Well well well, if it isn’t the consequences of 50+ years of terrible policy making. Who could’ve seen this coming except every other country on the planet?
You really think 5 months of a pandemic is going to expose this? New York is returning back to normal. The new surges will pass in the same time frame (5 months). The looming primary care crisis will show itself on a much longer time frame. It’s a snake that’s wrapping around, slow acting venom, and we’ll finally see it when it’s not just the ailing boomers that will need continuous care for ubiquitous things like Diabetes, but gen x, y, and z after it.
No one’s gonna die, that’s when it’s all going to come to a head. We cannot afford Medicare for all when everybody is fucking sick.
We should be able to afford it when the government takes its rightful place as health dictator. Ban alcohol. Ban tobacco. Ban fatty foods. Ban meat. Ban high fructose corn syrup. If not ban, make it so only rich white people can afford it. Then we can afford things by requiring doctors to either work within the system or they can’t be doctors. That takes care of them going into private care.
Ban, ban, ban, then force people to work for the government?
I'm not sure I want to live in the country you are suggesting we make.
What about drugs are legalized instead, and the medical sector is deregulated for example by removing residency requirements?
If a rating system can let anyone become the equivalent of a cab, we certainly can do the same with doctors educated abroad while also educating more at home.
The republicans had their chance. They fucked it up. They are the Washington Team Named To Be Determines of policy makers. All they did was piss people off. Unfortunately we now have to fall into the lap of big daddy government.
You guys are missing the point. I’m saying the general public is too unhealthy for this not to be extremely costly going forward, whether it’s for profit or non profit.
The only thing we solved is making sure you can live with the ailment.
We didn’t solve the cost of continuous care. Whoever is born today, will enter the demographic of questionable health in just 40 years. That means in our lifetime we’ll have almost 3 generations with garbage health inundating the healthcare system.
If you look at this from a socioeconomic standpoint, the poor are more obese and exercise less than the better off. Being poor is hard, so the wealth gap of the US looks to be partial cause of this, but the whole cause and effect is hard to determine here.
Certainly an issue insurers have been thinking about for a while.
Funding certain kinds of care with heavy taxes on things like smoking makes a lot sense.
Other things like unhealthy eating (or sitting, HN participants, lookin' at you) are so much harder to draw easy lines dividing contributing activity from everyday liberties that it makes less sense. You can work at the margins with something like soda taxes or maybe even incentives around bloodwork but the tradeoffs are less clear along with the dividing lines.
Your last sentence is logically equivalent to saying that no society can afford to give medical care to everyone, the only choice is who to ration it for, since Medicare-for-all is characteristically no different from any other comprehensive risk pool bridged over an entire population. And under conditions you're describing where the population truly is uniformly ill, every sub-population will look similar to the population at large, so no private insurance pool will do better by excluding some of the population.
No idea what you want to say, but in my country the situation is worse for about 100 years. Yes, we have free lack of health care: no resources shared to almost everyone, so we are equal in getting nothing.
The US centrally plans the healthcare supply and then doesn't control prices (sort of).
We can and should have lots more doctors (and other primary care providers), but we've long restricted that because people have wacky ideas about things like economics and intelligence.
> people have wacky ideas about things like economics and intelligence.
Boy howdy.
There are three major parts of the economy which are extensively regulated to achieve political goals: health care and higher education (on the national level with some state involvement) and housing (city-level zoning, with occasional other mandates particularly in places like California).
Notice then the three areas where prices have become radically more expensive over the past several decades, fomenting a crisis that threatens our prosperity as a nation: housing prices, higher education prices, health care prices...
At the time of my reading, their comment says "three major parts of the economy which are extensively regulated". I don't think that they're ignoring all others.
The issue with health care is it is a superior good. This means if someones incomes increases by 10%, people spend 12-13% more on health care.
Canada has more regulated health care than the US, and yet the health care has better outcomes and is delivered at a lower price. It isn't perfect, but having seen both systems, the Canadian one is overall better.
One of the reasons, although not the only one, for higher education prices is less subsidies for education at the state level.
I agree that city zoning, and the lack of quick public transit, explains much of the increased price of housing. But some of this increase in cost is due to increased population, and the amount of land in and close to cities being fixed. Higher density would help, but higher density housing to also more expensive to create than lower density housing. A lack of regulation also leads to outcomes like houses in Houston being build on flood plains.
There is a role for government and regulation, and a role for free enterprise, but to understand the balance one need to look a other countries it see if they have a better balance and what works well.
The AMA corrected course on this. The problem is not a lack of schools. The problem is a lack of hospitals to train them in as part of the residency. As long as residency is a thing, we have an insurmountable bottle neck.
Both are problems. Half the qualified med school candidates don't get accepted to any schools. Of course if we build more med schools we'd need more residencies too, but the government can just raise the subsidy they give residencies to create more.
which "policy making" hasn't turned out to be terrible?
why not call it "50 years of statism"? let the state make the policy and before you know crony capitalists and corrupt state employees (in healthcare, insurance and politics) create a mess that results in high costs, poor quality or shortages. why is anyone surprised?
the NYT has contributed to this mess by supporting increased role of government in healthcare (and not just in healthcare)
> Payers routinely reimburse health-care providers for specialized procedures at high rates, but primary-care visits—which might include chronic-disease management, routine vaccinations, or smoking and diet counselling—generate lower revenues. This imbalance is due, in large part, to the Relative Value Update Committee (R.U.C.), an extraordinarily powerful group of doctors that advises the federal government on reimbursement rates for physicians. The R.U.C. consists of thirty-one doctors convened by the American Medical Association; it’s structured such that each specialty has an equal say. On the R.U.C., urology, thoracic surgery, and head-and-neck surgery have, individually, about the same representation as all of pediatrics. The Centers for Medicare and Medicaid Services (C.M.S.), which has final authority to set payment rates for Medicare, has in many years accepted the R.U.C.’s recommendations nearly ninety per cent of the time.
