As a comedic article this is a good exaggeration of the extremes out there. On a somewhat more serious note, this is what Norwegian health care looks like:
1. The national government owns and operates the vast majority of hospitals and most specialised clinics. Most health care is covered by taxes, including a lot of drugs, but with an annual co-pay limit of around 300 US dollars. When I recently had an ear infection, my antibiotics weren't covered under this co-pay rule, but they weren't too expensive, only a few ten dollar bills. ERs are run by the national government.
2. The county governments own and operate a lot of the dental health clinics. Dental is not covered by the government, and is essentially completely privatised but with a public option. The county dentists do provide free dental to children, and now the Socialist Left Party has negotiated funding for 75% deductions for adults up to the age of 28 from next year.
3. The municipal governments run some basic family health clinics, own and operate most of the GP-offices, and run most elder care as well as long term care for people with with serious lasting health issues and cognitive developmental disorders. There's often some form of co-payment in all these, but they all mostly have the same annual co-pay limit as the national health service. Urgent care is municipal.
4. Private health care exists on all levels. There are private specialised clinics, private hospitals, private GPs, private dental, and private care homes. Some of these private institutions work within the public health services, some exist as almost completely parallel services which are mostly funded by employers. Some key companies are Aleris, Dr. Dropin, and Volvat.
The private insurance sector mostly exists for high paying jobs and/or key leadership positions. The quality of the public health services is mostly pretty good, but as with almost all public health care wait times can be an issue, so the private health insurers allow for "jumping the queue".
The OECD reported nearly 8000 US dollars in per capita spending (PPP) for 2022, whereas the US was at 12,500. Our lower spending probably has little to do with it being a mostly public payer public provider system, and more to do with it being a coherent system. The Netherlands and Germany both have private providers and private payment, but lower per capita spending than both Norway and the US.
One major issue with Norway's health care system seems to be income for health care professionals. The exhausting nature of the work, combined with relatively high education, means we're lacking qualified workers in large parts of the country, and due to taxpayer funding simply raising the salaries to attract workers isn't as simple as it could be in the US.
Edit: Also, as a listener of Colonel Andrew Heaton's podcasts, I feel obligated to point out how European health care is taken care of at the country level. There's the European Health Insurance Card which guarantees free or affordable health care when visiting another EU/EEA country or Switzerland, but otherwise health care is a national thing, not a (con-)federal one. As such, if the US were to emulate Europe, it would be a mistake to think the Norwegian or Dutch health care systems could be placed onto a continent sized country of 330 million people, doing it on the state level is essentially a must.
I like the "public free baseline, private insurance beyond that" model. I've said elsewhere that we need "Medicaid on Demand." Let anyone get on Medicaid just by clicking a button in an app. We can increase taxes to increase what Medicaid covers if we want. And letting people opt into the private system is much better for freedom.
The one big advantage that a pure monopoly provider run by the government has is how it deals with the "this treatment could help you, but the guy holding the pursestrings says he won't pay for it." This guy exists in every single system. In the US-style system, you're explicitly told there's this treatment and that we'll try to figure out how to pay for it, and then you get told it won't be and get mad. In the monopoly system, the doctor never even mentions it to you. (Or they get away with authorizing things a few times too many and then gets fired.) This leads people to think there's no such thing as denied treatment.
In the second system you never have someone finding the pursestrings guy to gun him down. They insist there's no such person exists.
From a freedom point of view, I think hiding this information from the patient is bad. But maybe we're not mature enough to be allowed that freedom and information.
*EDIT* not having the information can even lead to better outcomes. If you're told "sorry, there's nothing we can do" then you live out your last 20 months of life in relative peace, while being told there's chemotherapy inevitably leads to going through chemotherapy and you living through an excruciating 22 months of life. Making this decision for other people still sets off major red flags for me.
This pretty much describes the Danish healthcare system except the budget for healthcare is lower, leaving the system more stressed. One example is the major shortage of nurses due to many resigning over workload and low pay, and fewer studying for the same reason.
So? That just allows the government to spend real money to fund deficits rather than borrow/create it like the US. The advantage is we never have to pay it back, the downside is nonetheless inflation, as most of the value is invested in foreign markets. Norway also had to live a little conservatively initially, as the fund is funded through taxes and other revenue from oil and natural gas which would otherwise have been going straight into the national budget.
Norway's definitely fortunate, not saying otherwise, but Sweden, Denmark, and Finland all have relatively similar health care systems, and no oil revenue. The UK is also such an example, but they even cover dental.
Edit: The UK does have some North Sea oil and natural gas revenue, like Norway, but where there's a legitimate argument to be had about whether Norway is a petrostate or not, the UK is more in the same camp as the US, where oil is one part of a diverse economy.
My point is that Norway's health care is not fully funded by taxes, not even close. Their oil wealth is more vast than people imagine.
If the US had a similar setup, oil income would only contribute about 4% of our budget. This is despite the US being the world's largest oil producer *and* exporter.
But my point was that it doesn't matter. Basically the exact same health care system as Norway's exists in other countries that do not have oil wealth. Sweden, Denmark, Finland, and the UK all spend less per capita on health care than Norway does, but then their economies are also smaller.
