It's a truism that America's system was never designed -- it's a patchwork of different pieces that each pay for some people in some situations.
But I've been reading about our system, since I fell down a rabbit hole a couple years ago. Things are bad, yes, but there are actually interesting ideas out there, and real efforts at reform that are being tried.
For example, did you know Maryland has a different way of funding hospitals than most other states? [0] And that other states are interested in copying it?
A system built as a mish-mash patchwork is likely to be solved by a similar "ground-up" framework.
Each state should be free to experiment (as Maryland has done here) and the federal levels should be restricted to providing funding and basic guidelines that have to be met.
Part of the problem is that as you begin to delve in and see where the outflows are, you start to realize that fixing the fundamental problem involves making the people healthier in general, which will rumble the very foundations of Wall Street.
One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever.
Many countries around the world enjoy the benefits of coordinated public health departments. Part of the United States' poor response to COVID was because there was no central public health department that could work closely with state agencies to e.g. provide data about what's going on, share best clinical practices, etc. Each state is an island.
So no, I don't agree that the only goal of the federal government should be piggy bank. States should have a lot of latitude with their policies, but generally standardizing things across the nation would be a net positive.
Many countries around the world are the size of US States. The UK and Germany are only twice the size of California, for example.
The problem in the US isn't that we can't do things, it's that nobody can agree on what to do. And to solve that problem, let states do their own thing as much as we can, and it'll become obvious where the good systems are.
Or in other words, an argument needs to be made why the EU "works" with individual "states" doing their own thing, but the US cannot "work" unless it's considered as one large country.
Scalia was right in saying that the checks and balances slowing things down is a feature, not a bug, with respect to this. The Framers were right about protections against faction. I’m not sure they understood how badly malicious schemers could deliberately manipulate the system. Things just aren’t getting done, and it is killing people.
> generally standardizing things across the nation would be a net positive.
The person you replied to said
> federal... should be restricted to providing...basic guidelines that have to be met
You may be closer in opinion than you realize.
Btw what the person you responded to described is how the Canadian healthcare system - which many liberal-type Americans on Reddit appear to admire - works. The federal government sets standards and provides some funding. The provinces implement it their own way.
>One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever.
One of the great failings caused by federalism and those who simp for it is that when a bad solution is arrived upon or a solution becomes outdated immeasurable suffering is caused and prolonged by not letting those states who want to try and improve do so.
There were a dozen states who were on the precipice of having this solved before the feds stuck their dick in it. Remember Romneycare?
Amazing, every single dollar goes to care! Not a single dollar to overhead! Where are these insurance companies' profit margins coming from? How do they even pay their executives' salaries? Boy have I been mistaken about how inefficient the American system is
> How do they even pay their executives' salaries?
I suspect less goes to executives than you think. Most of it is going to pay employees in the insurance industry.
The irony is that they are being paid to say "no." Perhaps if they instead went to work as service providers, we could get more services for what we spend.
Healthcare executive pay is pretty darn high, more money than any family needs to live comfortably.
Keep in mind this is just for Blue Shield California. There are executives of other health insurance systems in other states and regions who are making similar compensation.
However, I'll go ahead and say right now that I support the idea of these executives being paid these salaries, but on one condition: that we first achieve the goal of 100% of Americans having affordable access to healthcare. Once that goal is achieved, then we can start paying executives big bonuses and incentives. Deal? (Yeah, right...)
Below is a summary of the compensation paid in 2024 to Blue Shield of California’s President and Chief Executive Officer (CEO), Chief Financial Officer (CFO), and top three highest paid executives (other than the CEO and CFO) who were employed by Blue Shield of California at year-end.
Epic Systems is a private company, so there's no executive pay information, but the founder Judy Falkner's estimated net worth is $7.8 billion. Perhaps Epic could reduce the price of its very expensive software for providers to help ease healthcare costs and maybe Judy could give up some of those billions and not notice any difference in her quality of life?
BCBS CA revenue is approximately $25B. The total of above is $25.6M. That's 0.1%.
You may view those salaries as appropriate for leading companies of this size or immoral and outrageous. But either way executive comp is not the big problem with US healthcare costs.
$14,570 per person is our healthcare cost per capita.
