An Article of the Modern Survival Guide
Hi, you’re reading the Modern Survival Guide! This is a long-running blog that tries to keep track of things that you, the modern person, might need to know about living in our crazy, chaotic, baffling modern world. And hoo boy. Have we got a doozy today.
For the last few entries I’ve been cranking out this mini-series on major crises which affect the US. If you live in the US, these affect you. If you don’t, thank your lucky stars and I’m sorry you have to deal with whatever your local version of national crises happen to be; every nation has some.
In the last few articles we covered political instability, the downfall of the US national narrative, inflation, the national debt, and the current housing crisis. This time around I’m diving into the mud pit that is an attempt at objectively reporting the state of the US healthcare system.
Ok, here’s the main thrust, and I’ll save you some reading: if you don’t have insurance or have bad insurance, and need a serious procedure done, go to Mexico. Or India. You will save enormous sums of money and get the same or better quality treatment, even if you have to fly there, even if you have to stay there for months. Both of those countries have a whole industry for American medical tourists. Seriously.
Here’s the secondary thrust, and I’ll save you some more reading: if you are from a country with socialized healthcare, keep it. If anyone tries to privatize your healthcare system, whatever you do, do not believe any of their promises. Run them out of town on a rail. Be told.
The more in-depth story is that Americans currently suffer from one of the most exploitative wealth extraction systems in the world, and it’s called the US healthcare system. This article will cover several of the ways it’s generating poor quality of care for Americans and make a brief mention of basically the only thing we can do about it — universal healthcare.
Let’s dive in.
The Big Problems with US Healthcare
The US does not have the best healthcare system in the world. Let’s lead with that, because there’s quite a lot of evidence to support this conclusion, including reports released by the US government.¹ Nor do we have the worst. What we have is the most expensive health care system in the world, and the costs do not equate to quality.² This is a serious indictment on our entire society, and it needs to be addressed.
There are a few different problems with US healthcare, they generally boil down to four big points (which is to say, this isn’t necessarily an exclusive list), and I would put them in roughly this order of priority:
- Affordability and insurance
- Accessibility and equity of care
- Administrative efficiency and tracking
- Variable quality of care and care outcomes
Each of these is nuanced and I’ll address them separately.
Affordability and Insurance
The US has the most expensive healthcare in the world. This is not an opinion. It is a fact. Even accounting for cost of living, the price tag each household, on average, pays for US healthcare is enormous. Healthcare spending in the US topped $4.2 trillion in 2021. That is a simply huge number, considering that the US GDP in 2021 was about $23 trillion. Most people spent about 12% of their paycheck on healthcare, or about $13,000 per person, which is also a huge number and, if you notice, not in line with the overall spending compared to GDP.³
For comparison, most Canadians spent the equivalent of about $5,500 US dollars on healthcare in 2022.⁴
Now, the important thing to note here is that the US number was with insurance. And the important thing to note about US insurance is that the insurance companies aggressively negotiate with healthcare providers. This is how you can get those wild claims reports that show a hospital charging something like $137,00 and the insurance paying them $15,000, and the hospital stops asking for more money. I made those numbers up, but this a common thing in the US and everyone here has seen a statement like that.
The kicker is that if you don’t have insurance, you don’t have bargaining power, and you are screwed. The hospital can and will charge you whatever they feel like, and if you want to live, you have to pay them. This is why I say go to Mexico or India if you don’t have insurance. You can fly to India and have heart surgery for less than $15,000. That’s a lot of money, but it’s a lot less than the hundreds of thousands of dollars a US hospital will charge you as an uninsured on under-insured person.
It’s important to remember that in the US, people routinely go bankrupt due to healthcare costs, and everyone in the US knows this. What I didn’t know before I wrote this article was that 40% of US bankruptcies are due to healthcare costs.⁵ Forty. Percent. Good grief.
And why, oh why, is US healthcare so expensive? The answer is insurance, greed, and lack of competition and oversight.