The US spent 16.6% of its GDP on health care in 2022, the highest of any OECD country, much higher than Norway's 8%, though less dramatically higher than Germany's 12.7%, and France's 11.9%. Norway without oil would probably have to dedicate more of its GDP to health care than it does today, sure, but no European country spends as much on health care as the US, whether in dollar amount or proportion of GDP.
How much of those countries pharmaceuticals and medical technologies also come from the US?
Most countries cap drug prices, but if the drugs don't exist in the first place -- or if the drug companies couldn't make bigger profits in the US -- there would be incrementally worse outcomes or higher costs.
I'm not saying the US is good and Norway is bad. I'm just pointing out that there are a lot of hidden costs that aren't accounted for on a given country's spending ledger.
Assuredly a lot of them, but Denmark and their Novo Nordisk (maker of Ozempic), along with BioNTech in Germany, the British-Swedish AstraZeneca, and the Belgian branch of Johnson & Johnson (called Janssen) are examples of medical and pharmaceutical companies in Europe with great international significance, many obviously recently in regards to the Covid-19 vaccines.
Yes the too expensive US health care system has some benefits, but even if the US implemented Rand Paul's HSA-based system with transparent consumer facing pricing, and more limited emergency insurance, rather than whatever Bernie Sanders and Hugo Chavez (/s) would like, prices would go down and there might be less money going into pharmaceutical innovation.
Rather than holding this civilisational grand debate over which continent is ultimately doing the most good for worldwide health (quite possibly North America due to the US), can we just recognise that the US health care system is barely a system and is too expensive for the people whose backs are bearing the cost? If the US fixing its health care does lead to less innovation, the western world could try to figure out some sort of grand reward style incentive system for innovation rather than rely on everyday Americans to ensure innovation.
Also, just an aside. Every time something about Norway is compared to essentially any other country the oil is used to dismiss the comparison. That's f*cking ridiculous when, as I pointed out in this discussion, the other non-oil rich Nordic countries tend to do the exact same as Norway. It's also not like Norway's economy had there not been any oil would be today's economy minus the petroleum sector. Petroleum is a brain drain in the Norwegian economy, and had there not been any our economy would likely look more like the Danish, Swedish, or Finnish economies; smaller than ours today, but not worlds smaller.
I've lived in the US most of my life but did spend several years in London and, as my (bad) luck would have it, my time in London featured a medical crisis that engendered extremely intense familiarity with the NHS. There are huge pros and cons comparing the NHS (public care, public funding) and the American system.
The huge pro for the NHS is, of course, the utter lack of concern over payment. My crisis involved a family member continuously hospitalized for more than 6 months, with lots of specialized treatment along the way. When it was all over, we just... walked out of the hospital. No need to talk with a billing supervisor, no hellish second act in which we tried to figure out how to prevent the bills from bankrupting us, nothing like that. I will never stop being thankful for that part of the system.
The huge con for the NHS is just how under-resourced the system is compared to the American system. NHS buildings, even hospitals, are almost shockingly shabby compared to their American equivalents. NHS facilities run out of basic supplies in a way that American hospitals never would (at one point we were staying in a NHS flagship hospital, which didn't have the resource constraints of most NHS facilities, and a nurse remarked to us that it was "rather royal" there because they never ran out of gauze pads or syringes). And the comparatively poor pay for doctors and nurses means that the NHS really struggles to recruit and maintain staff, in a way that impacts both wait times and quality of care.
US healthcare is much more expensive than other systems in large part because we've developed a system of providers and facilities that demand much more money than other nations. It's not all inefficiency and greed; we really do have a system that is higher quality in many ways (and that's not even touching on the fact that the US system effectively serves as the world's R&D center for new treatments and technologies, which US consumers pay for and the rest of the world free rides on). I don't think the US strikes the right balance, and am a fan of either state or national level single-payer options. But it's nonsense to suggest there are no tradeoffs, or that other nations' systems are obviously better.
You make many good points. But when factoring in the astounding amount of money spent on the health care in the US, then we can admit our system is worse than others if only because it costs twice as much as many countries for roughly similar results.
If the USA does a bunch of useless procedures that don't impact health, I guarantee the people getting those procedures wanted them, or at least didn't object provided someone else was paying.
So I grew up in a country with public insurance and private healthcare. It was fine, although I needed a colonoscopy, and the country decided that that procedure doesn't actually need you to be put under. That was terrible. Additionally, the medical care was covered, but the medications weren't, so seeing a doctor was "free", but the drugs themselves were potentially enough to put me into bankruptcy. (Canada)
I then moved to a country with multiple public insurance and public providers, but which also has a private, parallel system (many doctors actually work in both). I really prefer this, because now when I need a colonoscopy, if they ever decide they don't want to give me the good drugs, I can choose to eat lean for a week and go private. Medications are also "covered" if they're in the health basket (there is a maximum amount per quarter that you have to pay, it's not nothing, but it's manageable for most people). (Israel)
I like the two tiered system, because the option to wait for healthcare means that the private system can't actually go crazy with billing. The private system also provides a recourse when the public system is stingy (In the first country, if a procedure wasn't covered, then I just couldn't get it, there was no other option).
I do think that, for the United States (the centre of the universe), a system where each state guarantees its residents some basic level of (really crappy) health care, will force insurance companies to be more competitive. As far as I'm aware, this somewhat exists, but only with emergency medicine. Preventative options may actually be cheaper.