For one thing, cutting out even that tiny 0.1%, that's a savings of $15 a year if I wasn't paying my insurance company's CEO. I would absolutely love to keep that $15. The idea that more than one dollar every single month from every single person is going to the CEOs of all our healthcare services is actually INSANE when you think about it.
That really means that out of my $14,570 yearly healthcare cost I could be paying something like $5/month just on executive salary. Who knows, maybe it's even more!
This is, again, insane. Why do Cleveland Clinic executives need to be paid $30 million/year?
This isn't administrative cost, like all the hard-working people who do the clerical work that keeps these systems operating. This is just the salaries of an extremely small group of people, less than 10 people per company.
All of these entities are allowed to make excess profit and/or have loose definitions of non-profit status, and pay CEOs dozens to hundreds of times the salary of their lowest paid employees. There isn't really a limit to the amount they can compensate top executives.
Blue Shield of California has 4.5 million plan members, so all of these executive salaries combined add up to 49 cents per member per month. It's not a significant factor in premium costs.
I think that's highly significant. Keep in mind that that's only one provider in the system. You've also got to pay the executive salaries of your hospital system, your pharmacy chain, your drug company, medical equipment company, etc.
If we figure that every company involved in your $15k/year healthcare cost is paying 0.1-0.5% of their revenue to executive compensation (Cleveland Clinic as a random example pays 0.4% of revenue to the executives, $30 million) then we are talking about a small streaming video subscription worth of cost just which is allocated not on paying a productive group of administrators to keep the lights on, but instead paying excess incentives to an extremely small group of people.
In reality, if CEO compensation was capped to something reasonable like $500,000/year or 10x the pay of the lowest paid employee, there would still be CEOs and the quality of CEOs would not decline because it would still be the highest paid job on the market. Everyone involved in our economy would be just that much richer if the wealth wasn't getting unnecessarily concentrated.
> More than half of excess U.S. health spending was associated with factors likely reflected in higher prices, including more spending on: administrative costs of insurance (~15% of the excess), administrative costs borne by providers (~15%), prescription drugs (~10%), wages for physicians (~10%) and registered nurses (~5%), and medical machinery and equipment (less than 5%). Reductions in administrative burdens and drug costs could substantially reduce the difference between U.S. and peer nation health spending.
One of the best explanations I have ever read about American Healthcare. Even after such good infographic it is still hard to comprehend such complexity.
> The $441B in prescription drugs - the story of incentivizing American innovation over price controls.
This itself speaks for how messedup the entire design is.
Here's an idea. If other countries can provide healthcare for much less per patient, why can't they sell that to Americans?
In other words, allow US citizens to "opt out" of the US healthcare system and participate in the German one? You'd have to make some allowances for replacing taxes with costs, billing, and allow "German" healthcare to operate in the US ...
Basically every bit of the current system, from how much people are paid to how a hospital looks like, is a side effect of the way we pay for healthcare, and the way we decide which provider to select. So we cannot just wave a magic wand and get the German system, as a whole lot of capital decisions are now just straight out wrong.
We see similar things in education. People wonder how many European systems are cheaper than US universities: Well, it's very easy to see once you attend a university in Spain and then one in the US. The shape of the university, from facilities to salaries to class sizes, make them look like completely different organisms, even though 18 year olds come in from one side and come out with degrees in the other. And note that this is also connected to healthcare: How many doctors do we train, or bring in from other countries? How many years do they spend training, and how much debt do they incur getting training? How much are they going to ask in pay just to handle that debt?
Changing the US system is a very good idea, but the changes would be very traumatic to most people working for the system, or invested in the system. All of them would lobby against changes that make their lives worse, and therefore makes legislature that makes the change happen very difficult to pass.
Sure it’s fine. It’s also a significant pay cut for almost every American doctor.
Normal specialists in the US out-earn chief physicians in Germany by hundreds of thousands of dollars. All the fringe benefits in the world aren’t gonna buy you a new boat.
Are you comparing residents to specialists? They're not at all comparable. Residents in the US are typically within 3–7 years of graduating med school and are not able to practice independently. Specialists have typically finished 6–9 years of training after graduating medical school and are independent practitioners.
