# Why is healthcare in the USA such a clusterfuck? **URL:** \ **Category:** Great Debates\ **Created:** [June 6, 2015, 6:20pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805 "2015-06-06T18:20:43Z")\ **Posts on this page:** 20\ **Page:** 7
**Author:** ![carnivorousplant](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnivorousplant/32/3563_2.png) [@carnivorousplant](https://boards.straightdope.com/u/carnivorousplant)\ **Post date:** [June 12, 2015, 7:02pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/121 "2015-06-12T19:02:20Z")
> [@RickJay](#): > > Prescription drugs aren’t part of the Canadian health insurance system. I wonder how much [simponi](http://www.simponi.com/ankylosing-spondylitis/homehttp://www.simponi.com/ankylosing-spondylitis/home) goes for in Canada. It costs $1,000 per dose here. I’m sure there is a guy at my insurance company with the sole job of coming up with a reason to dump me. 🙂 ---
**Author:** ![Novelty\_Bobble](https://avatars.discourse-cdn.com/v4/letter/n/a3d4f5/32.png) [@Novelty\_Bobble](https://boards.straightdope.com/u/Novelty_Bobble)\ **Post date:** [June 12, 2015, 9:16pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/122 "2015-06-12T21:16:49Z")
> [@carnivorousplant](#): > > I wonder how much [simponi](http://www.simponi.com/ankylosing-spondylitis/homehttp://www.simponi.com/ankylosing-spondylitis/home) goes for in Canada. It costs $1,000 per dose here. I’m sure there is a guy at my insurance company with the sole job of coming up with a reason to dump me. 🙂 It is probably the same as for the UK, i.e. free. Or perhaps the local prescription rate of £8.40 at worst ---
**Author:** ![carnivorousplant](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnivorousplant/32/3563_2.png) [@carnivorousplant](https://boards.straightdope.com/u/carnivorousplant)\ **Post date:** [June 12, 2015, 9:37pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/123 "2015-06-12T21:37:50Z")
> [@Novelty\_Bobble](#): > > It is probably the same as for the UK, i.e. free. Or perhaps the local prescription rate of £8.40 at worst Darn it, I can’t move to the UK because of that gun ownership thing. 🙂 ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [June 12, 2015, 9:54pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/124 "2015-06-12T21:54:00Z")
> [@carnivorousplant](#): > > Darn it, I can’t move to the UK because of that gun ownership thing. 🙂 You can own guns in Canada. ---
**Author:** ![carnivorousplant](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnivorousplant/32/3563_2.png) [@carnivorousplant](https://boards.straightdope.com/u/carnivorousplant)\ **Post date:** [June 12, 2015, 9:58pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/125 "2015-06-12T21:58:52Z")
> [@Wesley\_Clark](#): > > You can own guns in Canada. Yeah, but it’s damn cold. There is of course, the Band and Levon Helm. :dubious: ---
**Author:** ![KarlGauss](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/karlgauss/32/3713_2.png) [@KarlGauss](https://boards.straightdope.com/u/KarlGauss)\ **Post date:** [June 12, 2015, 10:29pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/126 "2015-06-12T22:29:31Z")
I know I am more than late to this thread but, FWIW, will still add my two cents. In particular, there are a couple of factors at play with respect to US health care that have yet to be mentioned but that drive up the costs, needlessly. The first is that in countries with UHC, doctors often play the role of gatekeeper. And that can keep costs down. For example, in Canada, you won’t get in to see a specialist (and so won’t go on to receive all the very expensive testing that specialists do) unless you’ve been referred to one by your family doctor. You can’t simply say, “Hmmm, I had a palpitation, better see a cardiologist”). No, you must ‘convince’ your GP that a consultation with a specialist is justified. This has the effect of preventing unnecessary and even frivolous use of the health system (both of which I think are far more prevalent than many people realize). In contrast, as I understand it at least, anyone can arrange to see a specialist in the US so long as they, or their insurer, pays for it. Unlike in Canada, there is no prerequisite of actually _needing_ the consultation for medical reasons. The second point (which I may well have missed when I skimmed through the 125 posts of this thread) is that in the US, considerable costs are generated solely as a result of medicolegal considerations. All types of unnecessary (and expensive) tests are performed simply to cover the MD’s ass. This can become a self-perpetuating problem. Specifically, if the standard of practice is to perform coronary angiography on all middle-aged men with chest pain, then failure to do so is, by definition, a failure to meet the standard of care. The key, though, is that the ‘standard’ evolved not on the basis of evidence, but strictly on the basis of what the other physicians were doing (the so-called ‘reasonable man’ criterion). Rephrasing, even if it makes no sense to do angiograms on certain people, and even if there’s no medical evidence to justify the intervention, the physician is compelled to do the test regardless - otherwise he hasn’t met the standard of care and leaves himself wide open to lawsuits should the patient experience a bad outcome. Alas, there is virtually no way (in Canada, anyway) of rewarding those docs who decline to play the game and, by doing so, save the system a boatload of money. Two cents, two points. FWIW. ---