I also think that the lack of clarity and transparency in pricing and coverage is something that can be solved by legislation (you should be readily able to find out how much an elective procedure costs at different locations, and you should be able to immediately know if a procedure will be covered or not).
As a side note, Canadians HATE the idea of a two tiered system. The idea being that it isn't fair for rich people to be able to jump ahead of poor people. I'm sympathetic to this idea in principle, but I also think it's stupidly naive. The rich will always find some way to get ahead, and making them wait in line with the poor just means you have a longer line. (Plus, this lets doctors be compensated at market value, in addition to being compensated at "slave wages")
Fun fact: On page 5 of the Parliament-themed coloring book, the anus the MPs are sticking the tongue depressors in is mine, from back in my child modeling days.
Jeff, this article was the equivalent of throwing a perfect game. It started strong and just kept delivering the entire time. Multiple times I laughed so hard that I had to stop reading. I can envision your wife walking past behind you a few times, seeing that you were in the zone, and afraid to say anything to you to break the spell. People will tell their grandchildren about today's article. Enlist a friend to dump a Gatorade bucket over your head for this one.
Chiming in from Canada. Your system is not perfect. Is there such a thing? Too many who spout off about problems, perceived or otherwise, only highlight them to further agendas. I live under the worst health care system in western civilization and it is this way because it is public. Be careful what you wish for.
Our Canada Health Act was written with lofty ideals to ensure all had access to medically neccessary treatment.
"Medically neccessary treatment"
Where is it now? Ellective abortions as far as the eye can see. The ideologically driven mutillation of children. Only two examples, all paid for by us while people die because bureaucrats wont pay for their much needed treatment with that money. Treatments over cancer and other life threatenning diseases deemed too expensive to cure. People removed from transplant lists because they refuse experimental shots paraded as vaccines.
We have care doled out based on race or other criteria driven by identity politics.
Having trouble dealing? No problem, all doctors have been ordered by government to recommend MAID up front.
Doctors who disagree with any government edict whether it is vaccines or any other treatments bureaucrats and politicians dictate? You will have your license stripped and your life ruined. Perhaps you will even be forced into "re-education" training aka the soviet uinion, or worse, forced into a psyce ward and given harmful drugs in the hope you die, as one 80 year old physician discovered in Vancouver and only survived after two strokes.
Personally, I find the true dystopian part to be that countries that get more into the "Public" options, get more into offering assisted suicide options. And sometimes rather aggressively assisting.
I am Pro Life. That means I am against adventurous wars of politics, the death penalty in all cases, abortion except for the RILOM exceptions, cops being allowed to be as armed and dangerous as they are, and government facilitating assisted suicide.
People should be honest that health care is just a way to prolong the gold old dance macabre that we are all doing. There is little discussion about what makes all of this expense worth it. Why prolong life at all? The government has the least good answers to this question imaginable. The best answers to "Why am I dragging myself through this physical realm" are almost always found in private experiences and private reasons. It is an affront to liberty for a bureaucrat to decide how much your life is worth and offer you a quick way out if you don't want to wait three years for the hip replacement. It is perfectly respectful of liberty to give people all the facts, a clear idea that they will be responsible, like they are the captain of their own ship, and then let them decide how far they want to go to extend their life given the other choices they face.
People talk about this like we can banish death if we just vote for Medicare for All and I find it infantilizing on the verge of insulting to think that any just society will set a limit on what a life is worth in such a direct and calculating way. Government should have as little power of denial of life as possible. Even if that makes for a world where people are more vulnerable to economic hardship. Even if it leads to some inevitable bankruptcies. The fable of the ant and the grasshopper has a lot of wisdom here. Yes. This makes life harder in some ways. Teach that difficulty to your kids and teach it well. Get them to be a little afraid of winter if you want them to make good plans in the summer.
Prior to Obama care I could sell young ppl a medical plan with excellent coverage through BCBS of Illinois a comprehensive medical plan for $50 / month. No underwriting, they owned the plan and as long as they kept it, paid the premium it could not be canceled. Enter numb nuts Obama, that plan called the unaffordable dumb ass plan, that benefit cost just shy of $300/month - this for a young person under 30 most likely very healthy was considered great legislation. It’s a dualistic screw job. Bureaucrats and corp health care getting in bed together to believe they are working in public interest. I hope Dr Oz blows up the whole thing. Folks who know about these botch jobs are folks who try to help folks understand them. Medicare is another alphabet soup of bs, I’ll not touch that one as it’s not understandable to those with even IQ’s on the level of Johnny VonNeumann.
I've got issues with PPACA, but every time I interacted with the private insurance market prior to that, I had to fill out a form with 5 lines of space saying "include every health issue you've ever had. Don't use abbreviations or 'etc.'"
"No underwriting" means "no checks on pre-existing conditions" which (without a mandate) is just begging for people to wait until they get sick and they buy the insurance.
I don’t believe this. I lived in Chicago then and had to go without insurance for years because I couldn’t get anything affordable. I was self employed and tried various associations in addition to buying direct.