Healthcare insurance works when everyone including currently healthy people participate. What would happen is only Americans needing an expensive healthcare signing in.
The systems are so different there's no product to sell, it's a whole system of healthcare that permeates through society... You can't sell a national-level system of healthcare as a product, it's done through policy.
All the categories on the right side look perfectly reasonable. However what fraction of those big categories on the right, Hospitals and Physicians... that make up over half of the total, is siphoned off to pay for administratium or "shareholder value" and what fraction actually pays for medical care delivered?
If by shareholder value you include insurance companies etc not just the institutions themselves, it’s well over half.
Doctor time talking to an insurance company either directly or through paperwork is not actually providing any care during that time. Where things go vicious is because doctors are now so inefficient the time they are actually useful becomes increasingly valuable driving ever more paperwork to justify that time.
I'd really love to see the breakdown between how much we spend on physicians/doctors vs. caretakers (nurses, therapists, etc.) vs. how much on hospital admin and other stuff.
At least in UK's chart, "GP & Primary Care", "Private GP Services" and "Administration" are separated. Same in Germany too.
Yes, the diagrams are deeply flawed, in that they seem to suggest 100% of the money input to the system goes to hospitals, hospices, healthworkers, and so on.
I don't see a single outcome pointed at insurance companies... somehow.
> The outcome is $4.9T - which would make it the 3rd largest economy in the world, a high 8% admin costs - compared to the UK’s 2% admin, with medical bankruptcy still possible. We’ve never agreed on what we value. So we built a system that embodies our disagreement: employer-based coverage (market choice) plus Medicare (social insurance) plus Medicaid (safety net) plus exchanges (regulated markets).
> Decision #1: Workers pay at least twice
Here’s the first thing that jumps out: if you work a job in America (and you presumably do, to afford the internet where you’re reading this), you’re already paying for healthcare in multiple places on this chart:
Taxes: federal, state, and local taxes finance Medicare, Medicaid, and various public health programs in so many places. Our attempt at embedding it in single payer.
Payroll: if you’re employed, your employer pays taxes on Medicare (even though you presumably can’t use it until you retire at 65). This is a cost that doesn’t go to your salary.
Insurance premiums: get deducted from your paycheck to fund the employer group plans ($688B from employees alone).
> Could America make this choice? Technically, yes. Politically, we’d need to agree that healthcare is a right we owe each other, funded collectively through taxes. That would mean massive tax increases, eliminating private insurance as the primary system, and trusting a single federal agency.
The operational resistance alone would be too much: I’ve watched hospital execs squeeze out thinning margins and payer executives navigate quarterly earnings calls. We’re talking about unwinding a $1T+ private insurance industry, reconfiguring every hospital’s revenue model, and convincing Americans to trust the federal government with something they currently (sort of) get through their jobs. That ship didn’t just sail - it sank decades ago.
We've unwound industries before - if we have the political will we can do amazing things.
But the people in and using those industries have no desire to change so anything that does happen is likely to occur slowly from expansion - e.g, bringing Medicare to earlier and more people, and expand children coverage, etc.
I think there's some significant evidence that "users" of the private healthcare industry are actually quite unhappy about it. Due to some structural quirks of the US, it seems like it's less about how many people are happy or unhappy and more about how many dollars are spent in favor or opposition of a change.
Those are probably the easiest levels for simplification, but I'd expect significant pushback anyway. Something like start medicare at 55 would be a huge difference to most providers, just due to changes in reimbursement.
If we're gonna stick with private insurance in the US, we should detach it from employment. The current system has created a society of indentured servants, not for money, but for "health insurance". The current system is expensive for employers that are often mandated to provide health insurance plans. And it forces people to work for something they have little or no control over.
When you work for money, you can do whatever you want with the money once you've earned it. But being compensated with "health insurance", you've got almost no control over it; you get what the company gives you - and btw, you can't purchase the same thing on your own, with your own money (way too expensive for most middle-class folks).
Detach health insurance from employment. Open "health insurance plans" to the free market, just like auto insurance. Free employers from all the administrative overhead of managing health insurance for employees (the stock market will love it!) And let health insurance companies work for their actual customers (health care patients!)
