15% Tax

Jim’s original “Healthcare cost and Maternity death” ratio is a good one to judge the effectiveness of those $ spent. “Healthcare cost and Obesity” I think is not.

They are both terrible indicators actually. Well, obesity is not an indicator at all - how fat people are has next to nothing to do with health care effectiveness. If people are obese, they will NEED good health care, but good health care won’t stop them from getting obese.

Maternal mortality rates are not quite as bad, but they’re still bad. Mothers die in childbirth for a variety of reasons, including poor maternal health care, but the quality of maternal health care is usually not the issue, in developed countries like the USA. Sometimes it’s a lack of access to maternal care, like if 3-4% of your population has no access to prenatal care - because they are living there illegally, for instance. That will do wonders for increasing your maternal mortality rates, but it has more to do with immigration policies, border control and the economic state of your neighbours than the quality of health care.

Other factors are involved in maternal mortality rates: obesity, income inequality, age of childbirth, for instance, all increasing the rates in the USA through no fault of the health care system.

Making the link between health care spending and maternal mortality rates (or obesity) is an easy way to criticize US healthcare, but it misdirects the argument, since no amount of health care reform will fix those problems.

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Jim’s original “Healthcare cost and Maternity death” ratio is a good one to judge the effectiveness of those $ spent. “Healthcare cost and Obesity” I think is not.

Hey, folks, it was just an example—one of a hundred metrics that would show roughly the same things compared to other rich places:
Health care in the US is in aggregate very expensive, the average outcome is not correspondingly high, and the quality is unusually variable across the population.

As for maternal mortality, it comes from two main things: how sick the person was going in, and how good the care was before, during, and after birth.
It’s a pretty good all-in-one measure of how well overall health is ultimately being achieved.
But only to a modest degree can the general daily health of the population be addressed by a health care system.

Jim

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Singapore healthcare cost to GDP 5.9%
Singapore obesity rate 8.9%
They must be doing something right.

Singapore / Population: 5,947,208

Demographics of Singapore: Ethnic Chinese at 75.9% , ethnic Malays (15.0%) and ethnic Indians (7.5%), collectively making up virtually the entirety of its citizen population (98.4%).

Singapore is very different from the USA, France, etc.

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My theory is that the reason inflation runs rampant in both of those markets (healthcare & education) comes down to a basic disconnect between who is the receiver of the service and who is he payer.

Also, these two industries have not had the inflation-suppressing effects of off-shoring the labor supply.

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Maternal mortality rates are not quite as bad, but they’re still bad. Mothers die in childbirth for a variety of reasons, including poor maternal health care, but the quality of maternal health care is usually not the issue, in developed countries like the USA. Sometimes it’s a lack of access to maternal care, like if 3-4% of your population has no access to prenatal care - because they are living there illegally, for instance. That will do wonders for increasing your maternal mortality rates, but it has more to do with immigration policies, border control and the economic state of your neighbours than the quality of health care.

Other factors are involved in maternal mortality rates: obesity, income inequality, age of childbirth, for instance, all increasing the rates in the USA…

Maternal mortality is actually an excellent indicator. One, there is no gender difference. Two, the distribution of age is fairly similar in industrialized countries. Three, the care given is pretty much the same around the world (at least around the industrialized, Western world). It is true that maternal mortality rate is a function of healthcare access. So our very high maternal mortality reflects something that is fundamental broken about healthcare access. We should ask why France, with universal healthcare, spends only 11% of GDP while the US spends 19% of GDP without universal healthcare? Why a county that spends 19% of its GDP (and also consider that our absolute GDP is significantly larger than all other countries, our total spending in absolute terms will be even higher) would still let “income inequality” and “economic state” affecting the outcome of maternal care?

In short, access is an important component when judging the quality of care. A service can only be considered as “good” if I can get it. I would never give a restaurant 5-stars if I could never get a reservation.

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A service can only be considered as “good” if I can get it. I would never give a restaurant 5-stars if I could never get a reservation.

You demolish your own argument. A restaurant can perfectly well be 5 stars without you having access to it. In fact, high quality restaurants are often hard to get into, whereas McDonald’s (and Cuban health care) are topnotch for access. If you starve on the sidewalk outside a great restaurant, the problem is not with the quality of the food.

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A service can only be considered as “good” if I can get it. I would never give a restaurant 5-stars if I could never get a reservation.

You demolish your own argument.