Insurance is a fine idea in theory to protect things that you value. Insurance is not a fine idea to protect things that are necessary for life. Those are different considerations. Remember that insurance is a profit-based business. Their incentive is to extract the maximum amount of money from their customers while paying as little as they can get away with, which is why you get news articles about companies like Cigna auto-denying claims.⁶
Insurance drives up the price of healthcare for the average person and increases the cost of providing care because doctors have to become insurance experts in addition to being doctors. It’s not unusual for doctors and insurance companies to bounce claims back and forth until they are paid, which means the providers have to build the cost of that delay into their care bill.
Insurance also drives up the cost of health care for individuals because most insurance plans in the US, particularly low-premium plans, have deductibles: money that the consumer has to pay, out of pocket, before the insurance will pick up the bill. For low-income families who cannot afford high-quality insurance, the deductibles can be devastating and in many cases negate the point of having insurance in the first place.
Finally, insurance tends to represent an insidious and hidden cost in American healthcare because most people get insurance through their jobs. They never really see how much insurance is costing them, because their premium comes out of their paycheck automatically. This is a problem because it helps to obscure the cost, and consequently confuses the debate, on healthcare in general. One of the big arguments against socialized healthcare, for example, is that it costs too much. You have to remind people that it’s not a question of how much universal healthcare would cost, it’s a question of how much it would cost compared to what they are already paying for insurance.
There is also the simple element of greed on the part of healthcare providers. Most hospitals in the US are non-profit, but most hospitals in the US are also scamming both the US government and the American citizen by claiming that status. Non-profit hospitals are not really non-profit, is the takeaway. As per normal, unless you have a cap and effective monitoring on this sort of thing, the people at the top try to take the money.⁷
Of course, there are also for-profit hospitals, which make up about a quarter of the US market share, are growing in market share, and have consistently delivered sub-par performance. This is because quality care is an expense, and any for-profit enterprise seeks to cut expenses. That’s just capitalism. This is has resulted in high cost without high quality, and we’ll discuss more on why in a moment.⁸
Finally, we come to lack of competition and lack of oversight. One of the big theoretical selling points of a private healthcare system is that people can look at their options, weigh the costs, and make the best choice. That only works if competition is available, and if you can get access to quality of care metrics.
First off, finding any kind of quality of care metric for US hospitals is very difficult. Actually that’s half-true; you can find ratings online. The catch is whether or not you can trust them. Some of the best-rated hospitals in the nation have certain units where you would not want to be.
The bigger issue with competition is that most places in the country have immediate access to one hospital, or maybe an urgent-care unit, at best. We are currently suffering from a serious problem with rural hospital closures, in part because of COVID-related issues, in part because it’s inefficient to run rural hospitals, and in part because both of those points combined with certain states’ laws make it unfeasible to offer services.
That means that there are huge swathes of the country that are effectively in a medical desert, which is to say a monopoly situation. Capitalism has only one thing to say about monopolies. Monopolies do not, historically, result in quality when left to their own devices, and this is certainly true for the American healthcare system.⁹
This would not necessarily mean that quality of care should suffer (just price), except that we do not appear to be enforcing particularly good standards for quality of care in this country. For example, there are no comprehensive laws that effectively limit the number of patients a nurse can have at a hospital, with predictable consequences. I should note that this isn’t a complaint against private industry or universal healthcare, it exists independent of both. Quality care doesn’t just happen. As with any other human enterprise, if you want quality, you have to have effective auditing.
Hospitals have tons of auditing, don’t get me wrong. It’s simply that audit effectiveness appears to be significantly lacking, because any finding results in the equivalent of a slap on the wrist if you’re the only healthcare provider in town and not subject to managerial consequences as a result of an audit. If you want to affect a person’s behavior, hit them in their pocketbook. If you want to affect corporate behavior, you have to hit them in the pocketbook and the boardroom.
Accessibility and Equity of Care
There’s no getting around this, not everyone in America has the same access to healthcare. That should be immediately obvious from the prior discussion: if your access to care is dependent on the quality of your insurance, which it is for most of us, and if your access to insurance is dependent on your job, which it is for most of us, some of us are going to get the shaft.