This is more deadly than it appears on the surface.
For example, this article on life expectancy is a good read. One should pay close attention to the case of South Korea and how they are focusing on the health of the younger generation, which has the best payoff (By the way, I am both a citizen of the US and Croatia. The biggest difference: Croatia is going the right way, the US is not): https://www.washingtonpost.com/news/to-your-health/wp/2017/0...
About a year or so ago I subscribed to "direct/concierge primary care practice". I pay $80/month and in exchange getting an access to a primary doctor who takes care of keeping an eye on me, my blood pressure, all my prescriptions (some of which used to require monthly visits to specialists). I am also getting access to really cheap prices on labs, typically 30 min visits same or next day if I wanted (unlimited visits per months), EKG when I wanted to put my mind at peace right there in the office ($25 one time fee), etc. Doctor is available over the phone, text or email. Does not dismiss me when I mention "I've read on internet..." something and actually explains things. Basically, I think it will take care of the most of my health care needs, as well as puts my mind at ease thanks to easy access to the doctor.
The doctor also refers me to specialists who's cash-prices were often below my co-pays.
For major accidents I still have a traditional health insurance with high out-of-pocket limit bought at the marketplace (self-employed).
This practice existed for quite some time and thanks to the subscription-based fees (not episodic described in the article), I expect it to be a long-term sustainable business. It is also owned by the doctor as far as I am aware. They explicitly do not deal with private or public insurances. (Although by recent law changes I can charge monthly fee to HSA account).
There are a few practices like that in the area. Can't say if others are similar in experience, but fees - are. So it looks like it is possible to build sustainable business around primary care. But it takes a different approach.
DPC Frontier has a mapper with many, many practices on it along with prices, open date, and if it’s a “pure DPC” (i.e. no insurance) or hybrid (i.e. they also accept insurance for Medicare or other reasons).
https://mapper.dpcfrontier.com/
Disclosure: I am the founder of Akute Health which makes software for DPC practices.
https://www.akutehealth.com
In the future they'll also come armed and ready to rock and roll like the trauma team in cyberpunk 2077. I'm only half joking, with privitized military now a real thing I can see this being an actual service for the super rich
Thank you for sharing this anecdote. I don’t think enough people understand the value of direct primary care.
Of note, concierge primary care is more associated with something like one medical where you pay a membership in addition to your regular insurance co-pays. Direct primary care, or DPC, is full stop no insurance, only membership. And the doctor will limit their patient panel (the patients they see) to about 600 or even less to ensure they can provide amazing service to those patients. Generally, primary care doctors see 3000 or more patients.
Disclosure: I am the founder of a DPC software company. I absolutely love this model for so many reasons. I’d love to answer questions people have.
How does this work with the insurance dynamics though? You say no insurance full stop, does that make the cost prohibitively high for some? I feel like insurance in a way is similar to a membership model for the patient in terms of cash flow although definitely not the same for the doctors. I'm not in the US so I don't really understand how medicaid works over there
The average price for a DPC membership is about $65/month. In most states, the doctor can even dispense prescriptions at or near wholesale cost.
The idea is that higher utilization of primary care results in lower hospitalizations and specialist visits, which are very expensive for all parties. This has actually been proven in studies comparing total health spend by large employers before and after adding DPC for their employees. So spend a bit more in primary care, get high touch service, and lower cost in the long run.
Medicaid, btw, is our social safety net health insurance program. Most Americans have insurance though their employer which is usually a high deductible plan. Meaning, you have to spend thousands of dollars before insurance will start helping to cover the cost of healthcare for you.
Everything my doctor can do in the office, is part of the monthly fee. Everything on top of it - either cash or insurance. Labs are very cheap when ordering through my doctor (I am talking about $4-$8 for typical stuff). Prescription drugs - i fill through the insurance (fixed co-pay in my case) and if something major will happen, like accident or such, my regular insurance will kick in (after paying several thousands out of pocket)
The thing is - the most expenses I had throughout the years I lived in the USA were on primary doctor and labs. Only in one year out of 10 I had an accident where without a regular insurance I would be screwed.
So high-deductible plan + direct care is the most optimal setup for me right now.
My understanding is that a major cause of America's burgeoning healthcare burden is the food environment.
The argument I've heard smarter, better informed people than me make is: If healthcare were nationalized, it would incentivize the government to help fight the battle against itself in the context of unhealthy agricultural subsidies and policies.
When the government subsidizes farming corn on a massive scale, and all these corn-derived products make people obese and give them diabetes, it becomes counter to the government's own goals if its charter includes providing affordable healthcare to all.
If we don't stop subsidizing liquid sugar, it'll continue finding its way into everything possible.
What kills me is people proposing taxing products w/added sugar... talk about the American way; spend people's tax dollars on subsidies producing the sugar, then tax them again for consuming the thing you made cheap with their taxes! smh
I think you are misunderstanding the incentives that drive politicians if you think extra health care costs would make them change their subsidy policy. They subsidize because the recipients are powerful donors who want them. It isn’t because it is sound fiscal policy.
The smaller your donor base, the fewer people you have to make happy. My personal belief is that this is why income inequality is inversely correlated with democratic representation.
Food subsidies poll extremely well and the US votes for them. They are one of the least controversial public policies and not because of "powerful donors." Almost all countries subsidize food production and there are strong reasons why this is so. Primarily, countries want a robust domestic food surplus for social stability. High food prices or lack of food leading to famine are one of the highest causes of social unrest.
