, a fact checking organisation has incentives to align with or even become a lobby group. We've seen what happens to "fact checking" in the political sphere.
> Why would fact checking have an influence on lobbying?
Some would say, if a senator doesn't believe in climate change that's a question of fact, and if they merely received better advice they'd change their opinion.
A cynical person, on the other hand, would say they know full well that climate change is real but they've accepted money to pretend they believe otherwise. In that case, no amount of independent advice will change their minds, as it is not a question of facts but of money.
Not everyone. I will grant you that congress holds a low rating for Americans suggesting some level of understanding that they are being taken for a ride, but I genuinely think that if people in general population understood what is going on, there would be a lot more people taking action ( even if it is just taking it to FB and organizing a local page ). Sadly, I agree on the sentiment on 'fact checking'.
There's a really, really, really fine line to walk between preventing the AMA from lobbying congress to screw us and preventing actual grass roots people from paying someone to argue on their behalf.
Strongly disagree, that fine line will always be stretched beyond your definitions.
Besides, without lobbying groups working against you, the feedback loop of voting them out actually starts working. (no it's not a complete solution so please don't argue against that straw man, it's just the most important first step to unblock others)
> - Better end of life care. I think something around 40% of healthcare expenditure is on patients in the last 2 years of life. Patients and families would benefit from earlier access to hospice care and less aggressive therapies that only prolong suffering.
I feel like the choice has to be removed from families as our current system has proven that life will be extended regardless of quality simply due to the fact nobody wants to make a difficult choice. As the only quantitative item on the list and a very substantial one this should be ranked much higher in terms of priority (not sure if list was unordered or not).
Yes check the app while your limp unconscious body is shoved into the back of an ambulance. Type in appendectomy near me while you're writhing in pain in the passenger seat and decided, the hospital the next town over is a better deal
You use an absurd scenario, not sure why, but we both know there are tons of times you go to a medical provider where if you could pay less for a slightly longer car ride, you'd do it. But that information isn't even available now. The only fucking industry that is allowed to sell you stuff without telling you how much it will cost.
Who cares how much it costs if your health insurance cover it?
The reality is that healthcare is so expensive that it can bankrupt anyone who isn't a millionaire- which is why it needs to be mandatory and comprehensive.
Right now millions of Americans are basically committing fraud: they go to a doctor who has taken an oath to help you. The bill is not getting paid so the government has to step in anyway.
May as well make it official.
>Who cares how much it costs if your health insurance cover it?
At least under the current model, many people don't hit their deductible or max out of pocket. I know some older retired couples who are buying insurance on the market with 10k+ deductibles because they're generally in really good health, and the cost of insurance isn't absolutely insane with that level of deductible.
They would absolutely drive an hour rather than 5 minutes for non-emergency situations!
Exactly but why not blame the people who can't afford health insurance of committing fraud instead! After all if you're dying and have other choice than die or commit fraud, you're definitely a dirty fraudster!
So you're not qualified enough to fix what you don't know is wrong (is this pain in your leg a simple thing, is it an actual fracture you're just surviving on on pure adrenalin, is it microfractures that might take more to heal), but you think for some reason you (or an app) would be qualified enough to tell you how much you'd pay for "leg pain" ?
In my view, the fact that we don't know, is a major part of the problem. Our system is such an entangled web of business entities, that we probably have no idea where the money is coming from and going to. Everybody says that somebody else is gouging us, which means that they're all probably gouging us.
And they are all invested in each others bags. For instance I've read that doctors are major investors in health providers, are often the owners of the expensive equipment, and also heavily invested in the malpractice insurance industry.
Half of billing is multiple businesses billing one another.
It seems quite possible that what makes government health care more efficient is simply knowing where the money is going, if it's all coming out of one checkbook.
Predominantly (there's also general overall bureaucratic bloat with absurd numbers of administrators at all levels) .
It's certainly not the majority of healthcare workers.
Physicians are often scapegoated as responsible for healthcare costs when in reality physicians in Canada, New Zealand and Australia earn similar salaries without the massive cost blowout.
There can be instances where physicians are paid the same or more outside the US (I've heard family practice can pay better in Canada), but overall US physicians earn much more.
I guess it depends on your comparison - that article didn't include Australia, NZ or Canada.
Also if you factor in earnings and expenses over a lifetime (including cost of studying and the fact that many of the countries mentioned have free healthcare and education and far lower insurance requirements) it evens out substantially.