Nah, I’m thinking more of the “public option, with reimbursements that at least cover the cost of care plus a small margin. It’s a much younger risk pool, and it would be far cheaper to get these folks into plans that encourage preventive medicine instead of them just going to the ER.
It would also force the Obamacare market plans to be a little more honest. But this care really should be preventative + catastrophic coverage.
You could combine it into M4A but you’d need to raise reimbursement rates for a more expensive population, to ensure you’ve got enough providers will continue to accept it. Most hospitals will take it regardless because some reimbursement is better than none, but there already aren’t enough primary care physicians and they can easily have a complete patient load without taking Medicare.
"Preventive medicine" is the "waste fraud and abuse" of government spending. If only we could take care of that, costs would be saved, outcomes go up, taxes go down, everyone wins!
Nearly everything preventive that actually works to lower costs is already being done. A lot of things that people imagine are preventive when measured, or aren't cost-effective when done. ("Stop smoking" is great for a person, and stopping smoking has a 100% chance of stopping smoking. But from a public health arena it involves nagging people to stop smoking and they've already been nagged and decided to ignore it, so you can maybe squeeze out 1% by spending a giant pile of money.)
Last I checked ER use was, at most, 2% of national health care spending, with some measures saying it's as small as 0.5.% There are reasons to stop people from overusing their ER, but aren't going to save our pocketbooks by keeping them out of the ER.
"it would be far cheaper to get these folks into plans that encourage preventive medicine instead of them just going to the ER"
This isn't necessarily true at a population level, especially when we're talking about young and healthy risk pools, because the volume increase in healthcare consumption can end up swamping the per-patient savings. Prevention may be only 1% the cost of treatment, but if the affliction only affects 0.5% of the population, treating the afflicted is cheaper in aggregate than prevention for everyone.
Trust me, I am talking very basic preventative medicine. Annual checkups, generic drugs for very common conditions, etc. To help with primary care shortages, I’d push for larger numbers of residency slots and loan forgiveness if they sign a contract to take patients from the government plan for an extended period of time, say 20 years.
Primary care doesn’t pay all that well so this isn’t some big giveaway to the rich.
Annual checkups are a *great* example of how terrible the ROI is for preventative medicine at the population level. Unless a patient is already symptomatic (in which case they could just schedule an ad hoc appointment), a general checkup is exceedingly unlikely to detect anything, so doubling the number of people getting regular physicals is usually going to be a net increase on costs to the system.
To be clear - and I can’t edit on the app - but hospitals take Medicare and Medicaid patients because getting 85% of the cost of care back is still better financially for them as their fixed costs are so high. Empty beds kill hospitals.
I do want to shout out to my healthcare provider in the private-private model.. Kaiser in CA. I really don't have a single complaint. Costs my wife and I about $26k per year for their platinum HMO. Has gone up about 6% per year on average which sucks, but I understand why as Newsom's illegal immigrants need free care.
I would really like to see if the Kaiser model can be replicated across the country. A bunch of integrated insurer-providers that're clearly branded and don't have surprise out of network bills would be a good start to see if private health care is feasible.
One help is that the Kaiser doctors are employees with paid time off and 401ks. So there is no motivation for service manipulation to increase their billing.
“If I were to design a system from scratch, I’d probably go public/public that offers a low baseline of coverage.”
This is more or less what candidate Obama said in 2008, adding that since it was impossible to start from scratch, he’d propose reforms that worked on both public (Medicaid expansion) and private (more customers but greater regulation) areas. Hence the Big Fucking Deal of the Affordable Care Act, which I really hope Trump and his minions will not destroy.
If the obstinate Republicans had been willing to go to the negotiating table, we probably could have gotten medical tort reform along with it, which drives SO MUCH cost in malpractice premiums. Whole swathes of the country have little to no access to OB/GYN providers; their malpractice premiums are sky high because any mistake that hurts the baby becomes a giant tort due to the years of life affected.
Socialized medicine did a fantastic job back in the 70s and 80s. It kept cost trend down and that's why we have a gap between the US and Europe today.
But cost trend is basically the same between US and Europe today and it's not like you are going to fire 50% of the doctors and nurses in the country to change the baseline rate. So we are just kind of stuck and I don't think ACA 2.0 is a good use of political capital.
Seem to me the best system would be a (possibly age-related) partial tax credit that the person could use to purchase insurance. _Possibly_ the insurance companies would have some incentives to offer efficient options
At least this avoids the illusion that the employer is paying part of the premium of the plan/version of plan one choses is one factor in over insuring.
Would any non-employer plan be structured so than one would want to "use up" an amount of service before year end? At least Medicare does not do that!
And we have the Angus Deaton point, that for an employer health insurance is a fixed cost per employee, so employment of low-skill, low wage people is discouraged.
Employer "provided" health insurance is an additional tax on income in the same way that SS and Medicare taxes (also illusorily partly "paid for" by the employer) fall o income, not consumption.
As a comedic article this is a good exaggeration of the extremes out there. On a somewhat more serious note, this is what Norwegian health care looks like:
1. The national government owns and operates the vast majority of hospitals and most specialised clinics. Most health care is covered by taxes, including a lot of drugs, but with an annual co-pay limit of around 300 US dollars. When I recently had an ear infection, my antibiotics weren't covered under this co-pay rule, but they weren't too expensive, only a few ten dollar bills. ERs are run by the national government.
