Indefensible US healthcare data

[Chew Toy McCoy]

U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes

This cross-national comparison of health care systems assesses U.S. health spending, outcomes, status, and service use relative to 12 other high-income countries.

www.commonwealthfund.org

But I guess if you'd like to have a beer with your doctor then all that other stuff doesn't matter.

 

[mac_in_tosh]

Are you challenging American exceptionalism? The GOP would not be happy with you.

Between expensive, complicated insurance policies - if you're lucky enough to have one - and the undue influence of drug companies on doctors and the public, with their ubiquitous advertisements urging us to talk to our doctors, it's a big mess.

Here's one take on it:
The Medical System is a Complete Scam: You may want to Stay Away

 

[Chew Toy McCoy]

Are you challenging American exceptionalism? The GOP would not be happy with you.

Between expensive, complicated insurance policies - if you're lucky enough to have one - and the undue influence of drug companies on doctors and the public, with their ubiquitous advertisements urging us to talk to our doctors, it's a big mess.

Here's one take on it:
The Medical System is a Complete Scam: You may want to Stay Away

But in the US, and only in the US, you can have a doctor who is friendly and doesn't give you advise that leads to your demise!! And we have the top medical experience and technology that will comfort you in your lower life expectancy! And in other countries sometimes you need to wait! Have you heard about this? In the US nobody ever has to wait as long as you have premium insurance. If you don't, sorry not sorry. But we have a solid population who never has to WAIT! If you ever have to wait it's because you are a loser because of your bad life choices and you probably deserve to suffer or die as a result. More good news, you can easily buy a gun to efficiently fast track your exit strategy! Good riddance, loser. One less social security payment we need to worry about funding. 'MERICA!

 

[AG_PhamD]

I would point out country to country ratings like this are far more complex topics than headlines imply.

I think has in most cases little to do with quality of healthcare, obviously some degree insurance, affordability, accessibility (in terms of geography, adequate number of doctors or beds), and a lot to do lifestyle choices, genetic factors within the population, etc. And when it comes to a shortage of doctors, that’s entirely a self-imposed problem by the medical board.

There are obviously problems on the insurance end, but even if we subtract the uninsured and people who cannot afford to properly utilize healthcare, still the overall health of our population is pretty dismal. And a lot of that had to do with lifestyle- like diet and exercise.

During the pandemic there was a dramatic drop in American life expectancy. The CDC attributes part of this to COVID, but a lot of this has to do with long increasing rates of heart disease, obesity, and diabetes- deadly themselves but especially in conjunction with COVID. And the life expectancy is significantly impacted by the dramatic increase in suicides and opioid overdoses among young people.

The lack of access, lack of funding, and lack of social acceptance of mental healthcare is a massive issue in the US and frankly most of the world- even many countries with so called “model”healthcare systems.

Point being, of course there are issues with our healthcare system, but you can have all the access to healthcare in the world, but if you don’t take care of yourself, you’re not going to have the best possible outcomes.

 

[Roller]

The dismal state of U.S. healthcare can largely be attributed to:

1. Gross inequity in access/lack of guaranteed healthcare for all
2. For-profit insurers as middlemen (apologize for the sexist term)
3. Prioritizing treatment > prevention/personal responsibility

The solutions are much more complex.

 

[AG_PhamD]

The dismal state of U.S. healthcare can largely be attributed to:

1. Gross inequity in access/lack of guaranteed healthcare for all
2. For-profit insurers as middlemen (apologize for the sexist term)
3. Prioritizing treatment > prevention/personal responsibility

The solutions are much more complex.

Yeah, the solution is the problem. I don’t see a way for a nationalized healthcare system, especially in the way people like Bernie Sanders and Liz Warren have promoted, without imploding the entire healthcare system and wider industry. Most providers and many hospitals could not survive in their current form with government reimbursement rates. Many people would likely lose their jobs in all areas of healthcare that are not practitioners. There wouldn’t be the same amount of money for R&D. The aforementioned politicians wanted to also ban private pay, which would really screw over some fields. Those with the means would likely just travel abroad unless you ban medical tourism too. We’re so deep into the current system that radical changes would have tremendous implications for our country and could very possibly affect others indirectly.