More importantly, even the highest physician salaries are orders of magnitude less than insurance company CEO salaries.
Disclosure: I'm a physician, currently practicing in the US, previously in New Zealand and the UK.
I’ve got several friends who specifically moved to the US from Canada because the pay was so much better. No doubt it varies by circumstance, but docs ive known in the US pay off their $500k in student debt pretty quickly if they specialize.
And sure insurance CEOs are paid more, but there are also a several magnitude more doctors than insurance CEOs. You could pay all the CEOs $1 and the cost of healthcare isn’t going to budget much.
doctors in Australia, NZ and the uk generally have only 30-50k in loans. And earn a living wage during their residency (in Australia can reach 6 figures within 1-2 years as opposed to flat 45k for 6 years in the US)
> First, according to multiple sources, doctors’ salaries account for only about 8% of U.S. healthcare costs. Even a 40% cut in these salaries, which the Kaiser Family Foundation concluded would result from reimbursing providers at current Medicare rates, would reduce healthcare spending by only about 3%.
I'm not trying to convince anyone. That was just a passing observation on my part because, as an MD, I have a very good idea of why healthcare is expensive. But I lost any hope of making anyone who's not working the clinics understand this
Indeed, I think the deal should be: You go to medical school for free, then you work for the government for a nice professional salary. Malpractice insurance can be a government function.
An interesting side effect might be to change the demographics of who can become a doctor, maybe attracting more people from middle class or blue collar backgrounds.
As opposed to working for the insurance industry? My knee jerk response is that incentivizing the best and brightest has gotten us to where we're at now. I've read that doctors are deluged in paperwork and bureaucracy, and incentivized to choose treatment options based on insurance coverage. I've had more than one doctor say to me: "The insurance says I can do X but not Y," and "your treatment ends when your coverage runs out." Of the several doctors among my friends, those who are not also professors or entrepreneurs have opted for part-time status, or have retired early.
Incentivizing the best and brightest in the software industry has gotten us to where we have to give new computer science graduates a coding exam, to find out if they can program.
It's worth noting the debt burden that different medical education systems place on physicians. Debt load and lost income are huge in the US medical education systems.
Many people that browse this forum will likely have lifetime income similar to that of a physician.
It's much higher than other countries. There's also a 7 to 10 year period of medical school and residency where you're making no wage or a poor wage. People tend to get fixated on the attending-level annual salary while ignoring that piece. That's 7 to 10 years where you're not really building any savings, retirement, or wealth.
My wife (a doctor) and I (a non-SV software engineering who's career has taken a backseat to hers) ran the math. On an hourly basis, she will likely never come out ahead of me. She just has too many unpaid and low-paid hours in med school and residency to overcome. In aggregate, she will likely out-earn me - but that break-even point will be in our 50's with her having worked many more hours than me. That's 30 years into our careers.
I'm curious, you seam to have a particular animosity towards physicians. (Or at least animosity towards the idea that physicians should be well reimbursed.)
Is there a particular reason for this?
In a world where people are making billions for photo-sharing apps and financial rent seeking, is it really that egregious for people that treat disease to do well financially?
I don't want to paint with too broad a brush, but in Poland, physicians are genuinely a separate, well-organized labor class. As such, and I have not followed it as closely for a while, during last 'reform' what I heard was lip-service about patient care followed by implementation so bad that people actually opt for a private insurance ( if they can afford it ). If they are scapegoated, it is because they are part of the equation. Luckily for them ( and pharma for that matter ), they are the only part that is actually necessary.
The app thing is very true and so ridiculous, I at one point contracted for a health insurance company (with a team of 10 people) for over a year working on an app that never saw the light of day.
It was essentially a calorie and exercise tracker that also displayed your health insurance info, absolutely nothing special compared to fitness apps already out there, but millions of dollars down the drain.
Not everyone agrees on what “better” means though. When you start putting dollars and days into formulae around dying, many people lose their damn minds…
The simplest changes we could make would be to ban the addition of sugar to certain mainstream food categories (drinks, bread, sauces), and also to require nutritional information to be listed as per 100g, not per serving size.
Follow that by banning burning of coal and oil, we also remove a significant amount of noise and air pollution.
Next we can ban any hormone-disrupting chemicals (including as plastic additives) from being used in anything that will ever touch human food or drink, or ground water.