The healthcare system in the US is, indeed, the best...if you're rich. If you're not rich, you're gonna spend a lot of time on the phone, arguing with bureaucrats and getting treated like shit.
A friend of mine is rich. We both have a health insurance plan from UnitedHealthcare. His experience is radically different from mine. He can make a phone call, and actually talk to his doctor within a few minutes. He can see his doctor the same day he asks to. He talks to one person who manages all the BS for him.
Not all of it, but definitely the insurance part of it IMO.
It's hard to get an actual number, but many say nearly 1 million people work in health insurance in the US. And I'm not sure that even counts the people whose job it is to interface with them. That's a ton of jobs(and salaries) that likely wouldn't even exist in a sane system.
It's a truism that America's system was never designed -- it's a patchwork of different pieces that each pay for some people in some situations.
But I've been reading about our system, since I fell down a rabbit hole a couple years ago. Things are bad, yes, but there are actually interesting ideas out there, and real efforts at reform that are being tried.
For example, did you know Maryland has a different way of funding hospitals than most other states? [0] And that other states are interested in copying it?
[0] https://www.vox.com/policy-and-politics/2020/1/22/21055118/m...
A system built as a mish-mash patchwork is likely to be solved by a similar "ground-up" framework.
Each state should be free to experiment (as Maryland has done here) and the federal levels should be restricted to providing funding and basic guidelines that have to be met.
Part of the problem is that as you begin to delve in and see where the outflows are, you start to realize that fixing the fundamental problem involves making the people healthier in general, which will rumble the very foundations of Wall Street.
One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever.
Many countries around the world enjoy the benefits of coordinated public health departments. Part of the United States' poor response to COVID was because there was no central public health department that could work closely with state agencies to e.g. provide data about what's going on, share best clinical practices, etc. Each state is an island.
So no, I don't agree that the only goal of the federal government should be piggy bank. States should have a lot of latitude with their policies, but generally standardizing things across the nation would be a net positive.
Many countries around the world are the size of US States. The UK and Germany are only twice the size of California, for example.
The problem in the US isn't that we can't do things, it's that nobody can agree on what to do. And to solve that problem, let states do their own thing as much as we can, and it'll become obvious where the good systems are.
Or in other words, an argument needs to be made why the EU "works" with individual "states" doing their own thing, but the US cannot "work" unless it's considered as one large country.
This analogy is quite misleading, because, in addition to California, there is also Wyoming, with a population of less than <600k.
Scalia was right in saying that the checks and balances slowing things down is a feature, not a bug, with respect to this. The Framers were right about protections against faction. I’m not sure they understood how badly malicious schemers could deliberately manipulate the system. Things just aren’t getting done, and it is killing people.
"Many countries around the world enjoy the benefits of coordinated public health departments."
Many countries around the world are the size of a single state and lack the geographic diversity of the US.
> * there was no central public health department*
If only we had some sort of federal Center in charge of Disease Control... ;-)
But I agree with you that the CDC was weirdly passive during COVID. You'd think it would have been their moment to shine.
You said
> generally standardizing things across the nation would be a net positive.
The person you replied to said
> federal... should be restricted to providing...basic guidelines that have to be met
You may be closer in opinion than you realize.
Btw what the person you responded to described is how the Canadian healthcare system - which many liberal-type Americans on Reddit appear to admire - works. The federal government sets standards and provides some funding. The provinces implement it their own way.
>One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever.
One of the great failings caused by federalism and those who simp for it is that when a bad solution is arrived upon or a solution becomes outdated immeasurable suffering is caused and prolonged by not letting those states who want to try and improve do so.
There were a dozen states who were on the precipice of having this solved before the feds stuck their dick in it. Remember Romneycare?
> rather than each state having its own bespoke whatever
that's states' rights and it's enshrined in the constitution
> the only goal of the federal government should be piggy bank
that is indeed the only goal that the founders had in mind, as it should be
Amazing, every single dollar goes to care! Not a single dollar to overhead! Where are these insurance companies' profit margins coming from? How do they even pay their executives' salaries? Boy have I been mistaken about how inefficient the American system is
> How do they even pay their executives' salaries?
I suspect less goes to executives than you think. Most of it is going to pay employees in the insurance industry.