**Author:** ![carnivorousplant](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnivorousplant/32/3563_2.png) [@carnivorousplant](https://boards.straightdope.com/u/carnivorousplant)\ **Post date:** [June 12, 2015, 11:32pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/127 "2015-06-12T23:32:09Z")
> [@Novelty\_Bobble](#): > > It is probably the same as for the UK, i.e. free. Or perhaps the local prescription rate of £8.40 at worst I am curious how they manage that. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [June 12, 2015, 11:52pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/128 "2015-06-12T23:52:08Z")
> [@KarlGauss](#): > > I know I am more than late to this thread but, FWIW, will still add my two cents. In particular, there are a couple of factors at play with respect to US health care that have yet to be mentioned but that drive up the costs, needlessly. > > The first is that in countries with UHC, doctors often play the role of gatekeeper. And that can keep costs down. For example, in Canada, you won’t get in to see a specialist (and so won’t go on to receive all the very expensive testing that specialists do) unless you’ve been referred to one by your family doctor. You can’t simply say, “Hmmm, I had a palpitation, better see a cardiologist”). No, you must ‘convince’ your GP that a consultation with a specialist is justified. > > This has the effect of preventing unnecessary and even frivolous use of the health system (both of which I think are far more prevalent than many people realize). In contrast, as I understand it at least, anyone can arrange to see a specialist in the US so long as they, or their insurer, pays for it. Unlike in Canada, there is no prerequisite of actually _needing_ the consultation for medical reasons. > > The second point (which I may well have missed when I skimmed through the 125 posts of this thread) is that in the US, considerable costs are generated solely as a result of medicolegal considerations. All types of unnecessary (and expensive) tests are performed simply to cover the MD’s ass. This can become a self-perpetuating problem. Specifically, if the standard of practice is to perform coronary angiography on all middle-aged men with chest pain, then failure to do so is, by definition, a failure to meet the standard of care. The key, though, is that the ‘standard’ evolved not on the basis of evidence, but strictly on the basis of what the other physicians were doing (the so-called ‘reasonable man’ criterion). Rephrasing, even if it makes no sense to do angiograms on certain people, and even if there’s no medical evidence to justify the intervention, the physician is compelled to do the test regardless - otherwise he hasn’t met the standard of care and leaves himself wide open to lawsuits should the patient experience a bad outcome. Alas, there is virtually no way (in Canada, anyway) of rewarding those docs who decline to play the game and, by doing so, save the system a boatload of money. > > Two cents, two points. FWIW. The second point sounds like what Atul Gawande found when he compared medicare costs between high and low spending areas. The high spending areas did more procedures and more expensive ones, but health didn’t really improve because of it. As for the first point, it depends on the system. Many systems do not have gatekeepers. Taiwan has no gatekeeper system and they spend about 7% of GDP. Japan is the same, you can visit a specialist directly w/o going through a PCP. I’m sure lots of systems do not have gatekeepers. ---
**Author:** ![filmstar-en](https://avatars.discourse-cdn.com/v4/letter/f/50afbb/32.png) [@filmstar-en](https://boards.straightdope.com/u/filmstar-en)\ **Post date:** [June 13, 2015, 1:44am UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/129 "2015-06-13T01:44:11Z")
In the UK the local doctor, the General Practitioner is the gatekeeper to the world of specialists and consultants. There is a big dividing line between the public facing GP and the hospital based doctors. Generally the medical hierarchy that dominate hospitals and consultancies look down from a great height on the local family doctor. The UK NHS was formed in 1948 and it still has a lot of artifacts that came from the compromises it had to make with the Medical profession to get it off the ground. I have heard that the minimum charge for a visiting a US doctor is about $100 to cover the cost of various vitamin shots and other treatments and procedures they have to perform to ensure they are not vulnerable to negligence claims. In the UK, a visit to a GP will average about 7minutes and really they are oriented towards dealing with the very old and very young. You don’t go to a doctor unless there is something wrong with you. I get the impression that in the US, health insurance tends to encourage people to maximise the benefit they get from their expensive insurance premiums. After all, what is the point of paying for an insurance policy unless you make a claim when you think it is necessary? In the UK, a GP or hospital doctor or consultant can prescribe drugs. The price is the same, whatever the cost. Drugs are prescribed according to rules set by an NHS organsiation called NICE (National Institute for