Oh, no, people stopped having children. Whatever could be the reason.
And yet it still exists in the rest of the world. But people tend to think of it only as for rich people as opposed to covering things the rest of the world ignore. I'm not saying the US is perfect, but having lived under both kinds of healthcare, cost and quality are two reasons I'm in the US.
I pay the maximum possible in Germany for my health insurance and from what I understand I still pay less for healthcare than I would in the US.
Even if you have slightly more wait time, the cost is still way lower. Unless you have a US employer that pays the whole insurance for you (I don’t know if that’s possible)
As for US employers paying for everything... yes it's common. It used to be that they'd just cover everything via a 'PPO' plan with minimal 'co-pays'. Usually you'd pay $5-15 for a GP, ~$50 for urgent care, and ~$100 for an ER visit.
These days, many have switched to a 'High Deductible' plan, where the insurance comes with a 'max out-of-pocket'. After you've paid that amount, then everything is fully covered, but nothing is covered until you hit the deductible.
My current company has this plan, but puts the entire 'max out of pocket' value in what's called an 'HSA' (healthcare savings account). This money grows tax free and will eventually turn into a retirement account. So, if you have no health issues, then this becomes a free income stream. If you do have health issues, then you just spend this money every year and then insurance takes over and pays for the rest. This is common in the tech world these days... not sure about other industries TBH.
From the graphic the insurers take in $371.6b and pay out $241.9b in medical services costs.
That’s $130b on a pointless activity that uses up physical resources that would be better deployed elsewhere in the economy.
Healthcare needs to be provided as a matter of course, and “competition” won’t improve it or control it because there is always a supply side shortage of provision.
That’s a difficult problem to solve, but solving it by forcing a huge bill on expectant mothers and cancer victims, etc in a futile attempt to control demand is not the way.
Which is why the rest of the world charts a different path.
It seems like the core problems with US "system" come from having a "shadow" socialized system (by way of EMTALA[0]) that offloads costs onto the "free market" (read: patients or insurers who can pay) and a shocking inability to have a mature public conversation about how care will be rationed. (That conversation still happens but it's between providers and insurers and not subject to public scrutiny.)
[0] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
This guy is way out of his depth.
[1] https://www.rand.org/pubs/external_publications/EP71133.html
He does that a lot, tbf
And, of course, things like spurious denials drive up costs for them and for the providers. More direct costs, more costs at the provider they have to cover...
From the insurance company perspective, it's a win-win!
Spurious denials? Or improperly filed claims?
It's easy to find documentation of this. For example:
https://pmc.ncbi.nlm.nih.gov/articles/PMC10391242/
https://phrma.org/blog/70-denied-how-insurance-denials-are-d...
https://www.forbes.com/sites/joshuacohen/2026/05/04/independ...
Anecdote is not the singular of data, but when my late wife was dying of cancer, the oncologist was attempting to follow a standard care procedures. Preauthorizations were denied even after physician consultation.
My research showed me that the insurance companies contract with other companies (who they may or may not own) to handle the dirty work. It was only after learning the magic incantations to directly contact the "third-party" company that I was able to get traction.
"We do not believe this treatment is warranted."
"Well, her doctor believes it, so she's going to get the treatment. The only question is whether you pay now, or after I file a small claims case."
It was miraculously authorized at that point. It's the same fucking thing with car insurance. The poor people who can't fight really get screwed.
This is twice what the same role pays in most European countries. Unless she is well below that range for some reason, she is likely overpaid.
Everybody in healthcare, from the nurses to the hospital CEOs, makes far far more in the US than they would in a country with socialized medicine.
A 22% decrease and a return to providers having to consider the cost implications to their patients would be a good thing.
("Return" I know a 95 year old doctor who said he still carries some guilt from keeping a poor guy in the hospital an extra night back in 1955 days because he couldn't get some blood tests done quickly enough. $5. "We only need medical insurance because we have medical insurance" ain't too far wrong)
Overall, there are lots of nitpicks with this article but my personal takeaway is: if this is the best defense people can make for the US medical insurance system then that shows how bad it really is.