> it would incentivize the government to help fight the battle against itself in the context of unhealthy agricultural subsidies and policies.
It would also incentivize the government to restrict all manor of activities in the name of “health.” Want to go rock climbing? Pay a tax. Want to ride a motorcycle? Pay a tax. Want ice cream after a hard running workout? Pay a tax. Don’t exercise enough? Pay another tax. Allowing the government “incentives” creates incentives for the government to restrict the risk management autonomy of citizens.
And “liquid sugar” isn’t a problem. People choosing to consume too much of it is. I am perfectly healthy, normal weight, plenty of exercise and I like to drink Coke. Should I have to pay a tax or higher prices because some fat-ass makes the choice to drink it like water? Perhaps instead of taxing food, we instead tax obesity. Put the responsibility on the individual.
Surely you could afford an extra $0.10 here and there if it means millions of people would make better choices, yeah? Taxes don't work like you think they do. If you have a Coke now and then, it doesn't really affect you. If you drink three a day, it starts to add up.
If this is unpalatable, we could always just tax Coca Cola directly so they can pay for their sugar-induced health crisis.
If obesity were taxed, there would be pressure to put loopholes in those taxes. Somatypes and "thrifty genome" and so on would be perfect hooks to hang those loopholes on. Result? Questioning that science becomes politically untenable, at least in some universities and research labs. After all, "the grants just follow the illiction returns", as the poet once said:
Regardless of any minor variability in metabolism, you literally cannot get fat from things you don’t put in. This is like high school or middle school physics. This is by far the biggest factor in obesity (consumption).. such that everything else is essentially irrelevant. People with actual metabolism disorders either die or require replacement of enzymes, whether that’s type 1 diabetes or the rarer metabolism disorders.
If you eat high volume foods with calories at or below what you’re expending, you will not get fat, full stop. Starving people aren’t fat.
There are of course behavioral differences that dictate consumption, some of which are genetically influenced, but metabolism has not much to do with it.
>It would also incentivize the government to restrict all manor of activities in the name of “health.” Want to go rock climbing? Pay a tax. Want to ride a motorcycle? Pay a tax.
Okay I'll bite. Why shouldn't we do that? If you're going to 28x your death risk[1] by participating in a purely non-essential activity, why should you be able to externalize the costs to others?
>Perhaps instead of taxing food, we instead tax obesity. Put the responsibility on the individual.
That's actually not a bad idea. We kinda already have that for smoking, in the form of higher insurance premiums for smokers.
Who is going to decide which activities are "non-essential" ? How will they go about determining whether there are more benefits or costs associated with a particular activity?
Rock climbers can fall - they also build physical and mental fitness as well as learn to work together with and trust others in a high pressure environment.
Motorcyclists can crash, but they're choosing a form of transport that is far more efficient than a single passenger vehicle in many ways (fuel consumption, parking requirements, traffic impact).
People are already incentivized by nature to sort out on their own what sorts of activities will allow them and their communities to flourish. Let them. We will all be better for it.
>Who is going to decide which activities are "non-essential" ?
A nonpartisan government panel of scientists. I realize with the current political climate in the us, that might be a tall order, but that doesn't immediately mean the idea should be dismissed.
>How will they go about determining whether there are more benefits or costs associated with a particular activity?
Cost benefit analysis based on empirical evidence?
>People are already incentivized by nature to sort out on their own what sorts of activities will allow them and their communities to flourish. Let them. We will all be better for it.
The examples you've listed lie on a spectrum. Indoor rock climbing probably isn't too negative, all things considered. OTOH motorcycles is much harder to defend. You're really going to risk your life to save a few grand a year on gas and parking?
Like I said before none of this is new. The government has already deemed tobacco to be more harmful than good. As such, it's heavily taxed. I don't find it outrageous to tax things that are similarly obviously more harmful than good.
What you describe is the polar opposite of freedom. It should be immediately dismissed not due to the current political climate but instead because it would establish the ultimate nanny state full of red tape and bureaucracy.
No one should be arbitrating personal activities unless they directly and immediately impact those around you.
(And for the record, I vehemently disagree with sin taxes such as those for alcohol and tobacco. Legally requiring health warnings on the packaging, on the other hand, makes a lot of sense to me. Also note that alcohol and tobacco have much more consistent and severe health impacts than, say, refined sugar.)
Why does anyone even need to decide? Just look at the amortized costs for any activity, whether it is "essential" or not. Essential things still cost money. The only thing you might want to do is provide a rebate for taxes on "essential" activities. This still provides the market pressure for people to minimize costly activities (but doesn't ban it), while being net zero impact to revenue.
Someone mentioned there are 200 climbing accidents a year. Figure out how much that costs, and bake it into the cost of some climbing specific requirement (climbing permits? equipment? gym memberships?). I doubt the cost will be significant. And if it is, maybe we should rethink climbing as an activity.
Same with sugar. Figure out how much added sugar actually costs in terms of health impacts, and tax sugar appropriately. A key point of this strategy is that if you aren't consuming a large amount of e.g. soda, as a parent post claimed, then the tax is negligible anyways.
> Motorcyclists can crash, but they're choosing a form of transport that is far more efficient than a single passenger vehicle in many ways (fuel consumption, parking requirements, traffic impact).
> And “liquid sugar” isn’t a problem. People choosing to consume too much of it is. I am perfectly healthy, normal weight, plenty of exercise and I like to drink Coke. Should I have to pay a tax or higher prices because some fat-ass makes the choice to drink it like water?
Cut out the middleman - fund national healthcare directly with a tax on air pollution and sugar.
The idea that nationalized healthcare (paid for by the middle class) will encourage politicians to tax the unhealthy food of the lower classes is fantasy - this has not manifest itself in other Western countries which do have nationalized healthcare systems.