Finally we can legaize euthanasia for anyone aged 70 or older and with a terminal health condition.
With these changes you have a human population much healthier and less reliant on expensive healthcare.
You missed maybe the most important thing: Allow cities for humans to be built. The American suburbia model is unhealthy on so many different levels. This only became apparent to me on my trips back stateside after living in Europe for a while.
So, folks under 70 get out of suffering, but someone dying in their 30's can't get euthanasia? This seems cruel, especially so given the number of folks that suffer and die before they reach 70.
And it shouldn't be for financial reasons. I fully support someone's right to death, but I do not support creating systems that might encourage it. I also don't realistically care if the health condition is terminal: I care more that folks are suffering and want death to escape it.
On the euthanasia point I would agree that this should be a legal option (but on a humanitarian rather than a financial basis).
We definitely need do do a better job with end of life care/terminal diseases - in practice this would look like earlier/more hospice/compassionate care, less needless end of life treatments and interventions).
There is a difference between being hungry and needing something sweet to satisfy a craving even though you're full. The later is called hedonic hunger and is (IIUC) very similar to addiction neurologically.
seems symptomatic that you would rather give away some really basic freedoms and be treated like cattle just to avoid making the healthcare system public
It is 100% obvious that amounts spent on the military in the U.S. today are insufficient and will have to go much, MUCH higher than they are today. Probably 5x higher - to the Cold War 10-12% levels - because of standoff with China and Russia at same time.
It will still not be enough to win over China, but at least enough to keep the free world in existence. Otherwise democracy will be just simply gone from the world altogether in one generation.
Continuing to head in the direction of militarism, will continue the disaster of a world that we live in, and almost certainly guarantee the end of mankind.
>>Here's some food for thought: The number of physicians in the United States grew 150 percent between 1975 and 2010, roughly in keeping with population growth, while the number of healthcare administrators increased 3,200 percent for the same time period.
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>>Supporters say the growing number of administrators is needed to keep pace with the drastic changes in healthcare delivery during that timeframe, particularly change driven by technology and by ever-more-complex regulations. (To cite just a few industry-disrupting regulations, consider the Prospective Payment System of 1983 [1]; the Health Insurance Portability & Accountability Act of 1996 [2]; and the Health Information Technology for Economic and Clinical Act of 2009. [3])
In contrast, areas of medicine which are subject to much fewer subsidies and regulations, as a consequence of being electives, have seen prices actually decline in inflation adjusted terms. [4]
Regulations and subsidies do not seem to make other countries' systems inefficient. They make it so that folks are safe and that they can actually get health care.
I really want regulation in health care. I do not want medication to be a free-for-all like supplements are in the US. I'm not a doctor, after all, and they are slow to take supplements off the market even if they are harming or killing folks (take a look at diet pills to see this effect). I do not want average folks to be able to get antibiotics willy-nilly because I want to be able to take them when I'm old. And so on.
The big difference up to now has been that US hospitals have been run by a huge layer cake of administrators for a long time, while in other western countries healthcare workers have had much more direct control over how things are run.
This is changing fast though, and Europe is migrating to the US model at a rapid pace, with growing administrative layer and loss of control over prices. Interestingly, european politicians are also telling everyone that the problem is that docs earn too much and people tend to believe them.
I have so many issues with this: Europe is a big place and the countries do not exactly work in unison on these things. I only have experience in Norway - and that's only for the last 8 or 9 years. The prices have always been pretty standard - the doctors office doesn't set the rates, at least not in the public system (there is a private system, but the majority of doctors are in the public system). There hasn't been huge layers of administration, at least not in the way of the US - and this is, in part, because the insurances in the US create the layers of administrators. (Doctors offices do not need nearly as much staff for paperwork duties). For the end user, they've actually removed a layer - there were two types of deductibles that were merged into one (and is less than half the cost of the two combined)
And honestly, I find it very difficult to think that this is the administrative cake you were thinking. I also find it really difficult to think that Norway, Poland, Greece, Italy, Germany, and Britain are all taking the same steps and adding complexity.
Nope, that's just experience from daily life. I'm a doc in a public hospital in Switzerland, and also worked in the US.
Europe is still a bit behind in terms of admin, but getting there. And yes, american influence is felt all over Europe, with varying degrees of implementation among countries, as you noted.
