I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.
But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.
I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.
As a non-american (from South America) who lived in both USA an Europe:
Yes, in USA you get much more money, like you said 2x~5x, but then:
University is expensive as fck.
Health care is expensive as fck.
You have 5 days of paid sick leave per year in most companies.
You have 10 days of paid holidays per year in most companies.
In contrast, in Europe:
University was cheap or free.
Healthcare is cheap and universal.
If you are sick you are sick, either the company or the health insurance pay.
You have between 20 and 30 days of paid holidays.
This is why quality of life in Europe, is so superior. And again, I am saying this as a non-European.
One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $60K/year tuition prices. US universities charge on a sliding scale based on the applicants' families' ability to pay.
For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.
For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.
That said, it's entirely possible or someone to go out and sign up for bad investment private university with no aid and rack up $300K of debt by graduation if they're not paying attention to anything, but it's a myth to think that everyone does this.
The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.
> For an extreme example: Harvard's tuition is nominally $60K per year, but for families earning $200K or less it's $0. Many prestigious universities follow similar patterns resulting in a large percentage of students paying no tuition, the middle ground of students paying some fraction, and a small number of students from wealthy families subsidizing everyone else.
As someone from a country (Sweden) that to a larger extent has decreased people’s reliance on their families, and grown the welfare state instead, it’s weird to think that your parents wealth or income should have any impact on things like tuition, once you’ve reached the age of majority
Once I finished high school, my parents had nothing to do with my business as far as any institutions were concerned, and vice versa. But uni was tax-funded and free at the point of use. And when they get too old to care for themselves, it will likely be the government supporting them financially, not me (unless I strike it rich first, in which case I suppose they’ll spend their sunset years in style)
There's always this subtext that Europeans solve these problems just by caring more about human values, but the truth usually involves interesting sets of tradeoffs. So in Europe the norm, besides free university, is extensive tracking: in the US, your choice of major is essentially a consumer decision, where in many European systems it's fixed at a relatively early age by your performance on things like the Abitur.
I'm not saying the European system is bad. Certainly there's a lot to complain about with a system that asks 18 year olds to make life-defining decisions about both their career and their financial prospects. But the differences do go beyond whether or not you're on the hook for your tuition.
I don't quite understand what you mean by "tracking". Speaking of Germany, because you mentioned the Abitur. Yes your ability to enter certain universities and studies depends on your performance during the Abitur. That is to enter e.g. law or medicine at you chosen university immediately (there is a wait time multiplier, so you can wait if you don't get in immediately) requires a certain grade point average. However I don't understand how this is different from SAT scores in the US (except for maybe the ability to bypass SAT requirements by being super wealthy, but I'm not sure that would be a good thing). In my experience kids in the US tend to be obsessed about their university choices much earlier than the ones in Europe.
Also talking about Germany, unless things changed dramatically in the last few years, most natural sciences and engineering degrees don't require a grade point average.
I can mainly speak for Sweden, but basically the answer there actually is ”everybody who wants to and meets the minimum requirements (essentially having graduated high school)”
Sweden has higher gross enrolment in tertiary education than the US, and a larger proportion of older students (people who go back later in life to progress their education or change paths)
I’ve heard that in countries like Germany people are often ”locked in” by choices they’ve made at an early age. There’s an element of that in Sweden too (more vocationally-focused high school programs may not give you all the courses that you need to enter all university programs), but that is not too onerous to overcome if you change your mind later (you can do ”foundational studies” to bridge the gap, or just sit exams to prove that you’re qualified)
Edit: but it’s maybe also to your point that universities have limited seats, just like everywhere. Maybe your high school grades or score at the equivalent of the SAT aren’t high enough to study mathematics at the top-rated institution even if you’re qualified, because there are too many people ahead of you. But you will be able to go to uni somewhere to study something
Yes, but Americans have an incredible amount of student loan debt too. Something like $1.7 trillion. If you can get into one of the best schools in the world that has a huge endowment, then sure, you'll get grants and whatnot. It may even be free, in the case of Harvard. But then there's a long tail of schools that are honestly not that great, charging only slightly less than the top schools per year, with smaller aid packages, and kids sign up for crazy loans because they think they have to.
Personally I think the government should get out of the business of these loans, fully fund state schools to make them all free, and let the private schools and the private banking market deal with the rest of it. We were going down that path in CA until Reagan killed it when he was governor. [1]
Public service loan forgiveness (PSLF) exists and a huge number of people in medical professions actually take advantage of it. I know of multiple medical students and residents with over $500k in debt that are in the process of having all of their loans forgiven after 10 years in training and a total cost of approximately $75–150k for their entire education. Sure, that's still a decent amount of money, but it's very much worth the ROI.
IIUC, there was a bit of a scandal where the companies the DoE where paying to manage those 10 year forgiveness plans where giving incorrect advice and so a lot of people aren't going to qualify.