2. The county governments own and operate a lot of the dental health clinics. Dental is not covered by the government, and is essentially completely privatised but with a public option. The county dentists do provide free dental to children, and now the Socialist Left Party has negotiated funding for 75% deductions for adults up to the age of 28 from next year.
3. The municipal governments run some basic family health clinics, own and operate most of the GP-offices, and run most elder care as well as long term care for people with with serious lasting health issues and cognitive developmental disorders. There's often some form of co-payment in all these, but they all mostly have the same annual co-pay limit as the national health service. Urgent care is municipal.
4. Private health care exists on all levels. There are private specialised clinics, private hospitals, private GPs, private dental, and private care homes. Some of these private institutions work within the public health services, some exist as almost completely parallel services which are mostly funded by employers. Some key companies are Aleris, Dr. Dropin, and Volvat.
The private insurance sector mostly exists for high paying jobs and/or key leadership positions. The quality of the public health services is mostly pretty good, but as with almost all public health care wait times can be an issue, so the private health insurers allow for "jumping the queue".
The OECD reported nearly 8000 US dollars in per capita spending (PPP) for 2022, whereas the US was at 12,500. Our lower spending probably has little to do with it being a mostly public payer public provider system, and more to do with it being a coherent system. The Netherlands and Germany both have private providers and private payment, but lower per capita spending than both Norway and the US.
One major issue with Norway's health care system seems to be income for health care professionals. The exhausting nature of the work, combined with relatively high education, means we're lacking qualified workers in large parts of the country, and due to taxpayer funding simply raising the salaries to attract workers isn't as simple as it could be in the US.
Edit: Also, as a listener of Colonel Andrew Heaton's podcasts, I feel obligated to point out how European health care is taken care of at the country level. There's the European Health Insurance Card which guarantees free or affordable health care when visiting another EU/EEA country or Switzerland, but otherwise health care is a national thing, not a (con-)federal one. As such, if the US were to emulate Europe, it would be a mistake to think the Norwegian or Dutch health care systems could be placed onto a continent sized country of 330 million people, doing it on the state level is essentially a must.
I like the "public free baseline, private insurance beyond that" model. I've said elsewhere that we need "Medicaid on Demand." Let anyone get on Medicaid just by clicking a button in an app. We can increase taxes to increase what Medicaid covers if we want. And letting people opt into the private system is much better for freedom.
The one big advantage that a pure monopoly provider run by the government has is how it deals with the "this treatment could help you, but the guy holding the pursestrings says he won't pay for it." This guy exists in every single system. In the US-style system, you're explicitly told there's this treatment and that we'll try to figure out how to pay for it, and then you get told it won't be and get mad. In the monopoly system, the doctor never even mentions it to you. (Or they get away with authorizing things a few times too many and then gets fired.) This leads people to think there's no such thing as denied treatment.
In the second system you never have someone finding the pursestrings guy to gun him down. They insist there's no such person exists.
From a freedom point of view, I think hiding this information from the patient is bad. But maybe we're not mature enough to be allowed that freedom and information.
*EDIT* not having the information can even lead to better outcomes. If you're told "sorry, there's nothing we can do" then you live out your last 20 months of life in relative peace, while being told there's chemotherapy inevitably leads to going through chemotherapy and you living through an excruciating 22 months of life. Making this decision for other people still sets off major red flags for me.
This pretty much describes the Danish healthcare system except the budget for healthcare is lower, leaving the system more stressed. One example is the major shortage of nurses due to many resigning over workload and low pay, and fewer studying for the same reason.
Norway funds almost 20% of its budget from its sovereign wealth fund, which mostly comes from oil exports.
So the Just Stop Oil people should go after Norway's doctors!
So? That just allows the government to spend real money to fund deficits rather than borrow/create it like the US. The advantage is we never have to pay it back, the downside is nonetheless inflation, as most of the value is invested in foreign markets. Norway also had to live a little conservatively initially, as the fund is funded through taxes and other revenue from oil and natural gas which would otherwise have been going straight into the national budget.
Norway's definitely fortunate, not saying otherwise, but Sweden, Denmark, and Finland all have relatively similar health care systems, and no oil revenue. The UK is also such an example, but they even cover dental.
Edit: The UK does have some North Sea oil and natural gas revenue, like Norway, but where there's a legitimate argument to be had about whether Norway is a petrostate or not, the UK is more in the same camp as the US, where oil is one part of a diverse economy.
My point is that Norway's health care is not fully funded by taxes, not even close. Their oil wealth is more vast than people imagine.
If the US had a similar setup, oil income would only contribute about 4% of our budget. This is despite the US being the world's largest oil producer *and* exporter.
But my point was that it doesn't matter. Basically the exact same health care system as Norway's exists in other countries that do not have oil wealth. Sweden, Denmark, Finland, and the UK all spend less per capita on health care than Norway does, but then their economies are also smaller.
The US spent 16.6% of its GDP on health care in 2022, the highest of any OECD country, much higher than Norway's 8%, though less dramatically higher than Germany's 12.7%, and France's 11.9%. Norway without oil would probably have to dedicate more of its GDP to health care than it does today, sure, but no European country spends as much on health care as the US, whether in dollar amount or proportion of GDP.