Clinical Excellence). They have a list of drugs and rules for their prescription. You are not going to get any drug treatment that costs a $1M a shot if it extends you life by 6 months. They look at the big picture and whether a drug treatment is value for money. This is a major control on costs. The US system seems to invite elaborate and expensive treatments irrespective of their cost and benefit. I am sure the patients liked it. Interestingly, until recently, the French Healthcare system allowed patients to shop around looking for the best doctor or consultants. Again, it was a very popular with the French, who are famously hypochondriac. People would swap the cards of their favourite specialists. But…their health system became too expensive, so I don’t think they can do that anymore. There is big temptation for people to incorporate health care into their lifestyle and social routine if they feel so entitled by either insurance or a comprehensive universal scheme. No health service could afford all of the demands and expectations placed on it. There has to be some moderating influence. The US system seems to be only moderated by the ability of people to pay for the comprehensive insurance cover required and this gets spent on a great many treatments that are not required or have dubious benefit. There is no escape from death and taxes. ---
**Author:** ![carnivorousplant](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnivorousplant/32/3563_2.png) [@carnivorousplant](https://boards.straightdope.com/u/carnivorousplant)\ **Post date:** [June 13, 2015, 2:02am UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/130 "2015-06-13T02:02:04Z")
> [@filmstar-en](#): > > In the UK the local doctor, the General Practitioner is the gatekeeper to the world of specialists and consultants. I thought it worked that way in the USA. My “Primary care physician” sent me to the pain guy who gave me simponi and stopped the pain and effects of ankylosing spondilitis. ---
**Author:** ![Novelty\_Bobble](https://avatars.discourse-cdn.com/v4/letter/n/a3d4f5/32.png) [@Novelty\_Bobble](https://boards.straightdope.com/u/Novelty_Bobble)\ **Post date:** [June 13, 2015, 8:17am UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/131 "2015-06-13T08:17:49Z")
> [@carnivorousplant](#): > > I am curious how they manage that. **filmstar-en** has covered it pretty thoroughly. Treatments, whether expensive or not, are funded through a single pot of cash and apportioned by medical need. You only get it free if there is definite benefit for you and the medical practitioners have no incentive to push expensive treatments with only marginal benefits. Need cutting edge cancer treatment that is massively expensive but will cure you? You’ll get it at no cost and it doesn’t matter whether you are prince or pauper. Of course none of that stops anyone with masses of cash funding it themselves if they so wish, they just won’t have the NHS funding it for them. ---
**Author:** ![amarone](https://avatars.discourse-cdn.com/v4/letter/a/e0b2c6/32.png) [@amarone](https://boards.straightdope.com/u/amarone)\ **Post date:** [June 13, 2015, 12:13pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/132 "2015-06-13T12:13:57Z")
> [@carnivorousplant](#): > > I thought it worked that way in the USA. My “Primary care physician” sent me to the pain guy who gave me simponi and stopped the pain and effects of ankylosing spondilitis. It depends on your insurance. Some plans require a PCP, others do not. ---
**Author:** ![up\_the\_junction](https://avatars.discourse-cdn.com/v4/letter/u/f1d935/32.png) [@up\_the\_junction](https://boards.straightdope.com/u/up_the_junction)\ **Post date:** [June 13, 2015, 2:23pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/133 "2015-06-13T14:23:21Z")
It’s also worth noting the current Gov in the UK is intent on driving down the cost of the NHS even further. Some might even argue they have a mandate to try quite a range of things. I think this is interesting from a US pov because it indicates the extent to which the national health budget can be centrally controlled, is scrutinised in minute detail, and ultimately is democratically accountable. As Churchill said about democracy - UHC is the worst healthcare option, except for all the others. ---
**Author:** ![Clothahump](https://avatars.discourse-cdn.com/v4/letter/c/51bf81/32.png) [@Clothahump](https://boards.straightdope.com/u/Clothahump)\ **Post date:** [June 13, 2015, 2:30pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/134 "2015-06-13T14:30:27Z")
The start of the clusterfuck was the introduction of Medicare. We had a reasonably well-working system up to that time. It had issues, but nowhere near what we have now. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [June 13, 2015, 2:52pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/135 "2015-06-13T14:52:46Z")
> [@Clothahump](#): > > The start of the clusterfuck was the introduction of Medicare. We had a reasonably well-working system up to that time. It had issues, but nowhere near what we have now. US health spending has always been higher than other nations but it wasn’t until the 80s that it took off and went into its own category. Medicare was passed in 1965. [![](http://graphics8.nytimes.com/images/2009/07/09/business/econgraphic3.jpg) ](http://graphics8.nytimes.com/images/2009/07/09/business/econgraphic3.jpg) ---