I’ve already talked about rural hospitals, but there’s an equally important case to be made about quality of care for different racial groups within the US. The black community, for example, is now and has been routinely underserved by the healthcare industry.¹⁰ Same for the Hispanic community in general, and for most minority communities in the US for that matter. This has remained true despite the ongoing growth of these communities.
The reasons why are manifold, and range from simple racism to systemic racism to economic reasons. Again, any hospital that is charging patients for care is going to go where the money is, and that may not be a poor community, which in the US means minority communities. But we can’t and shouldn’t discount racism. Try to get opioid pain medications as a black person with sickle cell anemia in a US hospital. I dare you.
There’s another big problem with accessibility of healthcare in the US, and it is that the US healthcare system is teetering on the brink of a staffing apocalypse. This was true going into COVID, and it’s been worse coming out of COVID (if we can be, in fact, said to be coming out of COVID, which is debatable).
It’s increasingly hard to find general practitioners, for example, because it’s not profitable to be a general practitioner. Nurse practitioners are on the rise everywhere in the US — not to say anything against them, but this is an outcome of the lack of GPs, and while the verdict isn’t entirely in, the quality of care seems to have suffered as a result. Speaking of nurses, it’s increasingly hard to find a properly staffed nursing roster at any given hospital, because nurses are expensive and hospitals cut costs wherever they can. And you basically can’t find an example of a hospital that is fully staffed with techs.
This is a serious problem, as the availability of healthcare is one of those things that will determine, for obvious reasons, whether you live a happy and productive life. Valuing the lives of all our citizens is supposed to be something we are in favor of, as Americans, and yet it’s not something that is reflected in our healthcare reality.
Administrative Efficiency and Tracking
I’ve written about pieces of this issue before, and here’s the TLDR summary: you are, almost entirely, responsible for keeping track of your own healthcare in America. Appointments, priorities, communication between offices and hospitals — it’s all on you. This is a big problem, especially given the amount of money we pay for healthcare, because it puts the onus of care planning almost entirely on the patient. We don’t have a national healthcare registry. We don’t have a cross-specialist tracking system or program. We are, as a nation, lacking almost every tool needed to make this problem go away.
Now, for those of you who are shouting “FREEDOM” in the back of the room, who think that this is a good thing because it means you can tailor your own care: sit down. You don’t know what you’re talking about, and it shows. The whole point of having doctors is to have people in society who are trained to address the absolutely mind-boggling array of ways that the human body can go wrong. I don’t have the training to do it. You don’t have the training to do it. Let’s be humble, admit what we don’t know, and move on.
Even the people who have the training to do it don’t always get it right (but they stand a damn sight better chance that you or I). Doctors are subdivided into innumerable specialties because a GP doesn’t know enough to deal with everything involving neurobiology, for example. The body is a fearsomely, awesomely complex piece of machinery, and you are almost certainly not qualified to decide the path of medical care to fix even the most minor problem.
Let’s go ahead and plug that into our brains as a given, shall we? I don’t care how much you Google, you are not a healthcare expert. I’m not either. You have to be a seasoned practitioner expert to be able to make key healthcare decisions, such as:
- Do I need a follow-up appointment for this rash?
- How long can I wait before I go from my GP to my oncologist about that screening test?
- If my leg hurts, do I need to see an orthopedist, an immunologist, or a neurosurgeon?
- Am I taking my medication at the right intervals, in the right dosage?
Each of these questions requires a specialist, and those are both hard to find and hard to get to in America. There are several reasons why, but the biggest one is that the administrative staff of doctors’ offices in the US do not give the first shit about helping you once you leave their office. They do. not. care. Because it’s not their job. You’ve already paid them; their job is done, their scope has been met. It’s now your job to set up the next appointment, and here’s the kicker: most offices won’t even recommend that next specialist, because they don’t know your insurance well enough to know who’s in your network. It’s not their job.
YOU ARE GOING TO SCREW THIS UP. I have. Everyone I know has. The research says a disturbingly high proportion of us do with each incident, and we should keep in mind that this kind of thing compounds.¹¹ American life is not set up to make it easy for us to monitor what we have to do next in healthcare while also holding down a job and attending to the tasks required to support a family. Time is a limited resource.