Lots of hospitals are nonprofits, and doctors can make lots of money working at hospitals. There is no income cap for PSLF IIRC, as long as you're working for a qualifying entity (including nonprofits).
Anecdotally, it's worked out for a number of friends and people on /r/PSLF. There's definitely poor communication around PSLF, but it is a real program.
Yes, but I also know plenty of people that can't afford the loans that they have. I have friends and family that after a decade or more of repayment still owe the same amount they did when they got out of school. Some aren't paying theirs at all. It's going to be a problem, as only a third of borrowers are actually making payments [1], and debt forgiveness isn't going to solve the root of the problem.
Of course we can blame them for taking $60k out for studying something that will never get them a good paying job, but these are 18 year olds. I was lucky in that my parents are immigrants and were like "absolutely not, this is crazy, go to the flagship state school and study science". I paid off my $24k in loans in a couple years. Many didn't take that path.
Yes, granted it was over 20 years ago, but I came from a pretty broke household in the United States, and I went to a cheap state school instead of a nicer university or private school because I couldn’t imagine borrowing for school. The folks I know who were much more well off, seem to have had no problem borrowing what I considered to be exorbitant sums to both pay for school and live off of.
> For those who don't attend the prestigious universities with large endowments, average in-state state-run University tuition is under $10K, though again a large percentage of students receive some form of aids or grants to bring that number down even further.
This is an extremely important point that keeps getting ignored. People keep comparing _public_ schools in Europe to _private_ schools in America.
To further your point, just about every place has a community college where you can do the first two years of your education for about half the price of the state school. The total tuition for this route (2 years at community college, 2 years at a state school) is going to average just under $30,000 for 4 years. Which is definitely in the "work your way through college" range.
And this is before any financial assistance, which the majority of students receive.
Foreigners talking about how crazy expensive college is in the U.S., but they're likely mislead by people who took out large loans to go to extremely expensive private colleges. There's an easy way to stop this kind of debt - don't allow federal loans for private institutions. But no one is really interested in stopping it.
>People keep comparing _public_ schools in Europe to _private_ schools in America
Not necessarily the case. In Sweden private schools are paid for by the government, assuming they have been approved by the CSN (central agency for study-support(rough translation))
I don't know how that works in the rest of Europe, because I've never studied outside of Sweden. But in Sweden it doesn't really matter if the school is private or public. The only instance you have to pay yourself is if the school isn't sufficiently good to pass muster.
Also, again in Sweden at least, but possibly other parts of Europe as well, the tuition isn't effectively $0. The government will pay any student enrolled in higher education a monthly support. Back in my day it was 10k SEK per month (roughly 1000usd), no strings attached. Not sure how it currently stands but I imagine it hasn't changed much.
This money is meant to ease the burden on students, so that they can put more focus on studies.
"Working your way through collage" over here means you'll have a 20% job to pay for your cost of living minus the 10k SEK mentioned above.
The difference in cost of study is quite real, even taking your comment into account
One thing that's hard to understand from the outside is that almost nobody actually pays those mind-blowing $200K hospital bills. US hospitals charge on a sliding scale based on the applicants' families' ability to pay.
(I don’t mean to belittle your comment about universities which is factual and helpful. I’m just pointing out that US education system is just as fucked up as the US healthcare system the OP is talking about.)
Even people in the US don't understand why those $200K hospital bills aren't real.
Insurance providers (including government programs) have a fixed limit for what they pay for procedures. They pay min(billed_amount, allowed_amount) so providers don't want to risk leaving money on the table by having billed_amount < allowed_amount. To ensure this doesn't happen, they bill an arbitrarily high number with the expectation that insurance will lower it down to some much smaller number.
So every time you see posts on the internet where people talk about their "$200K hospital bill" they're always talking about that arbitrarily high value. If you have to pay cash for some reason, they will reduce the value to the cash pay amount which is in line with the insurance paid numbers.
Nobody ever pays those high hospital bill amounts.
That depends a lot on your insurance. For example, our out of pocket for my son's birth was somewhere in the neighborhood of $10k after insurance. I've met tons of people who would be bankrupted by that amount. What you're describing isn't true for people on High Deductible Health Plans, and those plans are a bit of a racket because they're frequently paired with HSAs where the employer gets to pocket anything left in the account at the end of the year. My son was essentially unplanned, in the sense that we gave up on trying to have a kid but weren't using birth control because over the previous 3 years we had not had a successful pregnancy. So an HSA would have been no help for us.
HSA funds are meant to roll over. Your employer generally should not be pocketing whatever's left over in the account. The idea is that many (most?) people are better off with a lower premium and higher deductible given that most years (for most people) aren't characterized by high medical expenditures; HDHP+HSA is closer in nature to actual "insurance", rather than a structured financing plan for health care.