How? The argument is simple. If I am not able to get a service, for me, that service doesn’t exist. Saying there is a great hospital but it only accepts people who are 7 feet tall means, it is not available for most people. So why would someone who is not 7 feet is going to give 5 star rating?

That 5 star rating for most people is meaningless. To use your own example, if I am dying of hunger, and I cannot get food from that great restaurant, what good it is to me. I may go for even banning anything other than McDonald.

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Other factors are involved in maternal mortality rates: obesity, income inequality, age of childbirth, for instance, all increasing the rates in the USA through no fault of the health care system.

Making the link between health care spending and maternal mortality rates (or obesity) is an easy way to criticize US healthcare, but it misdirects the argument, since no amount of health care reform will fix those problems.

From a qualitative perspective, my experience is that the US healthcare system is not as good as other countries where I have had healthcare. Rather than argue the finer points, perhaps better to recognize that there are opportunities for significant improvement in the healthcare system. Lots of other countries have illegal immigrants, obese people etc., etc. My only experience with the US being comparable to top other countries is Medicare.

Craig who has had healthcare in USA, Canada, Australia, France, Russia, Japan, UK, Thailand, Nigeria, Ghana (some were better than others!)

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There are mountains of research comparing US healthcare cost-effectiveness with that of other countries, done by everyone from the OECD to McKinsey. The broad consensus is that, over all, the US system is far less cost effective than that of most Western countries, Japan, and a number of others. I recall that Berkshire, Amazon, and JPMorgan banded together to tackle this behemoth problem … and soon thereafter gave up.

The big cost drivers in the US system include high admin costs (paperwork, admin staffing), a large for-profit element that’s driven by billing for volume of procedures rather than for outcomes, and high pharma costs (incl. outsized advertising expense). The system also devotes an inordinately large fraction of total spend on expensive procedures on elderly patients that add little if anything to their quality of life (as noted in a prior post). The situation is hardly helped by the fact that the US has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths (esp. firearms).

The US “system” is in reality 3 systems cobbled together and largely an accident of history (as noted previously). For folks with great insurance and drug coverage (like me), it’s arguably the best system in the world, esp. if one requires state of the art care. For most of the year, I live walking distance from a world-class university medical center from which I receive excellent care (including twice for life-threatening medical issues) at very little cost (to me).

For most folks post-Obamacare, the US system offers decent health care but at an unnecessarily high price. Other systems worldwide provide better care at less cost: they eliminate much of the overhead, most or all of the profit skim, and keep costs within an overall annual budget.

As for the under-insured and uninsured in the US (about 1/8 of the population), they get little regular preventive care and show up in the ER when they’re very sick or badly injured. They’ll have bills trailing them for many years, much of which they’ll never pay off.

A good overview is: https://www.commonwealthfund.org/publications/issue-briefs/2…

Somewhat dated, but still useful: https://www.mckinsey.com/~/media/mckinsey/dotcom/client_serv…

Tons of data and reports here: https://www.oecd.org/health/health-care-quality-outcomes-ind…

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The US “system” is in reality 3 systems cobbled together…
… folks with great insurance and drug coverage…
…most folks post-Obamacare, the US system offers decent health care but at an unnecessarily high price…
…the under-insured and uninsured…

Another interesting way to look at is it the duality of private sector and public sector payers.
It’s easy to think of the US as a private payer system, but the various Medicare, VA, etc programs are themselves huge.
IIRC, the US public sector healthcare spending per capita alone exceeds the Canadian total spend per capita.
Then there is the whole US private payer system on top.

It’s a very big business overall.
As an investor, I’m a fan. And as I’m not a US taxpayer or purchaser of health insurance, no biggie for me.
Maybe not true: I think my private insurance includes an expensive extra rider to allow treatment in the US if it comes up.
I almost never go to the US, so I just think of it as the “fly to the Mayo if needed” fee.

Jim

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Three, the care given is pretty much the same around the world (at least around the industrialized, Western world). It is true that maternal mortality rate is a function of healthcare access. So our very high maternal mortality reflects something that is fundamental broken about healthcare access.

Yes, this is essentially my point. Maternal mortality rates say very little about the quality of health care, but they say a lot about access to health care. The proper counterargument to my point is not that US healthcare is of poor quality, it is that the total US population (including illegal immigrants) has poor access to the excellent health care that most Americans enjoy. (Whether this is cost-effective health care is another question. Obviously, there are diminishing returns to investments in health care, with exagerated end-of-life care a prominent example. It may be that wealthy countries like the USA choose to spend more wealth on health care, once they have looked after their other material needs, and this may not be such a crazy thing to do.)