My understanding is that a major cause of America's burgeoning healthcare burden is the food environment.
That's only one factor. Another is car dependence and lack of pedestrian-friendly built environments.
There is a lot of research on just how much harm it does us to sit all day, every day. We sit in a car to make a long commute to work. We sit our desks. We sit in the car again.
And hitting the gym occasionally doesn't fully compensate for living like that.
Urban planners used to configure cities to help promote physical health and we don't do enough of that anymore. It's nigh impossible to escape a sick outcome when trapped in a sick system that makes healthy choices largely out of reach for most people.
Our metabolism increase from walking 5-15 minutes every day is significant. With individual car transportation there is little want or little ability to do so. Many schedules do not allow for daily 60 minute exercise routines at the gym which take 10-15 min to get there by car.
Every day US citizens waste hours life with transportation. I do believe in cars but I also believe we need to reshape how we live. If the US government allows our time to be wasted repeatedly by a variety of lobbies building infrastructure for a variety of interests it shows how little our leadership values the time of our citizens. I almost find it more egregious that government wants to waste the time of our citizens than wanting to eventually kill ourselves with emissions.
The US currently has an oversupply of labour and I suggest the US does something with it to reshape infrastructure to be less energy reliant.
The world should look into outfit and create houses with manditory natural cooling/heating, increase density in cities and towns to reduce habitat distruction and sprawl, reduce emissions of high GWP chemicals, and create a global political situation to reduce reliance on a failing economic system that incentivizes people to hide pandemics.
> Many schedules do not allow for daily 60 minute exercise routines at the gym which take 10-15 min to get there by car.
You can get that 60 minutes of exercise/physical activity if the transportation to various destinations is changed into a form of exercise for all or some part of it. In the case of a bicycle, it does require that destinations are less than 10 miles (16 kilometers) away, otherwise it would take too much time.
Growing food and subsidizing farmers that produce food is more for the National Security angle: without enough food, there will be rapid social instability and riots and a complete breakdown of society. It’s absolutely essential to produce much more food than can be possibly required by the populace.
True in general (well, except your final sentence), but the topic is the US, which has never failed to produce enough food to feed its population and is unlikely to to start failing now.
It doesn’t produce that food magically. A certain section of society needs to be dedicated to growing food and supported with subsidies if they can’t grow food economically.
Even in the absence of government subsidies, the US probably would'nt've experienced a shortage of food.
I'm not saying that it is impossible for the US to experience a food shortage or even that smart people in and out of government shouldn't worry about that eventuality. I am saying that current and past US programs to subsidize farmers probably do not do / have not done much to reduce that risk and that most of the group collectively deciding to continue the subsidies probably know or strongly suspect that.
In my experience, the elected representatives and other influencers arguing for the subsidies don't even use food security as an argument. (Again, like others in the thread, I am restricting myself to US food policy.) Instead, they argue that the family farm is a producer of particularly virtuous individuals, and it would be a shame if all the family farms were to be driven out of business by large corporations.
The US Midwest has the largest tract of arable land in the world and twice as large as the second largest. If the people of the world were redistributed among the countries so as to equalize the probability of famine among the countries, the US would probably end up with a population over a billion.
The farm subsidies started after the great depression when food shortage was a serious possibility and national security was forefront. While the rhetoric has shifted, the real purpose has not. Yes, the US has the geography to produce vast quantities of food, but that's all useless if no one is farming it. Even with subsidies agriculture is neither lucrative nor appealing for the vast majority of individuals. If the few remaining farmers go off and get better jobs, a huge amount of implicit knowledge will be lost and a lot of infrastructure would be left derelict. This might not be a problem in the short term, America is wealthy enough to import food, but should its suppliers ever try to leverage that position then America would not be able to instantly resume producing the food it needs. Every major power heavily subsidizes domestic agriculture for the same reason.
Canada is similar to the US in terms of food consumption, and yet Canada has much better health care outcomes and lower health care expenditures. I'm not saying food isn't a factor, I'm just wondering how big a factor it is compared to universal access to health care.
Anecdotally, it's at least partially the food. I was a little overweight when I moved to the US, and now I'm full blown fat. My lifestyle (aside for food), didn't change.
The main difference is availability and price, especially the latter. A decent lunch near my office in my home country was 20-30 bucks (converted in USD), and I made X/year. Now I make 3-4+ times X, and you can get more food than I can eat at shit like Panda Express for 6-8 bucks. So vs my income, it's almost 10 times cheaper.
If it wasn't for health concerns, it no longer made sense for me to cook. So I just had delivery/takeout almost every day after I moved (switching country is stressful, so I was happy to get all the time back I could get). Then the health issues cropped up. Now I'm trying to dial it back, but its tough.
I know a _lot_ of people who had similar things happened to them after they moved here, and anecdotally again, one of them moved back and started losing weight super fast, without really trying.
The US government already spends an absolutely incredible amount of healthcare, comparable to Canada or the UK (per capita). Medicare (old people), Medicaid (poor people) and VA, funds for people who don't pay emergency rooms. It's actually a huge amount of total spending, and while the government gets discounts (like health insurers) it's not radically more efficient.
The problem is, I think, often one of over-treatment. If hospitals are paid per procedure (as they are in the US) they are encouraged to do procedures that are actually bad for patients. Insurers can try to reign in over-treatment (to the horror of people who think that more healthcare is always a good thing), but regulators and customers (and activists) fear they do so targeting costs, not patient outcomes. It's all just a mess.
Here's a few issues:
* Over-testing is the most innocuous problem, but even tests aren't "free". At best, it's annoying and makes you not want to go back to see the doctor unless you know it's urgent (especially if it's costing you money or time). Tests might also the emphasis away from immediate treatments (both things that the doctor can do, and things the patient needs to do) as it becomes more of a "wait and see" game.