> Your interaction with the health insurer, on the other hand, feels like a struggle against an enemy who wants to destroy you.
Exactly, the big factor driving healthcare costs is that people like expensive providers. They like the fancy plan that covers their doctor, that doesn't limit them to a community hospital. Any choice that involves retaining even the slightest market leverage is a deal breaker for many people. I think all the clever stuff we do to optimize costs and increase transparency is worth doing and helpful, but like, it will still be expensive. We want that!
Meanwhile it is not really better to go to an expensive doctor, in terms of health outcomes. So the public health problem is to stop people (and employers) from voluntarily wasting their money on healthcare, so we can use it for better stuff.
The fancy plan.
I will say this: profit margin % is not the yardstick by which we should measure whether insurance companies are responsible for high health care costs in the US.
Any good hacker is familiar with Amdahl's Law, and the same principle applies here. You can optimize the insurance providers all you want and maybe recover about 1/6 the total cost of care. At the very least, the first place we should be looking is the biggest expense, which is also clearly not the insurance.
The problem is that people knee-jerk blame the one who they are giving money to. People think the teams are "Me and doctor vs. greedy insurance" whereas the reality of the situation is much more "Me and insurance vs greedy doctor".
The most efficient medical experiences I have had have both been ones where there were no insurance involved:
1. A USCIS surgeon, that was like 80 years old, running his own office, everything via check, on paper. Guy put more patients through per day then the big hospital systems special immigrant medical services did.
2. A specialized Eye Surgeon who did my wife's ICL eye surgery (which insurance wont cover). Ended up being the most efficient practice I've seen, every follow up and pre-surgery meeting was not separately billed. Just the surgery was. Eye Doctors / Surgeon spent a ton of time with you. And they had massive amounts of flexibility. But even the out of pocket surgery was probably less than an insurance covered surgery at a hospital.
Hmm, I think it's better to use a percentage than a fuzzy word like "common":
https://www.kff.org/health-costs/health-policy-101-employer-...
Figure 8
12% of covered single workers and 3% for families have the employer cover their premiums in full
When you have to pay a co-pay it is 5€ per prescription. You don’t pay for generalists, and do not pay for specialists if you get a recommendation from a generalist first.
There is no deductible.
Not everything is covered though, dental care often has limited coverage (only for the most basic services), so you end up paying yourself.
I never heard of a healthcare saving account, that’s an interesting and strange concept
That might be true to your specific location and set up, but I have some experience and family in healthcare, both in the US and outside of it, and it is definitely not like that for much of the US.
I would dearly love to know what "costs" of healthcare you are looking at when you say the US is preferable enough to actually move to/be in/stay in the US.
Because when I can have higher end insurance from my employer, and still be out $9K for a kidney stone after insurance, I'm not seeing it. That is an outlier, for me, I'll acknowledge, but it's still nearly five digits that had to come out of my pocket after my employer paid thousands, I paid premiums, for insurance (that is insurance-in-name-only).
Free market usefully means both sides can choose to participate in transactions which means price is how they do that. It is a useful concept but it doesn't cover everything, like what you mentioned and things like if emergency patients are shopping around hospitals or if the average consumer is capable of being well informed in such a market.
The biggest buyer is the Federal government and by law they are required to get the best deal, the government also restricts the supply of providers. It’s not a capitalist system at all. It’s a weird hybrid command economy with a consolidating cartel of providers and administrators.
No, it's much worse than that. How much time and money is spent by medical providers dealing with the billing?
Arguably at least twice as much -- the insurers have economy of scale that providers can't match.
And that's before you even get to the direct time and stress impacts on the consumer from bullshit denials.
Just go look for the local debate in any country with government healthcare and look for the parties who are pushing for change and their complaints.