If you are worried about access to good meals, the fact that you have restaurants that have earned a lot of stars doesn’t touch the question of whether people have adequate access to high-quality food. I don’t think there can be any serious debate about the excellent level of health care in the USA for people that have adequate coverage. I believe the problem is with the 10-20% of the population that has inadequate coverage, along with the serious epidemic of obesity that is clearly much worse in the USA than in other developed countries.

To illustrate how serious the obesity problem is, I calculated the average weight of (US) Americans, Canadians, French and Swedes last year, wondering whether the high covid mortality in the USA (pre-vaccination) might be partly a result of obesity. I don’t have all the references at my fingertips, but my results gave Americans as by far the heaviest (adjusted for slightly different heights from country to country), with Canadians about 10 pounds lighter, Swedes about 18 pounds lighter, and the French about 20 pounds lighter - this is the AVERAGE. Imagine what 20 extra pounds does to maternal mortality rates! Maternal mortality rates in the USA increased by more than 100% between 2001 and 2014 (https://bmcpublichealth.biomedcentral.com/articles/10.1186/s…), for instance, and I don’t think you could really make the case that this is because the quality of health care has gotten much worse.

dtb

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I’ve never understood why the poorest in the US wait for the emergency room. They should be on Medicaid, which takes care of everything. I’ve known a handful of people on it, including myself for a few years when I was disabled, and there were no bills and even medications were a fraction of what they are for Medicare folks.

The people who really suffer in the US are those who are above the Medicaid income limits and who live in a state that does not offer expanded coverage for those somewhat over the limits. And those who make too much to receive subsidies towards their premiums. Drug coverage can be a real backbreaker for these people, should they require something beyond generics. Those affected include anyone who received a deserved raise only to find out it’s kicked them out of the subsidy range and now their family of four must pony up for full freight, which negates the raises.

Not great, Bob!

SD

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I’ve never understood why the poorest in the US wait for the emergency room. They should be on Medicaid, which takes care of everything.

Medicaid coverage varies from state to state. There are a lot of poor people out there who do not qualify, and nor do they make enough to qualify for subsidies under the Affordable Care Act.

It’s a shame the Dems didn’t muster the votes to fix that problem in some way this go around. The Affordable Care Act originally solved that problem by mandating expansion of Medicaid to cover everyone with income below where the ACA subsidies kick in, but the Supreme Court threw that out.

A ‘simple’ fix would be to make the ACA subsidies available with no minimum income qualifier, but the Feds don’t want to do that because Medicaid is so much cheaper to offer, both for the government and for the people getting healthcare.

If I had the choice, I think I’d rather be on Medicaid than my ACA high deductible Blue Cross Blue Shield plan, but I’m not 100% sure. I guess the cost savings would outweigh the loss of choice, but I’d have to think about it.

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I’ve never understood why the poorest in the US wait for the emergency room. They should be on Medicaid, which takes care of everything.

Medicaid coverage varies from state to state. There are a lot of poor people out there who do not qualify, and nor do they make enough to qualify for subsidies under the Affordable Care Act.

I knew two people who you might think qualified for Medicaid, but are now both dead (and they were under 30 years old at the time). They were severely abused and their mother murdered when they were very young. They were “raised” by a schizophrenic grandmother until the local child-protective services removed them. The younger ones were put in foster homes and the oldest one in a mental hospital for a few years. They then aged out and were homeless.

There are programs for some homeless people, and what are what are known as “food stamps.” But to get food stamps, you have to have a place to live that has a refrigerator and a stove. And if you are homeless, you do not qualify. Sometimes they were in homeless shelters, but with their problems, they got drug problems and with that, they get kicked out of the homeless shelters. To get in to drug detox programs has a waiting list, and you cannot get into a drug rehab program (28 days) you must complete the detox program. And the rehab programs have even longer waiting lists. And they will not take you unless your Medicaid covers the entire 28 days, and in some states Medicaid only covers about two weeks. Meanwhile, you are homeless. If you are living on the street, in abandoned buildings, with a pimp, or anyplace you can find, your mental health and your physical health does not improve. When one of one of my friends was having severe pain problems, the Medicaid doctor would not prescribe pain medication until she got an x-ray, but she had to wait three weeks for an X-ray under Medicaid in her state. So she got pain med on the street and kicked out of the shelter for doing that.