* Drugs. Obviously they cost money, and they can have side effects. Over-prescription is widely recognised as a major issue.
* Cesareans when they're a bad idea.
* Heart surgery when it's a bad idea.
* Aggressive treatment (especially of cancer) that statistically decreases the quality-adjusted life years a patient has, but hey you have to do something right?
I could go on, but there's really a ton of things where a hospital should do nothing, but has a lot of pressure (from patients and profit motives) to act. While insurers can try to control this, I think it goes without saying that they're also not entirely the good guys, and giving them too much power to reject treatments is also a bit worrying. Confrontational systems might work in the legal system, but it's too slow and expensive to work in healthcare.
Let's look at the special interests the US has (it's not just corn syrup!):
* Caps on doctor training spots. Obviously this is not unique to the US, but a free market solution is hardly going to work when you cap supply.
* Existing players (insurers, hospitals) want high overhead (regulations, admin) to create a moat.
* Drug companies in the US want high drug prices. Australia will subsidise drugs, but only if the drugs are priced right (which creates an incentive for companies to offer deep discounts in Australia). In the US, this kind of bargaining doesn't happen to the same degree. People online keep telling me that the spending on drugs is good though, because it's driving research (it's fine with me if Americans want to spend all their money subsidising the rest of the world).
There is just way more money in being a specialist. I don’t really understand why specialists like radiologists or anesthesiologists make >500k by default While primary doctors make much less. In Germany the medical associations set reimbursements rates per specialty. I assume it’s similar in the US.
Simple solution: balance reimbursements towards primary care. But I assume there is a powerful lobby with deep pockets that will fight such a change.
The assumptions are incorrect. Medical associations may influence supplies to some degree but they don't set the price. Supply, demand, and what the market may bear do. There are also really several different healthcare systems. The government can set say VA rates and medicare to some degree. The sort of balancing done is encouraging more family doctors.
Radiology and anesthesiology are also two "cash cows" of procedures. All of internal medicine wants radiology for tests and needs anesthesiologists if surgical remedies are required.
Primary care pays less because it requires less additional training than the specialties. Although some specialties aren't higher - Children's Oncology for instance.
Medicare had been cutting radiology reimbursements for a while, to the point radiology had almost a 100 unfilled residency spots in the us a few years ago. Radiologists are being paid the bottom of market clearing rates. You pay them much less than what they make now, and you will have a severe shortage quickly.
It makes utterly no sense to become a radiologist in the USA.
Of all the specialties, it's one of the easiest to "offshore". Just send the data to Elbonia and have someone there examine it.
There was a company hyped on Wall Street doing this a number of years ago, but my Google skills are lacking and I can't seem to find it any more. IIRC they were sending the data to civilized countries such as New Zealand (great for time shifting if for nothing else). So maybe they just weren't competitive with Elbonia.
A big part of it is that nurses have been granted authority to do more procedures/prescriptions, and are now overlapping with doctors. For healthy people, a nurse practitioner could probably fulfill all of your standard medical needs.
You can see the effects of this in the clinics popping up inside a lot of grocery stores in the US. They have nurses on staff who can do standard procedures like flu shots, strep tests, common cold treatment etc. And to me, it seems, the outcomes are effectively the same. You get your tests, if it comes back as something known, they prescribe you meds. If not, they advise you to go to the hospital or a specialist.
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[ 0.22 ms ] story [ 96.1 ms ] threadNo one’s gonna die, that’s when it’s all going to come to a head. We cannot afford Medicare for all when everybody is fucking sick.
I'm not sure I want to live in the country you are suggesting we make.
What about drugs are legalized instead, and the medical sector is deregulated for example by removing residency requirements?
If a rating system can let anyone become the equivalent of a cab, we certainly can do the same with doctors educated abroad while also educating more at home.
The only thing we solved is making sure you can live with the ailment.
We didn’t solve the cost of continuous care. Whoever is born today, will enter the demographic of questionable health in just 40 years. That means in our lifetime we’ll have almost 3 generations with garbage health inundating the healthcare system.
Try to flatten that curve.
Your framing is boring, we need to figure out how to make the care as widely available as possible regardless of the payment model.
Funding certain kinds of care with heavy taxes on things like smoking makes a lot sense.
Other things like unhealthy eating (or sitting, HN participants, lookin' at you) are so much harder to draw easy lines dividing contributing activity from everyday liberties that it makes less sense. You can work at the margins with something like soda taxes or maybe even incentives around bloodwork but the tradeoffs are less clear along with the dividing lines.
Sounds like a problem.
We can and should have lots more doctors (and other primary care providers), but we've long restricted that because people have wacky ideas about things like economics and intelligence.
Boy howdy.
There are three major parts of the economy which are extensively regulated to achieve political goals: health care and higher education (on the national level with some state involvement) and housing (city-level zoning, with occasional other mandates particularly in places like California).
Notice then the three areas where prices have become radically more expensive over the past several decades, fomenting a crisis that threatens our prosperity as a nation: housing prices, higher education prices, health care prices...
Canada has more regulated health care than the US, and yet the health care has better outcomes and is delivered at a lower price. It isn't perfect, but having seen both systems, the Canadian one is overall better.
One of the reasons, although not the only one, for higher education prices is less subsidies for education at the state level.
I agree that city zoning, and the lack of quick public transit, explains much of the increased price of housing. But some of this increase in cost is due to increased population, and the amount of land in and close to cities being fixed. Higher density would help, but higher density housing to also more expensive to create than lower density housing. A lack of regulation also leads to outcomes like houses in Houston being build on flood plains.
