The Unique Hell Unleashed By Each Type of Health Care System
Choose your own dystopian nightmare!
The murder of UnitedHealthcare CEO Brian Thompson has ignited a discussion about health care systems. Some Americans covet the systems in Canada or many European countries, though people in those countries have chimed in to say “there are downsides.” Below are tales that I think are representative of the horror stories in each system. These tales are cartoonish and 100 percent made-up, but I think that the exaggerations are fair; the ridiculous elements all come from real-life problems.
Private provider, private insurer
You have a stomach ache. You immediately think “If I was my brother, I’d just end it right here and now,” because he doesn’t have insurance. Luckily, you do have insurance — you get it through your job. And as it happens, your spouse also gets insurance through their job, so you have a “spare” policy that does nothing for anyone except cause your household to make $10,000 less per year than you otherwise would.
You go to see your GP, and — just like always — she refers you to a specialist. You’re actually starting to wonder if your GP knows any words in English other than “go see a specialist”.
You call your insurance, and they have questions. Is your plan an HMO, PPO, OPP, or NAMBLA? What are the last 12 digits in your 20 digit ID number after the first 12 digits and excluding any letters or dashes, which are there for no reason at all? Do you have a notarized referral letter from your GP signed in blood and witnessed by six sworn federal judges? The insurance company sends you back to your GP for one more test, which turns out to be just her seeing how many tongue depressors she can stick up your ass. The answer is 20, and that satisfies your insurance, plus the pictures that the hospital puts on their web site net you $30 in “tips”.
Bad news, though: The specialist that your GP wants you to see is out of network. Your options are a guy one mile away from you who is being investigated by the International Criminal Court, or a guy widely agreed to be the best in the world, who is located on an oil rig 40 miles off the coast of Maine.
You go to see Oil Rig Guy. But you won’t actually see him — it turns out that he’s just the face of that consortium of doctors, sort of a Wizard-of-Oz-slash-Betty-Crocker type figure. You see one of his associates, who talks to you for two minutes and orders 50 tests. When you ask “Are all those tests necessary?” they look at you with puzzlement and ask: “You have insurance, right?” You leave without getting any treatment for your stomach, though you do set a new personal best with 22 tongue depressors.
You spend the next six months flying around the country getting tests, all of which are scheduled at 10:30 AM on work days. The tests mostly come back negative: You don’t have dropsy or Havana syndrome or hoof and mouth disease — your carburetor is fine. But one test suggests that you might have a disease that mostly affects intersex aboriginals over the age of 100. That doesn’t describe you, but good news: There’s a pill that cures that disease, so you doctor prescribes it.
Your insurance company balks at the pill, which is $600,000 per dose. Also, the pill is the subject of pending litigation, because a company has started making a generic that costs three cents a dose — it turns out the pill is just baking soda and lime juice ¯\_(ツ)_/¯!!! Of course, the pharmaceutical company points out that the pill cost $40 billion, 20 years, and the lives of 50 stout men to develop. While you wait for the lawsuit to play out, the insurance company demands more information: They want a full physical, and a list of everything you’ve ever eaten, and your entire family history going back to biblical times. They want to know if you’ve ever smoked, lived with someone who smoked, or watched Mad Men and thought that smoking looked kind of cool. Also: Why is a raven like a writing desk? They will pay your claim in full as long as you provide clear and honest answers to Thornak The Riddler, Regent Of Inquisitions And Out-Of-Network Claims.
Your claim is denied — it turns out your goose was cooked when you failed to fill in the “former employer fax number” line on your insurance application form. You drive to Mexico and buy the generic version of the pill, which causes you to grow a voluptuous set of breasts on top of your head.
The hospital sends you a bill for $32 million. When you ask why it’s so much, they point out that they’re legally obligated to treat the homeless guy who comes in with a fresh stab wound every day and the “young invincible” who will be in traction for 30 years after he chose not to buy insurance and then drove his speedboat off of Niagara Falls. Also, the AMA and American Society of Anesthesiologists will break the hospital’s thumbs if they don’t come up with $10 million by Friday. You hire a lawyer, and this inspires the hospital to send you a letter that says “How ‘bout you give us 60 bucks and we all walk away from this?” But then your lawyer gets disbarred for “liking” one of the rectal tongue depressor photos on the insurance company website, which turns out to be a violation of attorney-client privilege. So, you and the hospital reach a new agreement: You pay them $20,000 and your family’s credit is ruined for seven generations.
Also: Your stomach turned out to be fine — there was just a burr stuck to the inside of your sweater.
Private provider, public insurer
You have a stomach ache. You call your GP, who is 100 miles away and only accessible by dog sled. They schedule an appointment in 20 months, though they tell you that if your situation becomes life-threatening, you can see someone in 14 months.