The irony is that they are being paid to say "no." Perhaps if they instead went to work as service providers, we could get more services for what we spend.
Healthcare executive pay is pretty darn high, more money than any family needs to live comfortably.
Keep in mind this is just for Blue Shield California. There are executives of other health insurance systems in other states and regions who are making similar compensation.
However, I'll go ahead and say right now that I support the idea of these executives being paid these salaries, but on one condition: that we first achieve the goal of 100% of Americans having affordable access to healthcare. Once that goal is achieved, then we can start paying executives big bonuses and incentives. Deal? (Yeah, right...)
https://www.blueshieldca.com/content/dam/bsca/en/member/docs...
Below is a summary of the compensation paid in 2024 to Blue Shield of California’s President and Chief Executive Officer (CEO), Chief Financial Officer (CFO), and top three highest paid executives (other than the CEO and CFO) who were employed by Blue Shield of California at year-end.
Paul Markovich
President and Chief Executive Officer
$11,191,674
Sandra Clarke
EVP, Chief Operating Officer
$5,765,368
Peter Long
EVP, Strategy and Health Solutions
$4,360,245
Lisa Davis
EVP, Chief Information Officer
$2,873,613
Michael Stuart
EVP, Chief Financial Officer
$2,406,837
Some other CEOs:
Cerner (EMR provider to the VA), $35 million pay package: https://kffhealthnews.org/morning-breakout/cerner-to-pay-new...
Pfizer, $24.6M pay package: https://www.fiercepharma.com/pharma/rebound-year-pfizer-ceo-...
Epic Systems is a private company, so there's no executive pay information, but the founder Judy Falkner's estimated net worth is $7.8 billion. Perhaps Epic could reduce the price of its very expensive software for providers to help ease healthcare costs and maybe Judy could give up some of those billions and not notice any difference in her quality of life?
BCBS CA revenue is approximately $25B. The total of above is $25.6M. That's 0.1%.
You may view those salaries as appropriate for leading companies of this size or immoral and outrageous. But either way executive comp is not the big problem with US healthcare costs.
$14,570 per person is our healthcare cost per capita.
For one thing, cutting out even that tiny 0.1%, that's a savings of $15 a year if I wasn't paying my insurance company's CEO. I would absolutely love to keep that $15. The idea that more than one dollar every single month from every single person is going to the CEOs of all our healthcare services is actually INSANE when you think about it.
0.1% is actually a LOW amount for some entities in the system. For example, the Cleveland Clinic spends 0.4% of revenue on executive compensation: https://projects.propublica.org/nonprofits/organizations/340...
That really means that out of my $14,570 yearly healthcare cost I could be paying something like $5/month just on executive salary. Who knows, maybe it's even more!
This is, again, insane. Why do Cleveland Clinic executives need to be paid $30 million/year?
This isn't administrative cost, like all the hard-working people who do the clerical work that keeps these systems operating. This is just the salaries of an extremely small group of people, less than 10 people per company.
All of these entities are allowed to make excess profit and/or have loose definitions of non-profit status, and pay CEOs dozens to hundreds of times the salary of their lowest paid employees. There isn't really a limit to the amount they can compensate top executives.
> Why do Cleveland Clinic executives need to be paid $30 million/year?
So they can hire bodyguards?
Blue Shield of California has 4.5 million plan members, so all of these executive salaries combined add up to 49 cents per member per month. It's not a significant factor in premium costs.
I think that's highly significant. Keep in mind that that's only one provider in the system. You've also got to pay the executive salaries of your hospital system, your pharmacy chain, your drug company, medical equipment company, etc.
If we figure that every company involved in your $15k/year healthcare cost is paying 0.1-0.5% of their revenue to executive compensation (Cleveland Clinic as a random example pays 0.4% of revenue to the executives, $30 million) then we are talking about a small streaming video subscription worth of cost just which is allocated not on paying a productive group of administrators to keep the lights on, but instead paying excess incentives to an extremely small group of people.
In reality, if CEO compensation was capped to something reasonable like $500,000/year or 10x the pay of the lowest paid employee, there would still be CEOs and the quality of CEOs would not decline because it would still be the highest paid job on the market. Everyone involved in our economy would be just that much richer if the wealth wasn't getting unnecessarily concentrated.