There is a role for government and regulation, and a role for free enterprise, but to understand the balance one need to look a other countries it see if they have a better balance and what works well.
This isn’t a US only issue.
[1] https://www.ctvnews.ca/health/despite-more-doctors-many-cana...
Here's the article I read a few years back that made me think this is the case:
I know it's mises.org, so hold the pichforks until the end. Even if they're way off base, there's got to be some value to be gleaned:
https://mises.org/library/100-years-medical-robbery
Evidence to the limitations. https://skeptics.stackexchange.com/questions/4561/does-the-a...
why not call it "50 years of statism"? let the state make the policy and before you know crony capitalists and corrupt state employees (in healthcare, insurance and politics) create a mess that results in high costs, poor quality or shortages. why is anyone surprised?
the NYT has contributed to this mess by supporting increased role of government in healthcare (and not just in healthcare)
This is more deadly than it appears on the surface.
For example, this article on life expectancy is a good read. One should pay close attention to the case of South Korea and how they are focusing on the health of the younger generation, which has the best payoff (By the way, I am both a citizen of the US and Croatia. The biggest difference: Croatia is going the right way, the US is not): https://www.washingtonpost.com/news/to-your-health/wp/2017/0...
Archived version of link: http://archive.is/3EpBi
About a year or so ago I subscribed to "direct/concierge primary care practice". I pay $80/month and in exchange getting an access to a primary doctor who takes care of keeping an eye on me, my blood pressure, all my prescriptions (some of which used to require monthly visits to specialists). I am also getting access to really cheap prices on labs, typically 30 min visits same or next day if I wanted (unlimited visits per months), EKG when I wanted to put my mind at peace right there in the office ($25 one time fee), etc. Doctor is available over the phone, text or email. Does not dismiss me when I mention "I've read on internet..." something and actually explains things. Basically, I think it will take care of the most of my health care needs, as well as puts my mind at ease thanks to easy access to the doctor.
The doctor also refers me to specialists who's cash-prices were often below my co-pays.
For major accidents I still have a traditional health insurance with high out-of-pocket limit bought at the marketplace (self-employed).
This practice existed for quite some time and thanks to the subscription-based fees (not episodic described in the article), I expect it to be a long-term sustainable business. It is also owned by the doctor as far as I am aware. They explicitly do not deal with private or public insurances. (Although by recent law changes I can charge monthly fee to HSA account).
There are a few practices like that in the area. Can't say if others are similar in experience, but fees - are. So it looks like it is possible to build sustainable business around primary care. But it takes a different approach.
https://www.nextavenue.org/direct-primary-care-time-with-doc....
or
www.dpcfrontier.com/mapper/
Disclosure: I am the founder of Akute Health which makes software for DPC practices. https://www.akutehealth.com
Disclosure: I am the founder of a DPC software company. I absolutely love this model for so many reasons. I’d love to answer questions people have.
The idea is that higher utilization of primary care results in lower hospitalizations and specialist visits, which are very expensive for all parties. This has actually been proven in studies comparing total health spend by large employers before and after adding DPC for their employees. So spend a bit more in primary care, get high touch service, and lower cost in the long run.
Medicaid, btw, is our social safety net health insurance program. Most Americans have insurance though their employer which is usually a high deductible plan. Meaning, you have to spend thousands of dollars before insurance will start helping to cover the cost of healthcare for you.
The thing is - the most expenses I had throughout the years I lived in the USA were on primary doctor and labs. Only in one year out of 10 I had an accident where without a regular insurance I would be screwed.
So high-deductible plan + direct care is the most optimal setup for me right now.
The argument I've heard smarter, better informed people than me make is: If healthcare were nationalized, it would incentivize the government to help fight the battle against itself in the context of unhealthy agricultural subsidies and policies.
When the government subsidizes farming corn on a massive scale, and all these corn-derived products make people obese and give them diabetes, it becomes counter to the government's own goals if its charter includes providing affordable healthcare to all.
If we don't stop subsidizing liquid sugar, it'll continue finding its way into everything possible.
What kills me is people proposing taxing products w/added sugar... talk about the American way; spend people's tax dollars on subsidies producing the sugar, then tax them again for consuming the thing you made cheap with their taxes! smh
If it affects them personally then they'd jump like a cat on a stove; but if it only affects the budget they aren't going to respond to any incentive.
If the US was being influenced by financial incentives it wouldn't be doing many of the things it does. Like tax cuts or spending more money.
Powerful donors should not exist.
Increasing corn production also does not play to a crucial constituency in the Presidential elections...
This obsession with “rich donors” ignores that voters will also get mad at politicians for the consequences of eliminating those subsidies.
It would also incentivize the government to restrict all manor of activities in the name of “health.” Want to go rock climbing? Pay a tax. Want to ride a motorcycle? Pay a tax. Want ice cream after a hard running workout? Pay a tax. Don’t exercise enough? Pay another tax. Allowing the government “incentives” creates incentives for the government to restrict the risk management autonomy of citizens.
And “liquid sugar” isn’t a problem. People choosing to consume too much of it is. I am perfectly healthy, normal weight, plenty of exercise and I like to drink Coke. Should I have to pay a tax or higher prices because some fat-ass makes the choice to drink it like water? Perhaps instead of taxing food, we instead tax obesity. Put the responsibility on the individual.
If this is unpalatable, we could always just tax Coca Cola directly so they can pay for their sugar-induced health crisis.
You probably have better genes than my family. Lookup endomorph body type or reasons of reduced metabolism.
Evolution has inversed survival of the fattest, so it seems ;)
Somatypes are an ancient pseudoscience, while caloric intake relative to TDEE doesn't lie.