**Author:** ![filmstar-en](https://avatars.discourse-cdn.com/v4/letter/f/50afbb/32.png) [@filmstar-en](https://boards.straightdope.com/u/filmstar-en)\ **Post date:** [June 13, 2015, 3:51pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/136 "2015-06-13T15:51:16Z")
That graph is very interesting, it shows the US health expenditure started to take off at the beginning of the 1980s. [http://dpeaflcio.org/the-u-s-health-care-system-an-international-perspective/](http://dpeaflcio.org/the-u-s-health-care-system-an-international-perspective/) This article suggests three reasons: Big rises in chronic conditions related to obesity. High cost of new technology and drugs. High administration costs. Suddenly America got fat and the health system responded with lots of expensive treatments and bigger bills. Other countries must have gotten fat as well, but the health systems managed to contain the costs. I guess that is related to the fact that the US has a much higher level of private health care, that is not constrained by public budgets. So, all you have to do to fix this is…tax fat people? ---
**Author:** ![up\_the\_junction](https://avatars.discourse-cdn.com/v4/letter/u/f1d935/32.png) [@up\_the\_junction](https://boards.straightdope.com/u/up_the_junction)\ **Post date:** [June 13, 2015, 4:08pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/137 "2015-06-13T16:08:38Z")
Sure, the US is the only country with fat people. And the graph/link above showed cost of drugs is not a significant driver. That article is a nonsense - it’s ‘admin’, you know, all that insurance paperwork … right. ---
**Author:** ![up\_the\_junction](https://avatars.discourse-cdn.com/v4/letter/u/f1d935/32.png) [@up\_the\_junction](https://boards.straightdope.com/u/up_the_junction)\ **Post date:** [June 13, 2015, 4:15pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/138 "2015-06-13T16:15:58Z")
> [@Clothahump](#): > > The start of the clusterfuck was the introduction of Medicare. We had a reasonably well-working system up to that time. It had issues, but nowhere near what we have now. I don’t know how this works. Is Medicare still charged by professionals at the same rate as private work? ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [June 13, 2015, 4:35pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/139 "2015-06-13T16:35:10Z")
The obesity rate in Australia & New Zealand are almost as high as the US and they spend half what we do on health care. Every other wealthy country also has new technology and drugs to pick from. It isn’t like the US health care system is star trek compared to the rest of the world. Blaming fat people or medicare are pet theories, not actual solutions. ---
**Author:** ![Northern\_Piper](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/northern_piper/32/5304_2.png) [@Northern\_Piper](https://boards.straightdope.com/u/Northern_Piper)\ **Post date:** [June 13, 2015, 5:10pm UTC](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805/140 "2015-06-13T17:10:31Z")
> [@madsircool](#): > > It certainly doesnt work great. There are long waits and ever increasing costs. There are no good healthcare systems because people are living a lot longer and it costs the system a lot more money the older they get. Actually, the Canadian experience is that with targetted reforms, costs can be controlled while wait lists are cut: [How Canada’s health care reformers quietly bent the cost curve](http://healthydebate.ca/opinions/defying-expectations-how-health-care-reformers-quietly-bent-canadas-cost-curve) > [@](#): > > Health spending in Canada grew by only 2.6% this year, according to the Canada Institute for Health Information (CIHI). That’s a far cry from the 7% annual spending increases between 2000 and 2010. > > This is the fifth straight decline in the growth rate and the third year that per capita health spending has dropped in real terms. As a percent of GDP, Canada spends 11.2% today, down from a high of 11.6% three years ago. It’s fair to say that health care spending in Canada has essentially flat-lined since the economic downturn of 2008-09. > … > Well, looking at the most successful province, Ontario, the numbers are striking. For three years in a row, health care spending has increased by about 2% each year, less than the growth rate of the economy. As a percentage of GDP, Ontario is spending 6/10 of a percentage point less on health care than three years ago. > > Quietly and effectively, Ontario policymakers have tackled each of the major cost areas within the system. For example, spending growth rates for hospitals, for physicians, and for drugs are down dramatically due to structural reforms in the system. > … > Most importantly, while spending has come down, Ontario appears to have maintained timely access to care. Surgical wait times declined by about 8% this year and Ontario now has the lowest wait times in the country. CIHI reports that the standardized mortality rate in hospitals has dropped by 11% over the last three reported years in Ontario. There is little evidence that access or quality has suffered over the past four years as we have wrestled real growth in spending close to zero. [Previous page](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805.md?page=6) [Next page](https://boards.straightdope.com/t/why-is-healthcare-in-the-usa-such-a-clusterfuck/721805.md?page=8)