talk today about why healthcare costs in the United States are so phenomenally, fascinatingly
expensive, but first I have to blow your mind: Alright, so you've probably heard that the
reason that people enjoy "free" healthcare in Australia and the UK and Canada, etc, etc
is that they pay higher taxes. That money then goes into a big pot and is used to pay
for people's healthcare, but in fact, in the US, we spend more tax money per capita on
healthcare than Germany, Australia, the UK, or Canada. That's right Hank: you pay more in taxes for
healthcare than you would if you were British, and in exchange for those taxes, you get no
healthcare.
In fact, only about 28% of Americans get their
health insurance through government funded programs, mostly poor people, old people,
and Congresspeople. But as you can see in this graph our private healthcare spending
(most Americans are privately insured through their employers) is WAY higher than anywhere
else in the world. In total, the US currently spends about 18% of its gross
domestic product on healthcare costs. Australia by comparison? 9%.
Why is this? Well because everything costs
more, which seems obvious, but apparently isn't, because every article you read is like
"Oh it's because of malpractice insurance" or "it's because we're obese" or we go to
the doctor too much or people are prescribed too many medications. Well, not really. It's because everything costs more. A hip
replacement in Belgium costs $13,000.
In the US it's often over $100,000. Colonoscopies
average over $1100 a piece in the US; in Switzerland they're $655. And on average a month of the
drug Lipitor will cost you $124 if you live in the US. If you live in New Zealand? $7.
Now we are alsonot to bragricher than
all of these countries, so it makes sense that we should spend a little more on healthcare.
But we don't spend a little more. We spend a ton more. And vitally, we don't get anything
for that money, which means we are essentially paying people to dig holes and then fill those
holes back up. Like we don't live longerin fact we're 33rd in life expectancyand in
everything from asthma to cancer, according to one recent nonpartisan study, American healthcare
outcomes are "not notably superior." So why are we spending all of this money for
nothing? Well first, let's discuss some of the problems that are not actually problems.
For instance, the problem is not so-called
"overutilization:" the idea that Americans go to the doctor more and get more tests and
spend more time in hospitals. We know this because Americans actually go to the doctor
less than Europeans and spend much less time in hospitals, although to be fair, you can
stay in a Dutch hospital for seven nights for what it costs to stay in an American hospital
for one night, so no wonder we're hesitant. Also it is not because we're sicker than other
people. Everyone likes to blame obesity on our rising healthcare costs, but yeah, no.
That argument is just not supported by data.
For one thing, disease prevalence does not
affect healthcare costs that much. And for another thing, while we do have more obesity
in the United States, which sometimes leads to health problems, we have fewer smokers
and less alcohol consumption (really? Apparently yes). So that saves us a little money, and
if you compare us to like the British or the French, in the end it's probably a wash. Hank, the truth, as usual, is complex.
Like,
there are obvious inefficiencies in our healthcare system. For instance, not everyone has insurance.
If you don't have insurance, you still get healthcare, but you're responsible for paying
for that healthcare, which often you can't do, so you end up going bankrupt. That sucks
for you, obviously, because you're bankrupt, but it also sucks for the rest of us because
we have to pay not only for your care, but also for all the money the hospital spent
trying to get you to pay for your care. Also the only options available to uninsured people
are usually the most expensive options, like emergency rooms, which is just BANANAS.
But those
inefficiencies are hard to measure. Fortunately, there are things we can measure. So like I said before, because the US is one
of the richest countries in the world, you would expect us to pay a little more for healthcare
than most people. The question is, when do we pay MORE than you would expect us to pay,
and that turns out to be pretty interesting.
Let's start with malpractice and so-called
"defensive medicine." The idea here is that doctors are scared of huge malpractice suits
so they order a lot of unnecessary tests in order to, like, cover their butts. That
does contribute to our healthcare costs, like there are more MRI and CT scans in the US
than anywhere else. However, there are a bunch of states like Texas that have passed tort
reform to limit malpractice suits, and in those states healthcare costs have dropped
by an average of a whopping 0.1%. The biggest estimates for the total costs of defensive
medicine put it at around 55 billion dollars, which is a lot of money, but only 2% of our total
healthcare costs.
Another smallish factor: doctors (and to a
lesser extent, nurses) are paid more in the US than they are in other countries, and by
my possibly-faulty math we end up spending about 75 billion dollars more than you would
expect us to there. And then we have the cost of insurance and
administration costs, like paperwork and marketing and negotiating prices. That's about 90 billion
dollars more than you would expect us to spend. We spend about $100 billion more than you
would expect on drugs, not so much because we take MORE of them, but because the ones
we take cost more per pill.
Okay, and now for the big one. I'm gonna lump
inpatient and outpatient care together, because in the US we do a lot of things as outpatient
procedures, like gallbladder surgeries, that are often inpatient procedures in other hospitals.
We're just gonna make a big ball [gestures]. That big ball is $500 billion more than what
you would expect given the size of our economy. Per year.
Why? Because in the United States we do not negotiate
as aggressively as other countries do with healthcare providers and drug manufacturers
and medical device makers. So like in the UK the government goes out to all the people
who make artificial hips and says "One of you is going to get to make a crapton of fake
hips for everybody who is covered by the NHS. Here in the United Kingdom. But you better
make sure your hips are safe, and you better make sure that they are cheap, because otherwise
we're going to give our business to a different company." And then all the fake hip companies
are motivated to offer really low prices because it's a really huge contract.
Like think if
your company got to put hips inside of everyone in England and Scotland and Wales
and Northern Ireland (I guess not everyone. Just the people who need hips). But in the US we don't have any of that centralized
negotiation, so we don't have as much leverage. The only big exception is Medicare, the government-funded
healthcare for old people, which, not coincidentally, always gets the lowest prices.
So basically, Hank, in the United States,
providers charge whatever they think they can get away with, and they can get away with
a lot, because it's really difficult to put a price on, like, not dying. This is a phenomenon
called "inelastic demand," like if you tell me that this drug will save my life costs
$7 a month, I will pay you $7 a month for it. If you tell me that it costs $124 a month,
I will find a way to find $124 a month to pay for it. You can't negotiate effectively
on your own behalf for healthcare services because you NEED them.
And not like you need
a Macbook Air or the new season of Sherlock, but actual, physical need (I guess it is like
the new season of Sherlock). So basically, Hank, until and unless we can
negotiate as effectively with the people providing healthcare as Australians and British people
do, US healthcare costs will continue to rise faster than anywhere else in the world and
we WON'T get better healthcare outcomes. Hank, I know this video is long, although
it could have been much longer, but I am so tired of people offering up simple explanations
for what's wrong with our healthcare system. They say "Oh, it's malpractice," or "it's
doctors who must also be businesspeople" or "it's insurance companies" or "it's insane
rules for who can GET insurance." It's drug companies, it's government bureaucracy, it's
an inability to negotiate prices.
Yes, yes, yes, yes, and YES! It is all of those things
and more! It is not a simple problem, there will not be a simple solution, but it is probably
the biggest single drag on the American economy and it's vital that we grapple with it meaningfully
instead of just treating healthcare costs as political theatre. So I hope I've at least introduced the complexity
of the problem. I've put some thoroughly nonpartisan links in the doobly-doo for further reading.
Hank, welcome back to the United States. As you can see, everything is peachy here.
I'll
see you on Friday. Friendly reminder, educational videos are allowed to be more than four minutes long. All of the people who are commenting about how punished I am did not watch to the end of the video.
I feel dizzy..
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