Obviously there is a lot that can be done that’s less extreme as that conception of healthcare reform. And a ton that could be done even within the general confines of current system we have now.

One of the biggest drivers of cost rarely mentioned is the consolidation of healthcare networks and their market monopolization. Joining a healthcare network is pretty much the only way for hospitals to survive these days. And these networks, given enough market share, have tremendous power in dictating reimbursement rates which obviously gets ultimately passed to the insurance subscribers.

And here in Mass, the biggest problem is not the poor- they have MassHealth plans which are actually very good for the most part. It’s the lower-middle class, often with Healthcare Connector plans. They might be able to afford the premiums but after that, things get out of reach for even fairly routine healthcare. Preventive care gets sidelined until the catastrophic issues arise- at which point they definitely can’t afford that either.

 

[mac_in_tosh]

The dismal state of U.S. healthcare can largely be attributed to:

1. Gross inequity in access/lack of guaranteed healthcare for all
2. For-profit insurers as middlemen (apologize for the sexist term)
3. Prioritizing treatment > prevention/personal responsibility

The solutions are much more complex.

The dismal state of U.S. healthcare is driven by one thing: money.

 

[mac_in_tosh]

Point being, of course there are issues with our healthcare system, but you can have all the access to healthcare in the world, but if you don’t take care of yourself, you’re not going to have the best possible outcomes.

Agree. But what chance do average people have given they are inundated with commercials, seemingly half of which suggesting they ask their doctor about some drug with a weird name and the other half promoting the latest offering from a fast food joint? I don't know of any sustained effort by the medical profession to teach people how to take care of themselves.

 

[mac_in_tosh]

Yeah, the solution is the problem. I don’t see a way for a nationalized healthcare system, especially in the way people like Bernie Sanders and Liz Warren have promoted, without imploding the entire healthcare system and wider industry.

I'll grant that you know more about these things than I do given that you work in the system, but it's always curious to hear how the U.S. couldn't possibly do what every other western nation does. The goal in the U.S. is not to provide the best health care to its citizens, it's to make the most money.

 

[AG_PhamD]

I'll grant that you know more about these things than I do given that you work in the system, but it's always curious to hear how the U.S. couldn't possibly do what every other western nation does. The goal in the U.S. is not to provide the best health care to its citizens, it's to make the most money.

The TLDR version would be the entire healthcare industry- insurance, hospitals, private practices, pharmaceutical/biotech/medical supply companies, etc- would likely be turned upside down. I don’t believe the government would reimburse at rate equivalent to private insurers because it’s already the case they reimburse at substantially lower rates, especially with Medicaid. Many hospitals and practices would not be able to afford to operate or at least without making drastic cutbacks. Inevitably the government would also cap prescription costs like most other nations, which would cut R&D, and stifle innovation- perhaps the only benefit we are awarded for our outrageous prescription drug costs. More expensive, advanced treatments might also be on the chopping block, or at least harder to obtain than they already are.

Even if you just take the private health insurance industry- hundreds of thousands (if not millions?) of people would be out of a job directly. Not to mention many of the people involved with claims from the provider end. Not to mention brokers. Not to mention all the companies that support health insurers.

It’s not to say it couldn’t be done, but it would likely take decades. Obamacare took a number of years to fully implement and that was a bit messy despite not being that radical of a change in the grand scheme of things.

And while private insurance do a degree have a profit motive, it is mandated 80-85% of their revenue goes to claims. The rest goes to overhead and profit, which is usually in the lower single digits. We can debate how much a CEO makes, but big picture it’s a drop in a very big bucket. It’s also worth noting some states outsource administration of Medicaid programs to private insurance- like here in Mass.