Then ask yourself if you really would want the current administration in charge of your healthcare... if you'd like every four years to be a coin toss for how your healthcare was going to be for the next four years.
People arguing for public health care, are you ready to say you want Donald Trump to be in charge of your health insurance instead of a private provider? (because we're not in a magical fairy land where government is efficient and agrees with everybody's priorities)
And I want to win the lottery, marry a princess, and for my childhood dog to come back to life.
We all want things.
When we're advocating for government changes we need to be realistic and make good choices. Right now throwing an enormous amount of power at a dysfunctional government (public health care) is an insane bid completely disconnected from reality.
We need people to care about the basic functionality of government and for it's various pieces to do their duty. They aren't, so maybe let's shelve the idea of handing over control of our healthcare to them until they can deal with their cowardice in front of an aspirational king.
A public health care system should be independent of politics. Unfortunately, as the latest administration has shown, even if you designed it to be independent, such as the CFPB, it doesn't matter with an autocrat in charge. On the other hand, private industry does not have all that good a reputation for not effing with your healthcare.
I propose allowing buy into medicare at 5 years before regular eligibility. And a long phase in of lowering the eligibility age. Drop it by 6 months every year for 10 years, then 1 year every year for 10 years, then 2 years every year until everyone with work credits is eligible.
At the same time, start covering all kids up to some age with Medicaid (after all, kids tend to have no income, so if eligibility was based on their own income instead of household income, they'd qualify). First year, kids get covered until 6 months, next year until 1 year, etc.
When the Medicare and Medicaid ages meet, we have universal health care. It would take a long time to get there on my schedule, but it would be gradual, so everyone could adapt. And if future legislation could adjust the timeline as needed.
Also, clearly someone needs to add more residency slots.
Do you want Donald Trump to be in charge of public healthcare? Please stop suggesting we make all of those changes unless you're willing to say you want him to be in charge of it.
Also, having a baseline of public care and then private as an option on top doesn't sound like the boogeyman this is pitching it as to me. That seems like a great way to reduce the scope of what the state needs to be in charge of.
If the take is that government cannot possibly work for the people no matter what then yeah, all policy is bad.
Why is there always a supply-side shortage?
The AMA was concerned in the 90s re: "oversupply" of doctors and the impact on doctor salaries, lobbied the Republicans (around the "Contract with America" timeframe) and got language limiting NIH-funded residency slots codified.
The AMA is backpedaling on that stance now but the damage is already done.
This often proceeds over multiple rounds. And then either the company eventually pays, or the consumer has to pay and try to get reimbursed later.
You asked this question 30 minutes after even a casual reading of my other comment would have fully answered.
I would like to assume good faith, but your other comments indicate a high probability that you are an insurance company shill.
Why? Obvious if you know about the perverse incentive tqi mentions
I had an ACA "marketplace" plan back for my family back in 2017 when I was self-employed. My premiums were >$15K / year for a >$10K deductible and no tax credits (because of my income).
1. On average, how healthy is your group of ACA plan holders? If the group has a bunch of chronic conditions, they get more subsidy money to offset the increased care costs. Going to the PCP allows them to have official medical evidence of those conditions.
2. The government gives these plans quality ratings to help people compare them to each other. These ratings are partially based on how often patients get their annual screenings and patient satisfaction. A gift card for a PCP visit accomplishes both aims.
There are also more practical concerns. Preventative care is cheaper than an acute incident for the company. You'd rather catch an arrhythmia at a PCP appointment than pay for the cost of a heart attack.
It's literally Noah Smith, what did you expect?
bell-cot•1h ago
OTOH, this is a world where many people get yelling-and-cursing angry with a bottom-tier Post Office clerk in (say) Podunk, Montana over the latest increase in the price of 1st Class postage stamps. When that decision was made by a bunch of executives in Washington DC. Whose names the clerk doesn't even know.