What this means in practice is that tons of people are wandering around procrastinating setting up life-saving or life-enhancing appointments because they can’t find the time to do it, or it’s too much mental load, or they’re not sure what they’re supposed to do next. This has certainly been true in my life. And no one — no one — is helping them by default. You have to go looking for help, which is also a sink of time, knowledge, and mental load.
People die as a result of this. Frequently. In my own life, I’ve known several people who died as a direct result of having the burden placed on them to somehow know what to do next in their care — including my own father.
Any kind of tracking system is preferable to none in this case. A national healthcare registry would instantly save lives, as would a national prescription database and some sort of requirement that the offices involved in a patient’s care make a good faith effort to get them to the next specialist in the chain.
Variable Quality of Care and Care Outcomes
The previous sections lead up to this last point, which is that depending where you are and who you are in the US, you will get vastly different qualities of healthcare. You will literally live or die by this. All of us will, and it’s not a question of if, it’s a question of when, because that’s how health works: it doesn’t get better with time. Sooner or later, you will be in the grip of the US healthcare system if you live here.
If you are a rich white person, you have someone you can pay to manage your healthcare, and you live in an affluent area with good hospitals nearby, you will probably live to a ripe old age and have a good quality of life. It’s certainly medically possible to do so in this day and age, and the US has some of the best hospitals and doctors on the planet. Provided you have the time and experience, or can pay someone to navigate these waters, and have the money to pay the bills, you can do quite well. You will not be denied care, you will flit through the various medical systems on a cushion of cash. Life is good.
If you are a poor black person, you are going to have a rough time. Your life expectancy on average is a decade or so less than your white counterparts.¹² “On average” is a really nasty turn of phrase here, because it means that a significant proportion of people are going to die much younger than their white counterparts; decades, plural, rather than a decade, because that’s how averages work.
And even in the best hospitals in the US, even in the best healthcare systems, your quality of care will vary significantly, because the catch is that we don’t have “good hospitals” in the US, and we don’t have a good “healthcare system.” We have multiple healthcare systems, often operating out of the same hospital or the same region, and they are bad at talking to each other. Communication is literally lifesaving in healthcare, and the US systems are terrible at it.¹³
Finally, due to that last point and the aforementioned problems with doctors’ offices caring about you once you leave their premises, when you get home your care responsibility devolves right back to you. You’d better hope that the dysfunctional communications system provided you with enough information to manage your own care, which it frequently does not. This is a significant contributor to poor post-care outcomes in the US.
Fixing the US Healthcare System
To sum up, US healthcare can be very good, but is frequently frustrating, typically suboptimal, and always expensive. It seems like a very complex, very confusing topic, because it is. There’s no getting around that. Every discussion of healthcare is, by default, a discussion of applying limited resources to a nearly infinite problem.
This is the basis for most of the attack ads that run against the best available solution to the US healthcare systems’ problems, which is universal healthcare. Universal healthcare offers a solution for almost every problem in the current US system, because most of the problems with US healthcare stem from not having a centralized tracking and communications system, being reliant on insurance, and having a very profit-focused care provider network.
Universal healthcare can establish a centralized healthcare tracking network, removing or mitigating a large number of administrative problems which cause such tragic consequences in the US currently.
Universal healthcare removes the average citizen’s reliance on insurance, which means you don’t have to have a job to get access to good care. It also means you don’t have to deal with negative incentives like deductibles.
Universal healthcare pays doctors a living wage while removing overhead costs from their responsibility set, and removes the added burden of navigating insurance, which encourages doctors to actually work in areas of need which would not be otherwise profitable.
And universal healthcare means that medical providers are being paid to provide care, not being paid by the visit, which provides a better incentive for them to care about you over the long term.
Would it be expensive? Sure. Would some people be denied care for some procedures? Of course. Would it be more expensive than our current system? NO. Not by any accounting. Does your insurance already deny care for some procedures? You bet your ass it does. So all universal healthcare has to do is beat our current insurance-based system in cost and care availability, and it wins. That’s a pretty low bar.