Personally, I don’t believe healthcare is “a right” but it is an obligation given our nation’s resources. At the end of the day, regardless of how you administer insurance it’s the healthy paying for the sick and usually those with more provide for those with less. So I don’t care how it works so long as the quality exists. But any way you cut it it’s not an easy answer.

That said, I do have concerns about the government’s ability to manage such things given their track record (ie The VA). While they may not have a profit motive, governments often have a motive to cut costs. Maybe that’ll be different if the entire population is under the same program- but seeing Obamacare was highly controversial, I kind of doubt it.

 

[mac_in_tosh]

Personally, I don’t believe healthcare is “a right” but it is an obligation given our nation’s resources.

Not sure the distinction you are making but I think the wording in the Declaration of Independence is relevant: We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
(I didn't capitalize Rights.) How can one pursue a happy life living in fear of going bankrupt if they get sick or if they cannot obtain basic medical care?

In any case, we may not be talking about the same thing. For instance, many people on Medicare have it through private insurance. Their doctors don't work for the government. And questions of affordability go beyond the medical arena and into income tax policy, etc. It is quite complicated and would be a major disruption but, again, every other western nation seems to handle it. Maybe not perfectly, but our system is far from perfect.

 

[Chew Toy McCoy]

Inevitably the government would also cap prescription costs like most other nations, which would cut R&D, and stifle innovation-

I'm going to call bullshit on that one. The lion's share of R&D is already done with tax payer dollars. The large pharmaceutical companies are almost little more than price fixing marketing middlemen double dip gouging us for what our tax dollars researched. And it can't be proven otherwise because by law their finances can't be investigated,

 

[mac_in_tosh]

I'm going to call bullshit on that one. The lion's share of R&D is already done with tax payer dollars.

And there's this:
9 of 10 top drugmakers spend more on marketing than research

 

[Chew Toy McCoy]

And there's this:
9 of 10 top drugmakers spend more on marketing than research

I think the US and New Zealand are the only countries in the western world that haven’t banned pharmaceutical advertising. They are constantly releasing “new” medication where it’s negligible if it’s any different or better than what’s already on the market. In some cases what is already on the market is better. Does the FDA look into this? Fuck no. I wouldn’t be surprised to find out the only difference is one pill is white and the other is pink.

 

[AG_PhamD]

I'm going to call bullshit on that one. The lion's share of R&D is already done with tax payer dollars. The large pharmaceutical companies are almost little more than price fixing marketing middlemen double dip gouging us for what our tax dollars researched. And it can't be proven otherwise because by law their finances can't be investigated,

This is an argument that has significant misunderstanding. Indeed, a lot of the pre-clinical funding of research is supported by government grants- mainly studies to understand mechanisms of action and to some a far less degree compounds that may affect these mechanisms. Most clinical trials however are funded by pharmaceutical companies. The process of determining how to mass manufacturer drugs is entirely on the private industry. Developing new delivery mechanisms (ie medication patch, extended release, technologies) is usually also on the private industry. And the difference is Pre-clinical trials, especially those that don’t include animal studies, are not nearly as expensive as clinical trials (those that involve humans).

There are a few examples throughout historically virtually entirely developed and paid for by the government and the government handing it over to a pharma company for free, never receiving any compensation.

Moderna and the COVID vaccine is a decent example. Much of the vaccine funding came from a government grant and a lot of their previous mRNA research was funded by the government. Then they’re guaranteed billions in sales. And now 3 years later they want to tripple the price… which is ridiculous.

Vaccines tend to work a little differently in the pharmaceutical world for a number of reasons (mostly a lack of profitability compared to other products). Obviously COVID was a unique case entirely. But such situations definitely are not the norm.

If we wanted to cut the cost of bringing new drugs to market (and therefore the cost of existing drugs), we would limit or ban the advertising of pharmaceuticals, particularly the direct to consumer marketing. Marketing is said to account for about half the cost of bringing a drug to market.