If obesity were taxed, there would be pressure to put loopholes in those taxes. Somatypes and "thrifty genome" and so on would be perfect hooks to hang those loopholes on. Result? Questioning that science becomes politically untenable, at least in some universities and research labs. After all, "the grants just follow the illiction returns", as the poet once said:
https://www.thecrimson.com/article/1987/9/29/borking-up-the-...
I lost 25 kg. In 6 months, with counting calories and all. But the amount of effort I had to deliver for a normal weight is almost exponentially more
1 hour strength training per day
1 hour cardio in the morning
No alcohol
6 * eating small portions
8 hours of sleep
1 cheat meal per week
Every day, no exceptions.
Regardless of any minor variability in metabolism, you literally cannot get fat from things you don’t put in. This is like high school or middle school physics. This is by far the biggest factor in obesity (consumption).. such that everything else is essentially irrelevant. People with actual metabolism disorders either die or require replacement of enzymes, whether that’s type 1 diabetes or the rarer metabolism disorders.
If you eat high volume foods with calories at or below what you’re expending, you will not get fat, full stop. Starving people aren’t fat.
There are of course behavioral differences that dictate consumption, some of which are genetically influenced, but metabolism has not much to do with it.
Okay I'll bite. Why shouldn't we do that? If you're going to 28x your death risk[1] by participating in a purely non-essential activity, why should you be able to externalize the costs to others?
>Perhaps instead of taxing food, we instead tax obesity. Put the responsibility on the individual.
That's actually not a bad idea. We kinda already have that for smoking, in the form of higher insurance premiums for smokers.
[1] https://en.wikipedia.org/wiki/Motorcycle_safety#Crash_rates_...
Rock climbers can fall - they also build physical and mental fitness as well as learn to work together with and trust others in a high pressure environment.
Motorcyclists can crash, but they're choosing a form of transport that is far more efficient than a single passenger vehicle in many ways (fuel consumption, parking requirements, traffic impact).
People are already incentivized by nature to sort out on their own what sorts of activities will allow them and their communities to flourish. Let them. We will all be better for it.
A nonpartisan government panel of scientists. I realize with the current political climate in the us, that might be a tall order, but that doesn't immediately mean the idea should be dismissed.
>How will they go about determining whether there are more benefits or costs associated with a particular activity?
Cost benefit analysis based on empirical evidence?
>People are already incentivized by nature to sort out on their own what sorts of activities will allow them and their communities to flourish. Let them. We will all be better for it.
The examples you've listed lie on a spectrum. Indoor rock climbing probably isn't too negative, all things considered. OTOH motorcycles is much harder to defend. You're really going to risk your life to save a few grand a year on gas and parking?
Like I said before none of this is new. The government has already deemed tobacco to be more harmful than good. As such, it's heavily taxed. I don't find it outrageous to tax things that are similarly obviously more harmful than good.
No one should be arbitrating personal activities unless they directly and immediately impact those around you.
(And for the record, I vehemently disagree with sin taxes such as those for alcohol and tobacco. Legally requiring health warnings on the packaging, on the other hand, makes a lot of sense to me. Also note that alcohol and tobacco have much more consistent and severe health impacts than, say, refined sugar.)
Someone mentioned there are 200 climbing accidents a year. Figure out how much that costs, and bake it into the cost of some climbing specific requirement (climbing permits? equipment? gym memberships?). I doubt the cost will be significant. And if it is, maybe we should rethink climbing as an activity.
Same with sugar. Figure out how much added sugar actually costs in terms of health impacts, and tax sugar appropriately. A key point of this strategy is that if you aren't consuming a large amount of e.g. soda, as a parent post claimed, then the tax is negligible anyways.
> Motorcyclists can crash, but they're choosing a form of transport that is far more efficient than a single passenger vehicle in many ways (fuel consumption, parking requirements, traffic impact).
Motorcycles aren't actually that efficient. A prius gets better gas milage than many (most?) motorcycles: https://www.latimes.com/news/la-hy-throttle2apr02-story.html
At least a prius has a chance of carrying more than one person.
yes. we tax darts and alcohol - the medical cost of sugar probably well exceeds all risky outdoor activities by orders of magnitude. ~200 climbing accidents a year vs https://www.forbes.com/sites/danmunro/2013/10/27/sugar-linke...
The idea that nationalized healthcare (paid for by the middle class) will encourage politicians to tax the unhealthy food of the lower classes is fantasy - this has not manifest itself in other Western countries which do have nationalized healthcare systems.
Then again just ditching the subsidies would get the same thing done with less paperwork...
That's only one factor. Another is car dependence and lack of pedestrian-friendly built environments.
There is a lot of research on just how much harm it does us to sit all day, every day. We sit in a car to make a long commute to work. We sit our desks. We sit in the car again.
And hitting the gym occasionally doesn't fully compensate for living like that.
Urban planners used to configure cities to help promote physical health and we don't do enough of that anymore. It's nigh impossible to escape a sick outcome when trapped in a sick system that makes healthy choices largely out of reach for most people.
Every day US citizens waste hours life with transportation. I do believe in cars but I also believe we need to reshape how we live. If the US government allows our time to be wasted repeatedly by a variety of lobbies building infrastructure for a variety of interests it shows how little our leadership values the time of our citizens. I almost find it more egregious that government wants to waste the time of our citizens than wanting to eventually kill ourselves with emissions.
The US currently has an oversupply of labour and I suggest the US does something with it to reshape infrastructure to be less energy reliant.
The world should look into outfit and create houses with manditory natural cooling/heating, increase density in cities and towns to reduce habitat distruction and sprawl, reduce emissions of high GWP chemicals, and create a global political situation to reduce reliance on a failing economic system that incentivizes people to hide pandemics.