Your GP wants you to see a specialist. When you ask “which one?” they say “Why, the only one in the country, of course!” And that specialist has bad news: The treatment you need is deemed “elective”. You wonder why that’s the case, so you do a little research and learn that it had to do with an omnibus bill that got stuck in Parliament in the ‘80s, and there was this arts funding rider and a controversial statement about the Falklands War, and long story short: Your thing is not covered by national health insurance. You write to your member of Parliament to complain, and they send you back a Parliament-themed coloring book.
You google “supplemental private health insurance in my area,” and the only thing that comes up is a Facebook page for a guy named Razor Dave. You message Dave, and he agrees to meet you down by the docks at 1 AM. When you get there, Dave has a few crumpled up health insurance policies laid out on a blanket. You choose the policy with the least amount of blood on it, pay Dave with a combination of cash, drugs, and sex, and voila: You now have insurance that will pay for six percent of your procedure!
OR…
You have a stomach ache. You call the hospital, and they immediately send a limousine to pick you up. You are rushed into the hospital and examined by a team of professionals while you’re given a complimentary pedicure and flute of champagne. Your stomach ache can be cured by a pill that costs $600,000 a dose, and when a nurse points out that a generic pill will do the same thing, a doctor smacks her across the face. The brand name version of the pill is provided free of charge, and you take it while being serviced by one of the hospital’s “climax induction specialists”.
Also: Your tax rate is 80 percent. Health care is just about the only thing your country does — other social needs are neglected, and your military is in such a sorry state that your country could be conquered by a dozen guys with pointy sticks. Doctors are fabulously wealthy, as are nurses, climax induction specialists, and the on-site sommeliers employed by every hospital. You sometimes wonder if it makes sense for your hospital to have an infinity pool and an IMAX 3-D theatre while your town doesn’t even have a library, but it would take an act of Parliament to change anything. And you think it’s strange that the doctors prescribed the $600,000 pill even after they found that your pain was being caused by a burr stuck to the inside of your sweater.
Public provider, public insurer
You have a stomach ache. You don’t want to wait 20 months for an appointment, so you go to the ER, which is in a building made of old milk cartons held together by Elmer’s glue. You spend three hours filling out forms and develop carpal tunnel syndrome because you had to press down really hard on the forms, which were on carbon paper — the hospital doesn’t have a Xerox machine.
Eventually, you see the doctor: He’s wearing sweatpants and a Mötley Crüe t-shirt. His first question is “are you a cop?” and his second question is “can you loan me some cash?” He examines you, but he really rushes through it after he gets a ride request — he’s also an Uber driver. He scrawls the name of a specialist on a McDonald’s wrapper and tells you to take it to the Ministry Of Kafkaesque Mindfuckery.
You spend several months completing the forms, mind puzzles, and tests of strength thrown at you by the MOKM. Luckily, after solving the riddle of The One Bureaucrat Who Always Lies And The One Bureaucrat Who Always Tells The Truth, your claim is approved! Unfortunately, the procedure you need is deemed elective and scheduled for the year 2036. So, you buy supplemental insurance from Razor Dave, who is now your country’s second-largest insurance provider, with millions of customers nationwide.
OR…
Once again, it’s limousines and champagne flutes all around! And this time, you can’t help but notice that many of the people providing service sort of look alike. And in fact, they all sort of look like…the Prime Minister! And that’s because your health care system has become a vehicle for graft by the power-holders in your country.
Your Prime Minister’s second cousin once removed refers you to your Prime Minister’s college roommate’s idiot nephew, who recommends you for surgery, to be performed by your Prime Minister’s favorite concubine’s great aunt. All of this is “free”, though, again: Your tax rate is 80 percent. Surgery goes very badly: Not only did your surgeon leave her reading glasses in your incision, but also your country was conquered by Guam while you were under anesthesia, because your military is just four guys armed with paper towel tubes.
If there’s a through-line here, it’s that stuff costs money. Some people imagine that getting the government involved in health care causes that care to be free and unlimited, and if you think I’m strawmanning: Check out this tweet thread. In reality, governments who get involved in health care — which is most of them — have to decide whether to constrain costs at the expense of service or provide generous plans that cost a fortune. There is no free lunch. And designing an optimal system requires acknowledging that reality.
If I were to design a system from scratch, I’d probably go public/public that offers a low baseline of coverage, and there would still be private providers and private insurance. I can see a billion potential problems with that system. But I think it might be the least bad, and in a part of the economy where the stakes are high and markets don’t function in a way we find acceptable, “least bad” is going to be the best we can do.