 

[AG_PhamD]

Not sure the distinction you are making but I think the wording in the Declaration of Independence is relevant: We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
(I didn't capitalize Rights.) How can one pursue a happy life living in fear of going bankrupt if they get sick or if they cannot obtain basic medical care?

In any case, we may not be talking about the same thing. For instance, many people on Medicare have it through private insurance. Their doctors don't work for the government. And questions of affordability go beyond the medical arena and into income tax policy, etc. It is quite complicated and would be a major disruption but, again, every other western nation seems to handle it. Maybe not perfectly, but our system is far from perfect.

I’m speaking to the most extreme examples of nationalized healthcare. While you could have 3rd party private insurers administer nationalized healthcare, that still keeps us in a very similar boat as to what we have now where healthcare costs are inflated in part by the private insurance market.

Generally speaking I think private insurers (providing private insurance or administering public plans) do a much better job than when the government administers plans. But a government run plan is much more create a more efficient system.

We are not a perfect system and not remotely close to being one. That said, we do offer some of the best treatments and practitioners in the world. But undoubtedly access and affordability is a massive problem and the current system is not sustainable. Not to mention factors like increased chronic diseases like obesity, diabetes, heart disease- an aging baby boomer generation and declining birth rate, ever increasing costs + inflation, the fact people are living longer, etc.

 

[mac_in_tosh]

Generally speaking I think private insurers (providing private insurance or administering public plans) do a much better job than when the government administers plans.

We all have frustrating stories about our private insurance plans. Having no experience with government administered plans I can't make the comparison. But, generally speaking, government agencies are forced to operate with bare bones budgets that are continually under attack so it's almost expected that there would be issues. So the comparison is not really private vs. government because one side is forced to work understaffed and with outdated systems.

There are other nations where people are generally satisfied with their government administered plans. The basic difference is those governments believe in investing in their people.

 

[Yoused]

I think has in most cases little to do with quality of healthcare, obviously some degree insurance, affordability, accessibility (in terms of geography, adequate number of doctors or beds), and a lot to do lifestyle choices, genetic factors within the population … During the pandemic there was a dramatic drop in American life expectancy. The CDC attributes part of this to COVID, but a lot of this has to do with long increasing rates of heart disease, obesity, and diabetes …

Just try watching broadcast television: it is rife with ads for come enjoy our food, it is so delicious, aren't you hungry? Commercials do not force people to eat too much or eat garbage, but their impact cannot be overlooked. The food industry has been pushing the obesity/heart-disease epidemic upon the country hard, for decades, and we just let them, because, freedom.

And the life expectancy is significantly impacted by the dramatic increase in suicides and opioid overdoses among young people.

Suicides and substance abuse are largely a socio-economic problem. When you look at the bottom, and there is nothing between you and it, you do your best to avoid getting there.

 

[AG_PhamD]

We all have frustrating stories about our private insurance plans. Having no experience with government administered plans I can't make the comparison. But, generally speaking, government agencies are forced to operate with bare bones budgets that are continually under attack so it's almost expected that there would be issues. So the comparison is not really private vs. government because one side is forced to work understaffed and with outdated systems.

There are other nations where people are generally satisfied with their government administered plans. The basic difference is those governments believe in investing in their people.

I can only speak from the provider end of the things. MassHealth (Mass Medicaid) is administered by 3rd parties (several different companies patients can choose from) to run a lot smoother than my experience with Husky (CT Medicaid), CarePath (NH Medicaid), and NY and RI Medicaid. Most surprising is CT given a huge market of insurance employees (Hartford, CT is considered the insurance capital of the world). I have a bit of experience with Tricare (military insurance) having worked at the VA, and that insurance was a mess- as is reported in the media from time to time.

That said, there’s also some very bad private providers. Cigna and United Healthcare/Optum are companies I routinely find difficult to deal with. I also had the misfortune of have a UHC-Optum plan at one point. They were riddled with problems, like being charged copays that were not on my plan.

Obviously there are variations in plans even among private insurers and even among public plans. And public plans vary considerably state to state. But private plans have different incentives than public plans. As do their employees.