You can get that 60 minutes of exercise/physical activity if the transportation to various destinations is changed into a form of exercise for all or some part of it. In the case of a bicycle, it does require that destinations are less than 10 miles (16 kilometers) away, otherwise it would take too much time.
I'm not saying that it is impossible for the US to experience a food shortage or even that smart people in and out of government shouldn't worry about that eventuality. I am saying that current and past US programs to subsidize farmers probably do not do / have not done much to reduce that risk and that most of the group collectively deciding to continue the subsidies probably know or strongly suspect that.
In my experience, the elected representatives and other influencers arguing for the subsidies don't even use food security as an argument. (Again, like others in the thread, I am restricting myself to US food policy.) Instead, they argue that the family farm is a producer of particularly virtuous individuals, and it would be a shame if all the family farms were to be driven out of business by large corporations.
The US Midwest has the largest tract of arable land in the world and twice as large as the second largest. If the people of the world were redistributed among the countries so as to equalize the probability of famine among the countries, the US would probably end up with a population over a billion.
Funny enough, if you chopped off the fattest 5-6 states, the USA would compare more favorably.
Sources: https://en.wikipedia.org/wiki/List_of_countries_by_obesity_r...
https://ourworldindata.org/obesity
https://worldpopulationreview.com/country-rankings/obesity-r...
That is self evident in social behavior. Your theory is just an easily trotted out bogeyman.
The main difference is availability and price, especially the latter. A decent lunch near my office in my home country was 20-30 bucks (converted in USD), and I made X/year. Now I make 3-4+ times X, and you can get more food than I can eat at shit like Panda Express for 6-8 bucks. So vs my income, it's almost 10 times cheaper.
If it wasn't for health concerns, it no longer made sense for me to cook. So I just had delivery/takeout almost every day after I moved (switching country is stressful, so I was happy to get all the time back I could get). Then the health issues cropped up. Now I'm trying to dial it back, but its tough.
I know a _lot_ of people who had similar things happened to them after they moved here, and anecdotally again, one of them moved back and started losing weight super fast, without really trying.
The problem is, I think, often one of over-treatment. If hospitals are paid per procedure (as they are in the US) they are encouraged to do procedures that are actually bad for patients. Insurers can try to reign in over-treatment (to the horror of people who think that more healthcare is always a good thing), but regulators and customers (and activists) fear they do so targeting costs, not patient outcomes. It's all just a mess.
Here's a few issues:
* Over-testing is the most innocuous problem, but even tests aren't "free". At best, it's annoying and makes you not want to go back to see the doctor unless you know it's urgent (especially if it's costing you money or time). Tests might also the emphasis away from immediate treatments (both things that the doctor can do, and things the patient needs to do) as it becomes more of a "wait and see" game.
* Drugs. Obviously they cost money, and they can have side effects. Over-prescription is widely recognised as a major issue.
* Cesareans when they're a bad idea.
* Heart surgery when it's a bad idea.
* Aggressive treatment (especially of cancer) that statistically decreases the quality-adjusted life years a patient has, but hey you have to do something right?
I could go on, but there's really a ton of things where a hospital should do nothing, but has a lot of pressure (from patients and profit motives) to act. While insurers can try to control this, I think it goes without saying that they're also not entirely the good guys, and giving them too much power to reject treatments is also a bit worrying. Confrontational systems might work in the legal system, but it's too slow and expensive to work in healthcare.
Let's look at the special interests the US has (it's not just corn syrup!):
* Caps on doctor training spots. Obviously this is not unique to the US, but a free market solution is hardly going to work when you cap supply.
* Existing players (insurers, hospitals) want high overhead (regulations, admin) to create a moat.
* Drug companies in the US want high drug prices. Australia will subsidise drugs, but only if the drugs are priced right (which creates an incentive for companies to offer deep discounts in Australia). In the US, this kind of bargaining doesn't happen to the same degree. People online keep telling me that the spending on drugs is good though, because it's driving research (it's fine with me if Americans want to spend all their money subsidising the rest of the world).
People have to realize that the wealth America gained post WW2 was poured into making life comfortable and easy (institutionally and economically).
This had the unintended consequence of making Americans (on average) some of the unhealthiest humans in the world.
Simple solution: balance reimbursements towards primary care. But I assume there is a powerful lobby with deep pockets that will fight such a change.
Radiology and anesthesiology are also two "cash cows" of procedures. All of internal medicine wants radiology for tests and needs anesthesiologists if surgical remedies are required.
Primary care pays less because it requires less additional training than the specialties. Although some specialties aren't higher - Children's Oncology for instance.
"Supply, demand, and what the market may bear do."
I agree about "what the market may bear". Normal supply and demand market ideas really don't apply to a lot of medical areas.
Of all the specialties, it's one of the easiest to "offshore". Just send the data to Elbonia and have someone there examine it.
There was a company hyped on Wall Street doing this a number of years ago, but my Google skills are lacking and I can't seem to find it any more. IIRC they were sending the data to civilized countries such as New Zealand (great for time shifting if for nothing else). So maybe they just weren't competitive with Elbonia.
Here's a similar comment someone made on HN a few days ago: https://news.ycombinator.com/item?id=23882138
Here's the first Google hit on "remote radiology": https://argusrad.com/8-remote-radiology-benefits/
includes: Why waste years specializing when some "scab" can undercut you?Welcome to the global race to the bottom!
Why learn relativity and quantum mechanics when some one can undercut you ?
there just aren’t that many people willing and capable.
You can see the effects of this in the clinics popping up inside a lot of grocery stores in the US. They have nurses on staff who can do standard procedures like flu shots, strep tests, common cold treatment etc. And to me, it seems, the outcomes are effectively the same. You get your tests, if it comes back as something known, they prescribe you meds. If not, they advise you to go to the hospital or a specialist.