“Pay Every Claim” Is Not a Viable Model for Any Health Insurance Company
The murder of UnitedHealthcare CEO Brian Thompson has been met with shock, sadness, and, uh…unconstrained glee? Tweets, TikToks, and Facebook posts were overrun with comments along the lines of “LOL thoughts and prayers are OUT OF NETWORK 😂😂😂!!!” Aside from being unbelievably hack, isn’t that also deeply sick? I was recently conflicted about making
Rashida Tlaib and Jamaal Bowman Demonstrate How to Not Think About Economics
Rashida Tlaib and Jamaal Bowman have co-authored a bill. We really need to get them these t-shirts:
I've lived in the US most of my life but did spend several years in London and, as my (bad) luck would have it, my time in London featured a medical crisis that engendered extremely intense familiarity with the NHS. There are huge pros and cons comparing the NHS (public care, public funding) and the American system.
The huge pro for the NHS is, of course, the utter lack of concern over payment. My crisis involved a family member continuously hospitalized for more than 6 months, with lots of specialized treatment along the way. When it was all over, we just... walked out of the hospital. No need to talk with a billing supervisor, no hellish second act in which we tried to figure out how to prevent the bills from bankrupting us, nothing like that. I will never stop being thankful for that part of the system.
The huge con for the NHS is just how under-resourced the system is compared to the American system. NHS buildings, even hospitals, are almost shockingly shabby compared to their American equivalents. NHS facilities run out of basic supplies in a way that American hospitals never would (at one point we were staying in a NHS flagship hospital, which didn't have the resource constraints of most NHS facilities, and a nurse remarked to us that it was "rather royal" there because they never ran out of gauze pads or syringes). And the comparatively poor pay for doctors and nurses means that the NHS really struggles to recruit and maintain staff, in a way that impacts both wait times and quality of care.
US healthcare is much more expensive than other systems in large part because we've developed a system of providers and facilities that demand much more money than other nations. It's not all inefficiency and greed; we really do have a system that is higher quality in many ways (and that's not even touching on the fact that the US system effectively serves as the world's R&D center for new treatments and technologies, which US consumers pay for and the rest of the world free rides on). I don't think the US strikes the right balance, and am a fan of either state or national level single-payer options. But it's nonsense to suggest there are no tradeoffs, or that other nations' systems are obviously better.
As a comedic article this is a good exaggeration of the extremes out there. On a somewhat more serious note, this is what Norwegian health care looks like:
1. The national government owns and operates the vast majority of hospitals and most specialised clinics. Most health care is covered by taxes, including a lot of drugs, but with an annual co-pay limit of around 300 US dollars. When I recently had an ear infection, my antibiotics weren't covered under this co-pay rule, but they weren't too expensive, only a few ten dollar bills. ERs are run by the national government.
2. The county governments own and operate a lot of the dental health clinics. Dental is not covered by the government, and is essentially completely privatised but with a public option. The county dentists do provide free dental to children, and now the Socialist Left Party has negotiated funding for 75% deductions for adults up to the age of 28 from next year.
3. The municipal governments run some basic family health clinics, own and operate most of the GP-offices, and run most elder care as well as long term care for people with with serious lasting health issues and cognitive developmental disorders. There's often some form of co-payment in all these, but they all mostly have the same annual co-pay limit as the national health service. Urgent care is municipal.
4. Private health care exists on all levels. There are private specialised clinics, private hospitals, private GPs, private dental, and private care homes. Some of these private institutions work within the public health services, some exist as almost completely parallel services which are mostly funded by employers. Some key companies are Aleris, Dr. Dropin, and Volvat.
The private insurance sector mostly exists for high paying jobs and/or key leadership positions. The quality of the public health services is mostly pretty good, but as with almost all public health care wait times can be an issue, so the private health insurers allow for "jumping the queue".
The OECD reported nearly 8000 US dollars in per capita spending (PPP) for 2022, whereas the US was at 12,500. Our lower spending probably has little to do with it being a mostly public payer public provider system, and more to do with it being a coherent system. The Netherlands and Germany both have private providers and private payment, but lower per capita spending than both Norway and the US.
One major issue with Norway's health care system seems to be income for health care professionals. The exhausting nature of the work, combined with relatively high education, means we're lacking qualified workers in large parts of the country, and due to taxpayer funding simply raising the salaries to attract workers isn't as simple as it could be in the US.
Edit: Also, as a listener of Colonel Andrew Heaton's podcasts, I feel obligated to point out how European health care is taken care of at the country level. There's the European Health Insurance Card which guarantees free or affordable health care when visiting another EU/EEA country or Switzerland, but otherwise health care is a national thing, not a (con-)federal one. As such, if the US were to emulate Europe, it would be a mistake to think the Norwegian or Dutch health care systems could be placed onto a continent sized country of 330 million people, doing it on the state level is essentially a must.