One of them hanged herself and another died of a street drug. Medicaid does not take care of everything in the two states I am familiar with.

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In NC, impoverished adults do not get Medicaid, no matter how poor you are, unless you have minor children, or are disabled.

Hows that for a nice incentive to have kids in a bad situation?

NC has been turning down the opportunity to expand Medicaid with the Feds paying 95% of the incremental cost ever since Obamacare passed. It’s an ongoing tragedy for thousands of people in the state. It’s been hard on hospitals, forced to offer ‘free’ care in the emergency room for this population, with many rural ones closing in recent years, and other once good non-profit hospitals selling themselves out to large for-profit chains, as happened to my local hospital, with care abruptly getting much, much worse there.

NC legislators: not good at math. They’d rather ‘encourage’ the poor to pull themselves up by their own bootstraps than accept federal aid on their behalf. Kinda like cutting off one’s nose to spite your face, if you ask me.

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I’ve never understood why the poorest in the US wait for the emergency room. They should be on Medicaid, which takes care of everything. I’ve known a handful of people on it, including myself for a few years when I was disabled, and there were no bills and even medications were a fraction of what they are for Medicare folks.

A big factor is being able to navigate the process to qualify for Medicaid in the first place. I have helped someone with multiple cognitive issues - OCD, depression, anxiety, all bundled up with a big helping of executive function disorder - qualify for Medicaid and some other benefits programs. It involves a lot of documentation and paperwork. I believe that without my help, and that of their sibling, they would never have been able to navigate the system to receive medical coverage or housing assistance - and probably would have died on the streets years ago in misery and terror. Multiply that by millions of mentally ill people in the US who don’t have that much help, and I started to get a handle on what homeless people live (and die) with.

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I currently live in Texas, the poster-child for poor leadership on medical care for the poor. Current leadership under Gov Abbott has forfeited an estimate 100 BILLION in federal funds, mostly because they didn’t like Obama. Texas consistently ranks as one of the worst states for having the most uninsured, and we also rank deal last in the availability of prenatal care.

https://www.statesman.com/story/news/politics/politifact/202…

https://www.texmed.org/Template.aspx?id=59688

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oddhack: I believe that without my help, and that of their sibling, they would never have been able to navigate the system to receive medical coverage or housing assistance - and probably would have died on the streets years ago in misery and terror. Multiply that by millions of mentally ill people in the US who don’t have that much help, and I started to get a handle on what homeless people live (and die) with.

Kudos to you, oddhack.
I’ve observed the same, in a person with a similar “ecosystem” of challenges.

:+1:
ralph

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I’ve never understood why the poorest in the US wait for the emergency room. They should be on Medicaid, which takes care of everything.

Medicaid absolutely does not “take care of everything”. Dental coverage is crap, for example - one cleaning visit/year, good luck finding an office which takes it, and there’s a pretty good chance of the dentist letting you know how much contempt they feel for people on Medicaid, to boot, based on my friend’s experience. As for mental health coverage, almost nothing. You can get some group therapy and medications. If you go to Kaiser Permanente, for example, you’ll quickly find there are no therapists available - they outsource virtually all of it, the wait time for a single appointment is many months, and therapists qualified to deal with complex suites of problems are off in private practice making $300/hour.

So when you see that scary, toothless guy on the street yelling and mumbling to himself - maybe he’s just consistently made a lot of really poor choices that brought him to that point. But more likely he’s seriously ill and has found that there is literally no meaningful help available to him.

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Yes, this is essentially my point

Good. Yet you decide to keep arguing.

I don’t have all the references at my fingertips, but my results gave Americans as by far the heaviest (adjusted for slightly different heights from country to country), with Canadians about 10 pounds lighter, Swedes about 18 pounds lighter, and the French about 20 pounds lighter - this is the AVERAGE. Imagine what 20 extra pounds does to maternal mortality rates

How strange. You said maternal morality rates cannot be compared across countries because of illegal immigrants. But illegal immigrants are no longer an issue for comparing obesity rates across countries. I guess illegal immigrants are only an issue for data points that contradict you.

Let’s try to get to the point: Do you believe healthcare acceess is in crisis? A yes or no will do.