How much of those countries pharmaceuticals and medical technologies also come from the US?
Most countries cap drug prices, but if the drugs don't exist in the first place -- or if the drug companies couldn't make bigger profits in the US -- there would be incrementally worse outcomes or higher costs.
I'm not saying the US is good and Norway is bad. I'm just pointing out that there are a lot of hidden costs that aren't accounted for on a given country's spending ledger.
Assuredly a lot of them, but Denmark and their Novo Nordisk (maker of Ozempic), along with BioNTech in Germany, the British-Swedish AstraZeneca, and the Belgian branch of Johnson & Johnson (called Janssen) are examples of medical and pharmaceutical companies in Europe with great international significance, many obviously recently in regards to the Covid-19 vaccines.
Yes the too expensive US health care system has some benefits, but even if the US implemented Rand Paul's HSA-based system with transparent consumer facing pricing, and more limited emergency insurance, rather than whatever Bernie Sanders and Hugo Chavez (/s) would like, prices would go down and there might be less money going into pharmaceutical innovation.
Rather than holding this civilisational grand debate over which continent is ultimately doing the most good for worldwide health (quite possibly North America due to the US), can we just recognise that the US health care system is barely a system and is too expensive for the people whose backs are bearing the cost? If the US fixing its health care does lead to less innovation, the western world could try to figure out some sort of grand reward style incentive system for innovation rather than rely on everyday Americans to ensure innovation.
Also, just an aside. Every time something about Norway is compared to essentially any other country the oil is used to dismiss the comparison. That's f*cking ridiculous when, as I pointed out in this discussion, the other non-oil rich Nordic countries tend to do the exact same as Norway. It's also not like Norway's economy had there not been any oil would be today's economy minus the petroleum sector. Petroleum is a brain drain in the Norwegian economy, and had there not been any our economy would likely look more like the Danish, Swedish, or Finnish economies; smaller than ours today, but not worlds smaller.
I've lived in the US most of my life but did spend several years in London and, as my (bad) luck would have it, my time in London featured a medical crisis that engendered extremely intense familiarity with the NHS. There are huge pros and cons comparing the NHS (public care, public funding) and the American system.
The huge pro for the NHS is, of course, the utter lack of concern over payment. My crisis involved a family member continuously hospitalized for more than 6 months, with lots of specialized treatment along the way. When it was all over, we just... walked out of the hospital. No need to talk with a billing supervisor, no hellish second act in which we tried to figure out how to prevent the bills from bankrupting us, nothing like that. I will never stop being thankful for that part of the system.
The huge con for the NHS is just how under-resourced the system is compared to the American system. NHS buildings, even hospitals, are almost shockingly shabby compared to their American equivalents. NHS facilities run out of basic supplies in a way that American hospitals never would (at one point we were staying in a NHS flagship hospital, which didn't have the resource constraints of most NHS facilities, and a nurse remarked to us that it was "rather royal" there because they never ran out of gauze pads or syringes). And the comparatively poor pay for doctors and nurses means that the NHS really struggles to recruit and maintain staff, in a way that impacts both wait times and quality of care.
US healthcare is much more expensive than other systems in large part because we've developed a system of providers and facilities that demand much more money than other nations. It's not all inefficiency and greed; we really do have a system that is higher quality in many ways (and that's not even touching on the fact that the US system effectively serves as the world's R&D center for new treatments and technologies, which US consumers pay for and the rest of the world free rides on). I don't think the US strikes the right balance, and am a fan of either state or national level single-payer options. But it's nonsense to suggest there are no tradeoffs, or that other nations' systems are obviously better.
You make many good points. But when factoring in the astounding amount of money spent on the health care in the US, then we can admit our system is worse than others if only because it costs twice as much as many countries for roughly similar results.
"Similar"
Life expectancy is just demographics.
If the USA does a bunch of useless procedures that don't impact health, I guarantee the people getting those procedures wanted them, or at least didn't object provided someone else was paying.
So I grew up in a country with public insurance and private healthcare. It was fine, although I needed a colonoscopy, and the country decided that that procedure doesn't actually need you to be put under. That was terrible. Additionally, the medical care was covered, but the medications weren't, so seeing a doctor was "free", but the drugs themselves were potentially enough to put me into bankruptcy. (Canada)
I then moved to a country with multiple public insurance and public providers, but which also has a private, parallel system (many doctors actually work in both). I really prefer this, because now when I need a colonoscopy, if they ever decide they don't want to give me the good drugs, I can choose to eat lean for a week and go private. Medications are also "covered" if they're in the health basket (there is a maximum amount per quarter that you have to pay, it's not nothing, but it's manageable for most people). (Israel)
I like the two tiered system, because the option to wait for healthcare means that the private system can't actually go crazy with billing. The private system also provides a recourse when the public system is stingy (In the first country, if a procedure wasn't covered, then I just couldn't get it, there was no other option).
I do think that, for the United States (the centre of the universe), a system where each state guarantees its residents some basic level of (really crappy) health care, will force insurance companies to be more competitive. As far as I'm aware, this somewhat exists, but only with emergency medicine. Preventative options may actually be cheaper.
I also think that the lack of clarity and transparency in pricing and coverage is something that can be solved by legislation (you should be readily able to find out how much an elective procedure costs at different locations, and you should be able to immediately know if a procedure will be covered or not).