I can understand that outsiders don't believe what we have to say when political propanganda is so strong. But for us insiders, it's really crystal clear what is happening. It used to be that problems arising in clinical management was solved by asking frontline workers what they needed. Healthcare workers had a lot of control over their working environment. Nowadays, admins are taking all decisions from above. European hospitals are now in competition with the private sector due to changes in the billing and insurance system coming from the US. As a result, european hospitals are now managed much more like your usual run-of-the-mill company than they used to. This is a terrible result for anyone but upper management.
>>Regulations and subsidies do not seem to make other countries' systems inefficient.
Other countries' healthcare systems are growing increasingly more inefficient as well, with the proportion of GDP expended on healthcare rapidly rising, with many seeing it double over the last 40 years. [1]
And they face critical shortages, like this case of a woman in Canada who had to wait two years to get a test that diagnosed her with cancer, because of a shortage of state-licensed doctors:
>>I really want regulation in health care. I do not want medication to be a free-for-all like supplements are in the US.
I think the best of both worlds would be most regulations being opt-in, while disclosure regulations are mandatory.
More specifically, I think healthcare would benefit from legalizing the provision of medical service by un-certified individuals, as well as providing more than one tier of certification, where people who can't afford fully certified practitioners, but would like the assurance of some certification, have that option.
Instead of making it illegal for individuals who don't possess full certification to practice medicine, the law could instead require medical practitioners to disclose their level of certification, and any warnings the state provides in relation to that.
So for example, an uncertified doctor/nurse may be required to disclose not only that they are uncertified, but also the warning that the state strongly advises against using uncertified medical practitioners.
Why providing these options is critically important is that sometimes the prescribed institutions fail, and an escape hatch is a life saver, as in the case of a woman in Canada mentioned above.
>>I do not want average folks to be able to get antibiotics willy-nilly because I want to be able to take them when I'm old.
If the negative externalities of irresponsible antibiotic use is your concern, maybe you could advocate specifically regulations on antibiotic use.
When you advocate wholesale centralized gatekeeping of all manner of healthcare interaction, you deny people a way to escape failures of over-regulation, like regulations that prevent people from accessing life-saving medical products/services in a timely manner [2][3] or deny people access to a vaccine due to a risk from side effects that is orders of magnitude lower than the risk the vaccine mitigates. [4]
> Other countries healthcare systems are growing increasingly more inefficient as well, with the proportion of GDP expended on healthcare rapidly rising, with many seeing it double over the last 40 years.
There are two (mostly) unrelated issues: the efficiency of the healthcare system and increasing availability of effective but expensive treatments.
I believe we have already reached the point where even 100% of GDP is insufficient for healthcare. There is always something more you can do, something better you can try. No matter how much money you choose to spend, somebody must eventually make the decision to withhold better care because the economy is not big enough.
There is in fact a correlation between per capita GDP, and the proportion of GDP expended on healthcare, so you may be correct. It's worth noting that the US has much higher per capita GDP than most OECD countries.
In any case, the price inflation seen in highly regulated vs lightly unregulated markets is, to me, telling:
- Dismantling the insurance/big hospital complex that milks the US population for the enrichment of c-suite executives.
- Removing the capacity for lobbying by insurance companies, large hospital groups, device and pharma companies (so they're less able to price gouge consumers).
- Price transparency on all links of the chain of healthcare delivery.
- Changing the incentives for physicians and other providers towards expensive, often harmful and unnecessary interventions.
- Facilitating improved therapeutic relationships between providers and patients (More time spent, more communication, more incentives for harm reduction).
- Social changes including less stigma for things like drug use, greater emphasis on community cohesion and care.
- Demilitarization (Not only are absurd amounts of money spent on the military that could be redirected to better community health services; but innumerable veterans (not to mention foreign and local civilians) are injured psychologically and physically annually in the absurd pursuit of 'global security'.
- Better end of life care. I think something around 40% of healthcare expenditure is on patients in the last 2 years of life. Patients and families would benefit from earlier access to hospice care and less aggressive therapies that only prolong suffering.
- A greater emphasis on preventative health and lifestyle choices (better diet, exercise and sleep regimes - ideally within the context of a long term health care provider relationship).
Its very typical of modernism (especially in the US) to think that the way to address everything is a nice app with a better UI. This also facilitates the corporate narrative of marketing the shiny new thing to throw money at (make money for the company) to solve everything whilst digging the hole even deeper (and letting society absorb the collateral damage).
EDIT* Thanks for the feedback, I have added some of the points made by others to the list above.