Given the nature of our politics I honestly would not trust the government too much power over the healthcare system. Under one party it might be fine, but then get benefits stripped out under the next party. And when you look at how stripped out and expensive Medicare has become, the diminishing returns of social security, all the problems with Tricare/the VA, down to things like how poorly government agencies handled COVID, let’s just say I have significant concerns.

It’s not to say it can’t be run well, but it’s not guaranteed. In the private world at least there is some degree of choice. In reality there is no perfect health plan or health system- except maybe for those who can afford to be self-insured with virtually endless resources.

I would also point out satisfaction isn’t a great metric. While you may say you are unsatisfied with your healthcare, it doesn’t mean you’ll be satisfied with the plan someone else is satisfied with. Cost is obviously going to be a large driver of satisfaction. If you pay little-nothing, you will tolerate more issues, especially if you only require routine healthcare as most people do. But if you need imminent care and are on a waiting list, especially if you’re not used to that, you won’t be happy.

The grass is always greener on the other side, but if you look that the UK’s NHS, they currently have 6.2m patients on waiting lists and almost 25k patients have been waiting for over 2 years. Hospital admission wait time is almost 4hrs now, with some waiting as long as 12hrs. They are considering this a crisis, not surprisingly. And most European healthcare systems are experiencing serious at the moment. Take a look at Spain, Sweden, and France. Canada too is in trouble too.

Much of the accessibility issues stem from the self imposed limits on the number of physicians and the disincentives of being a general practitioner. And in Non-American healthcare workers earn far, far less money than the US.

But I don’t have any answers. At the end of the day though, I believe everyone should have accessible, affordable healthcare- regardless of how it’s paid for. I am merely stating the pros and cons and risks and benefits.

 

[AG_PhamD]

Just try watching broadcast television: it is rife with ads for come enjoy our food, it is so delicious, aren't you hungry? Commercials do not force people to eat too much or eat garbage, but their impact cannot be overlooked. The food industry has been pushing the obesity/heart-disease epidemic upon the country hard, for decades, and we just let them, because, freedom.



Suicides and substance abuse are largely a socio-economic problem. When you look at the bottom, and there is nothing between you and it, you do your best to avoid getting there.

You have a point about marketing. At the same time there’s a lot of temptations in life and it’s not like there isn’t a significant amount of education in various formats to promote healthy living. It’s definitely a complex situation and one not helped by pharmaceuticals be pushed as magic bullets without requiring lifestyle changes and the expectation from society that everything can and should be solved with a pill. With the rapid development of technology we have become conditioned for things to be easy.

I would say addiction/suicide is a very complex issue. Socioeconomics is a factor in the US, but it’s not a universal one. There are many poorer countries with lower suicide rates. And suicide rates are higher than previous eras with lower quality of life. There is a huge cultural component. And when considering money, it’s usually not just income, there is often a financial crisis- one loses their job, runs into financial trouble, is getting divorced, etc.

Native Americans have the highest risk of suicide. Then next group are white people- middle aged males often from rural areas with access to guns. Suicides in the black community historically occur at less than half the rate as the white community, despite average income and wealth disparities.

Opioid addiction for the longest time was primarily found in poor communities. Pain killers eventually found their way into middle class and affluent communities- which then switched to fentanyl. Now we’ve progressed to where it’s pretty much a universal problem. And opioid addiction, like many hard drug addictions, is pretty much guaranteed to bankrupt you. Look at Alex Murdaugh. The difference between opioids and something like meth or crack/cocaine is that opioids have a far better chance of killing you.

Mental illness is the biggest predictor of suicide and probably addiction too. Many suicides are directly or indirectly related to addiction. Obviously those with more means are more likely to get treatment, but most people- even among the wealthy, sadly will never seek treatment.

From what I can see, the biggest driver in the rise in suicides, especially among younger people, is loneliness- and this directly correlates to the pandemic, the massive rate of single men, an increasingly online world, etc.