As a side note, Canadians HATE the idea of a two tiered system. The idea being that it isn't fair for rich people to be able to jump ahead of poor people. I'm sympathetic to this idea in principle, but I also think it's stupidly naive. The rich will always find some way to get ahead, and making them wait in line with the poor just means you have a longer line. (Plus, this lets doctors be compensated at market value, in addition to being compensated at "slave wages")
Fun fact: On page 5 of the Parliament-themed coloring book, the anus the MPs are sticking the tongue depressors in is mine, from back in my child modeling days.
Jeff, this article was the equivalent of throwing a perfect game. It started strong and just kept delivering the entire time. Multiple times I laughed so hard that I had to stop reading. I can envision your wife walking past behind you a few times, seeing that you were in the zone, and afraid to say anything to you to break the spell. People will tell their grandchildren about today's article. Enlist a friend to dump a Gatorade bucket over your head for this one.
Chiming in from Canada. Your system is not perfect. Is there such a thing? Too many who spout off about problems, perceived or otherwise, only highlight them to further agendas. I live under the worst health care system in western civilization and it is this way because it is public. Be careful what you wish for.
Our Canada Health Act was written with lofty ideals to ensure all had access to medically neccessary treatment.
"Medically neccessary treatment"
Where is it now? Ellective abortions as far as the eye can see. The ideologically driven mutillation of children. Only two examples, all paid for by us while people die because bureaucrats wont pay for their much needed treatment with that money. Treatments over cancer and other life threatenning diseases deemed too expensive to cure. People removed from transplant lists because they refuse experimental shots paraded as vaccines.
We have care doled out based on race or other criteria driven by identity politics.
Having trouble dealing? No problem, all doctors have been ordered by government to recommend MAID up front.
Doctors who disagree with any government edict whether it is vaccines or any other treatments bureaucrats and politicians dictate? You will have your license stripped and your life ruined. Perhaps you will even be forced into "re-education" training aka the soviet uinion, or worse, forced into a psyce ward and given harmful drugs in the hope you die, as one 80 year old physician discovered in Vancouver and only survived after two strokes.
I havent even written of wait times etc.
Be careful what you wish for
Jesus, get a grip.
Cant refute a word? Hurl a mindless, smug comment.
Personally, I find the true dystopian part to be that countries that get more into the "Public" options, get more into offering assisted suicide options. And sometimes rather aggressively assisting.
I am Pro Life. That means I am against adventurous wars of politics, the death penalty in all cases, abortion except for the RILOM exceptions, cops being allowed to be as armed and dangerous as they are, and government facilitating assisted suicide.
People should be honest that health care is just a way to prolong the gold old dance macabre that we are all doing. There is little discussion about what makes all of this expense worth it. Why prolong life at all? The government has the least good answers to this question imaginable. The best answers to "Why am I dragging myself through this physical realm" are almost always found in private experiences and private reasons. It is an affront to liberty for a bureaucrat to decide how much your life is worth and offer you a quick way out if you don't want to wait three years for the hip replacement. It is perfectly respectful of liberty to give people all the facts, a clear idea that they will be responsible, like they are the captain of their own ship, and then let them decide how far they want to go to extend their life given the other choices they face.
People talk about this like we can banish death if we just vote for Medicare for All and I find it infantilizing on the verge of insulting to think that any just society will set a limit on what a life is worth in such a direct and calculating way. Government should have as little power of denial of life as possible. Even if that makes for a world where people are more vulnerable to economic hardship. Even if it leads to some inevitable bankruptcies. The fable of the ant and the grasshopper has a lot of wisdom here. Yes. This makes life harder in some ways. Teach that difficulty to your kids and teach it well. Get them to be a little afraid of winter if you want them to make good plans in the summer.
Prior to Obama care I could sell young ppl a medical plan with excellent coverage through BCBS of Illinois a comprehensive medical plan for $50 / month. No underwriting, they owned the plan and as long as they kept it, paid the premium it could not be canceled. Enter numb nuts Obama, that plan called the unaffordable dumb ass plan, that benefit cost just shy of $300/month - this for a young person under 30 most likely very healthy was considered great legislation. It’s a dualistic screw job. Bureaucrats and corp health care getting in bed together to believe they are working in public interest. I hope Dr Oz blows up the whole thing. Folks who know about these botch jobs are folks who try to help folks understand them. Medicare is another alphabet soup of bs, I’ll not touch that one as it’s not understandable to those with even IQ’s on the level of Johnny VonNeumann.
> No underwriting
How.
I've got issues with PPACA, but every time I interacted with the private insurance market prior to that, I had to fill out a form with 5 lines of space saying "include every health issue you've ever had. Don't use abbreviations or 'etc.'"
"No underwriting" means "no checks on pre-existing conditions" which (without a mandate) is just begging for people to wait until they get sick and they buy the insurance.
I don’t believe this. I lived in Chicago then and had to go without insurance for years because I couldn’t get anything affordable. I was self employed and tried various associations in addition to buying direct.
I think you just proposed an M4A variant, so you’re basically a Bernie Bro now
Nah, I’m thinking more of the “public option, with reimbursements that at least cover the cost of care plus a small margin. It’s a much younger risk pool, and it would be far cheaper to get these folks into plans that encourage preventive medicine instead of them just going to the ER.