To be slightly sarcastic about it, this is such a complex problem that every industrialized nation except the US has come up with a workable solution. That’s not to say they are perfect solutions, because there is no perfect solution. Stop asking for one; perfection doesn’t exist. But every other industrial nation on this planet offers its citizens better access to healthcare overall than the US, and it’s embarrassing that we haven’t followed suite.
The problem goes back to the attack ads. People in the US are predisposed to reject anything that comes with the label of “socialism,” and this is the very definition of a socialized system. Any mention of universal healthcare in the US is immediately met by a howling horde of right-wing pundits screaming about death panels and shouting up every single flaw of every single national healthcare system around the world. These same pundits conveniently ignore the legion of horror stories that anyone with the internet can quickly find about US healthcare outcomes.
Folks, part of the point of writing a series called the “Modern Survival Guide” is to call out this kind of hypocritical BS. So, to be entirely clear for my US readers: we don’t have the best healthcare in the world. Not even close. Every single other industrialized country to which I have traveled in my life, and some of the third-world countries for that matter, offer better access to healthcare than the average American citizen. Period, full stop.
Whenever someone from any conservative movement criticizes universal healthcare, the only question for them that matters is if they have a better plan. And we already know that privatized care is worse — we’ve been living that experiment for seventy years. The results are pretty solid. Make no mistake, a fair few of the problems with universal healthcare systems internationally stem from conservative parties in other countries sabotaging their national healthcare systems by cutting costs and personnel.¹⁴
So let that be our lesson: no matter what healthcare system we choose, it should be well-staffed, well-funded, and accessible to all. The easiest, most effective way to do that — by far — is a universal healthcare system. Every year we have the opportunity to implement this in America. Every year we fail. It’s past time for us all to lean on every single one of our elected representatives to do the right thing for America and get us out of the creaky, expensive, tragically inept healthcare system that we all currently live with.
¹Some sources include:
Mirror, Mirror 2021: Reflecting Poorly
The 2021 edition of Mirror, Mirror was constructed using the same methodological framework developed for the 2017…
How does the quality of the U.S. health system compare to other countries? - Peterson-KFF Health…
The coronavirus pandemic has resulted in millions of cases across the globe. The United States has one of the highest…
How Good Is the Quality of Health Care in the United States?
Quality of health care is on the national agenda. In September 1996, President Clinton established the Advisory…
²Some sources include:
Trends in health care spending
Learn about current trends in healthcare costs in the US. Here you'll find answers to questions like "how much does the…
The National Health Expenditure Accounts (NHEA) are the official estimates of total health care spending in the United…
³Some sources include:
Percent of median income spent on health plans U.S. 2020 | Statista
In the United States, average employee premium contributions and deductibles as a percentage of median household income…
New State-By-State Report: In 37 States, Workers' Health Insurance Premiums and Deductibles Take Up…
Although employer health insurance coverage has proved to be relatively stable during the COVID-19 pandemic, the costs…
⁴As reported by the Canadian Institute for Health Information:
National health expenditure trends, 2022 - Snapshot
Back to National health expenditure trends November 3, 2022 - A summary of key findings from CIHI's National Health…
⁵As reported by the National Library of Medicine:
⁶As reported in ProPublica:
How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them
When a stubborn pain in Nick van Terheyden's bones would not subside, his doctor had a hunch what was wrong. Without…
⁷As reported by Open the Books
Forbes: Top U.S. Non Profit Hospitals and CEOs are Racking Up Huge Profits
The rising cost of healthcare is undermining the American Dream. Families who are working hard to get ahead now pay…
¹⁰For more reading on this topic, see the following:
Understanding and Addressing Racial Disparities in Health Care
Racial disparities in medical care should be understood within the context of racial inequities in societal…
Racism and Health
Racism is a system -consisting of structures, policies, practices, and norms-that assigns value and determines…
3. Black Americans' views about health disparities, experiences with health care
Black Americans offer a mixed assessment of the progress that has been made improving health outcomes for Black people…
¹⁴Britain is the classic example of a nation self-sabotaging a working system. https://www.independent.co.uk/voices/nhs-crisis-covid-privatisation-funding-b2255741.html