Beat me to it. This chart is only 1/2 complete. It doesn't show where the money goes after hospital care, for instance.
[flagged]
https://www.commonwealthfund.org/publications/issue-briefs/2...
> More than half of excess U.S. health spending was associated with factors likely reflected in higher prices, including more spending on: administrative costs of insurance (~15% of the excess), administrative costs borne by providers (~15%), prescription drugs (~10%), wages for physicians (~10%) and registered nurses (~5%), and medical machinery and equipment (less than 5%). Reductions in administrative burdens and drug costs could substantially reduce the difference between U.S. and peer nation health spending.
Overhead which is associated with hospital spending, but not paid to the hospital, should not flow to the hospital in a Sankey diagram.
Physician salaries are only 8% of total healthcare spending. Care to revise your screed?
One of the best explanations I have ever read about American Healthcare. Even after such good infographic it is still hard to comprehend such complexity.
> The $441B in prescription drugs - the story of incentivizing American innovation over price controls.
This itself speaks for how messedup the entire design is.
I wish they had this per capita in each country, so we could compare them.
Here's an idea. If other countries can provide healthcare for much less per patient, why can't they sell that to Americans?
In other words, allow US citizens to "opt out" of the US healthcare system and participate in the German one? You'd have to make some allowances for replacing taxes with costs, billing, and allow "German" healthcare to operate in the US ...
Basically every bit of the current system, from how much people are paid to how a hospital looks like, is a side effect of the way we pay for healthcare, and the way we decide which provider to select. So we cannot just wave a magic wand and get the German system, as a whole lot of capital decisions are now just straight out wrong.
We see similar things in education. People wonder how many European systems are cheaper than US universities: Well, it's very easy to see once you attend a university in Spain and then one in the US. The shape of the university, from facilities to salaries to class sizes, make them look like completely different organisms, even though 18 year olds come in from one side and come out with degrees in the other. And note that this is also connected to healthcare: How many doctors do we train, or bring in from other countries? How many years do they spend training, and how much debt do they incur getting training? How much are they going to ask in pay just to handle that debt?
Changing the US system is a very good idea, but the changes would be very traumatic to most people working for the system, or invested in the system. All of them would lobby against changes that make their lives worse, and therefore makes legislature that makes the change happen very difficult to pass.
I don't think US doctors will want to work for German pay.
Resident salary: approx. € 60,000 - 75,000 Specialist salary: approx. 75,000 € - 98,000 Senior physician salary: approx. € 90,000 - € 150,000 Chief physician salary: approx. € 150,000 - € 370,000
Seems fine? Especially if you subtract a substantial amount of benefits fringe.
Sure it’s fine. It’s also a significant pay cut for almost every American doctor.
Normal specialists in the US out-earn chief physicians in Germany by hundreds of thousands of dollars. All the fringe benefits in the world aren’t gonna buy you a new boat.
Are you comparing residents to specialists? They're not at all comparable. Residents in the US are typically within 3–7 years of graduating med school and are not able to practice independently. Specialists have typically finished 6–9 years of training after graduating medical school and are independent practitioners.
Source: am a US physician.
US doctors earn that every 8 weeks.
That's why you let German doctors work for German++ pay ;).
Healthcare insurance works when everyone including currently healthy people participate. What would happen is only Americans needing an expensive healthcare signing in.
The systems are so different there's no product to sell, it's a whole system of healthcare that permeates through society... You can't sell a national-level system of healthcare as a product, it's done through policy.
All the categories on the right side look perfectly reasonable. However what fraction of those big categories on the right, Hospitals and Physicians... that make up over half of the total, is siphoned off to pay for administratium or "shareholder value" and what fraction actually pays for medical care delivered?
If by shareholder value you include insurance companies etc not just the institutions themselves, it’s well over half.
Doctor time talking to an insurance company either directly or through paperwork is not actually providing any care during that time. Where things go vicious is because doctors are now so inefficient the time they are actually useful becomes increasingly valuable driving ever more paperwork to justify that time.
I'd really love to see the breakdown between how much we spend on physicians/doctors vs. caretakers (nurses, therapists, etc.) vs. how much on hospital admin and other stuff.