It would also force the Obamacare market plans to be a little more honest. But this care really should be preventative + catastrophic coverage.
You could combine it into M4A but you’d need to raise reimbursement rates for a more expensive population, to ensure you’ve got enough providers will continue to accept it. Most hospitals will take it regardless because some reimbursement is better than none, but there already aren’t enough primary care physicians and they can easily have a complete patient load without taking Medicare.
"Preventive medicine" is the "waste fraud and abuse" of government spending. If only we could take care of that, costs would be saved, outcomes go up, taxes go down, everyone wins!
Nearly everything preventive that actually works to lower costs is already being done. A lot of things that people imagine are preventive when measured, or aren't cost-effective when done. ("Stop smoking" is great for a person, and stopping smoking has a 100% chance of stopping smoking. But from a public health arena it involves nagging people to stop smoking and they've already been nagged and decided to ignore it, so you can maybe squeeze out 1% by spending a giant pile of money.)
Last I checked ER use was, at most, 2% of national health care spending, with some measures saying it's as small as 0.5.% There are reasons to stop people from overusing their ER, but aren't going to save our pocketbooks by keeping them out of the ER.
"it would be far cheaper to get these folks into plans that encourage preventive medicine instead of them just going to the ER"
This isn't necessarily true at a population level, especially when we're talking about young and healthy risk pools, because the volume increase in healthcare consumption can end up swamping the per-patient savings. Prevention may be only 1% the cost of treatment, but if the affliction only affects 0.5% of the population, treating the afflicted is cheaper in aggregate than prevention for everyone.
Trust me, I am talking very basic preventative medicine. Annual checkups, generic drugs for very common conditions, etc. To help with primary care shortages, I’d push for larger numbers of residency slots and loan forgiveness if they sign a contract to take patients from the government plan for an extended period of time, say 20 years.
Primary care doesn’t pay all that well so this isn’t some big giveaway to the rich.
Annual checkups are a *great* example of how terrible the ROI is for preventative medicine at the population level. Unless a patient is already symptomatic (in which case they could just schedule an ad hoc appointment), a general checkup is exceedingly unlikely to detect anything, so doubling the number of people getting regular physicals is usually going to be a net increase on costs to the system.
I dunno, I think the annual labs are important, at least.
To be clear - and I can’t edit on the app - but hospitals take Medicare and Medicaid patients because getting 85% of the cost of care back is still better financially for them as their fixed costs are so high. Empty beds kill hospitals.
Oh my gosh this was entertaining. Well done.
I do want to shout out to my healthcare provider in the private-private model.. Kaiser in CA. I really don't have a single complaint. Costs my wife and I about $26k per year for their platinum HMO. Has gone up about 6% per year on average which sucks, but I understand why as Newsom's illegal immigrants need free care.
I would really like to see if the Kaiser model can be replicated across the country. A bunch of integrated insurer-providers that're clearly branded and don't have surprise out of network bills would be a good start to see if private health care is feasible.
One help is that the Kaiser doctors are employees with paid time off and 401ks. So there is no motivation for service manipulation to increase their billing.
Public/public with a private option seems similar to the UK system with the NHS.
But I agree there is no free lunch, and as Thomas Sowell says, there are no solutions, only trade offs.
“If I were to design a system from scratch, I’d probably go public/public that offers a low baseline of coverage.”
This is more or less what candidate Obama said in 2008, adding that since it was impossible to start from scratch, he’d propose reforms that worked on both public (Medicaid expansion) and private (more customers but greater regulation) areas. Hence the Big Fucking Deal of the Affordable Care Act, which I really hope Trump and his minions will not destroy.
If the obstinate Republicans had been willing to go to the negotiating table, we probably could have gotten medical tort reform along with it, which drives SO MUCH cost in malpractice premiums. Whole swathes of the country have little to no access to OB/GYN providers; their malpractice premiums are sky high because any mistake that hurts the baby becomes a giant tort due to the years of life affected.
Say what you will about my country, it provided Ukraine with the best 155mm paper towel tubes.
I spent a disturbing amount of time looking at that Mad Meg picture at the top.
Socialized medicine did a fantastic job back in the 70s and 80s. It kept cost trend down and that's why we have a gap between the US and Europe today.
But cost trend is basically the same between US and Europe today and it's not like you are going to fire 50% of the doctors and nurses in the country to change the baseline rate. So we are just kind of stuck and I don't think ACA 2.0 is a good use of political capital.
Seem to me the best system would be a (possibly age-related) partial tax credit that the person could use to purchase insurance. _Possibly_ the insurance companies would have some incentives to offer efficient options
At least this avoids the illusion that the employer is paying part of the premium of the plan/version of plan one choses is one factor in over insuring.
Would any non-employer plan be structured so than one would want to "use up" an amount of service before year end? At least Medicare does not do that!
And we have the Angus Deaton point, that for an employer health insurance is a fixed cost per employee, so employment of low-skill, low wage people is discouraged.
Employer "provided" health insurance is an additional tax on income in the same way that SS and Medicare taxes (also illusorily partly "paid for" by the employer) fall o income, not consumption.