At least in UK's chart, "GP & Primary Care", "Private GP Services" and "Administration" are separated. Same in Germany too.
Yes, the diagrams are deeply flawed, in that they seem to suggest 100% of the money input to the system goes to hospitals, hospices, healthworkers, and so on.
I don't see a single outcome pointed at insurance companies... somehow.
The article takes this on a couple times:
> The outcome is $4.9T - which would make it the 3rd largest economy in the world, a high 8% admin costs - compared to the UK’s 2% admin, with medical bankruptcy still possible. We’ve never agreed on what we value. So we built a system that embodies our disagreement: employer-based coverage (market choice) plus Medicare (social insurance) plus Medicaid (safety net) plus exchanges (regulated markets).
> Decision #1: Workers pay at least twice
Here’s the first thing that jumps out: if you work a job in America (and you presumably do, to afford the internet where you’re reading this), you’re already paying for healthcare in multiple places on this chart:
> Could America make this choice? Technically, yes. Politically, we’d need to agree that healthcare is a right we owe each other, funded collectively through taxes. That would mean massive tax increases, eliminating private insurance as the primary system, and trusting a single federal agency.The operational resistance alone would be too much: I’ve watched hospital execs squeeze out thinning margins and payer executives navigate quarterly earnings calls. We’re talking about unwinding a $1T+ private insurance industry, reconfiguring every hospital’s revenue model, and convincing Americans to trust the federal government with something they currently (sort of) get through their jobs. That ship didn’t just sail - it sank decades ago.
We've unwound industries before - if we have the political will we can do amazing things.
But the people in and using those industries have no desire to change so anything that does happen is likely to occur slowly from expansion - e.g, bringing Medicare to earlier and more people, and expand children coverage, etc.
I think there's some significant evidence that "users" of the private healthcare industry are actually quite unhappy about it. Due to some structural quirks of the US, it seems like it's less about how many people are happy or unhappy and more about how many dollars are spent in favor or opposition of a change.
Those are probably the easiest levels for simplification, but I'd expect significant pushback anyway. Something like start medicare at 55 would be a huge difference to most providers, just due to changes in reimbursement.
"A Fairytale Map of Every Dollar of America's $5T Healthcare System" is the complete, accurate title.
Is this funded by an insurance company?
The author calls himself a "Real Estate Novelist and recovering healthcare consultant" (https://substack.com/@andrewtsang).
If we're gonna stick with private insurance in the US, we should detach it from employment. The current system has created a society of indentured servants, not for money, but for "health insurance". The current system is expensive for employers that are often mandated to provide health insurance plans. And it forces people to work for something they have little or no control over.
When you work for money, you can do whatever you want with the money once you've earned it. But being compensated with "health insurance", you've got almost no control over it; you get what the company gives you - and btw, you can't purchase the same thing on your own, with your own money (way too expensive for most middle-class folks).
Detach health insurance from employment. Open "health insurance plans" to the free market, just like auto insurance. Free employers from all the administrative overhead of managing health insurance for employees (the stock market will love it!) And let health insurance companies work for their actual customers (health care patients!)
Or, just open Medicare to all.
The healthcare system in the US is, indeed, the best...if you're rich. If you're not rich, you're gonna spend a lot of time on the phone, arguing with bureaucrats and getting treated like shit.
A friend of mine is rich. We both have a health insurance plan from UnitedHealthcare. His experience is radically different from mine. He can make a phone call, and actually talk to his doctor within a few minutes. He can see his doctor the same day he asks to. He talks to one person who manages all the BS for him.
> If you're not rich, you're gonna spend a lot of time on the phone, arguing with bureaucrats and getting treated like shit
Sounds a lot like the Spanish healthcare system.
So it's a jobs program
Not all of it, but definitely the insurance part of it IMO.
It's hard to get an actual number, but many say nearly 1 million people work in health insurance in the US. And I'm not sure that even counts the people whose job it is to interface with them. That's a ton of jobs(and salaries) that likely wouldn't even exist in a sane system.
Where are salaries? Where are administration overhead? Where are insurance company profits and dividends coming from?
This whole thing loses all credibility by not listing those things.