HSAs are triple tax advantaged retirement accounts. Not taxed on contribution, gains, or withdrawals for qualified expenses. In the worst case it becomes like a pretax IRA because after age 65 you will not pay a penalty on non qualified expenses - but qualified expenses tend to increase with age. For many it should be their primary retirement account.
Even for people with certain chronic conditions (not in perfect health), depending on how good/expensive the PPO offered by the employer, it might still work out better to do HDHP/HSA.
You can get as many basically free HSA accounts from Fidelity.
HSA is your money like a retirement account is. It’s one of the most tax advantaged ways to save money.
More or less all high income earners who do not have a chronic health issue are better off choosing a HDHP paired with a HSA - especially if the company provides any sort of matching benefit. Keep that account as an additional retirement account and pay out of pocket for most healthcare needs.
Think of it also as actual insurance vs. a pre-paid health plan.
The math of course changes for folks who are not highly paid, or have expensive chronic health conditions that would result in maxing out the deductible each year.
You are likely thinking of a FSA which is use it or lose it.
FSA is just a 30%-ish discount on medical expenses. It is useful for eye glasses and such. A lot of QoL services qualify for FSA, including weight loss coaches and therapy.
Heck my (prescription) meta ray bans were paid for in part with FSA funds.
You are I are both commenting on a subthread started by a comment that included "What you're describing isn't true for people on High Deductible Health Plans, and those plans are a bit of a racket because they're frequently paired with HSAs where [...]", none of which is true. I don't care about FSAs and am not trying to argue with anybody about them, but that preceding comment is very wrong about HSAs and HDHPs.
Note that another word that straightforwardly describes this behavior is "fraud". Medical bills aren't like a bill from a car mechanic where there is a contract (either written or at least implied because the mechanic will readily give you estimates and quotes).
In the medical context, the only contract in the picture is possibly between the medical provider and the healthcare management organization. It would be fine if providers only sent the fake bills to them as they're both willingly playing this perverse game.
But the problem is when they send their fake numbers to patients as if they're some kind of legitimate bill. Medical bills to patients are presented on a "cost reimbursement" basis - helping you cost them this much, so you are responsible for reimbursing them. By inflating the numbers 3-5x they are straight up lying about the costs they incurred. That's fraud.
>The average US college student graduates with around $30-40K debt depending on whether they go public or private, which isn't all that hard to pay off when our wages are already significantly higher than other countries. We're especially lucky in tech where our compensation differential relative to other countries more than makes up for the cost of university education.
This is such a weird excuse for bad policy. Making more money[0][1] somehow means its okay to saddle students with an average debt of $30-40 thousand dollars. A downpayment on a first home would be a much better use of that money, for example.
Really, the average US citizen is nickel and dimed to death with this sort of thing, from health insurance, to dental, to lots of other required but not accounted for as required costs (like cars and associated car insurance).
Not to mention, we have little safety net in the US, you're really going to hurt if you have a bad run of luck after job loss. No qualms in allowing people to become homeless as a matter of policy.
If someone were to ask me, I would say that we in the US have it completely backwards in respect to how the average citizenry is expected to live. Its not thriving, its constantly having some kind of lingering potential disaster to plan for.
[0]: which I sincerely wonder about the true veracity of this statistic
[1]: Don't forget too, that more and more struggle to pay their student loans each year and the trend has generally been that its getting worse, not better.
What policy are you referring to? Cost-conscious students can (and most should) stay in-state, do their first year or two at a city/community college (my kids knocked out core STEM classes there --- over summers, not for cost reasons --- and found the teaching markedly better), and then transfer into a commuter university. The "average" student debt owed primarily by the top income quintile in this country and captures the cost of out-of-state selective university, which are a luxury good.
The implicit policy that student loans are an acceptable and benign form of debt for the average citizen. Everything said after is predicated on this idea.
It's very funny to see the US perspective here. $30-40k debt for a new graduate of an average university sounds crazy expensive to virtually everyone outside of the USA, I would bet. I paid $0 for my university, as did most of my colleagues, but even if I had had to pay the tuition, it would have amounted to $4k total for a 4-year bachelor's degree, or $6.5k total for a 6-year bachelor's + master's, at one of my country's premier state universities (and consider that private universities are a joke here, just diploma mills).
Granted, none of the top universities in my country even makes it to the top 500 in the world, so maybe this isn't a completely fair comparison? Actually, it's expensive by some other EU country standards - public schools in France and Germany, including PSL (ranked 28th in the world) and TUM (ranked 22nd), are free for all EEA applicants, with some nominal yearly registration fees (amounting to $1k in total for a 4-year degree). A more expensive school, like ETH Zurich (rank 7 in the world), is $4500 total for a 4-year degree if you're a Swiss citizen or EEA citizen with a Swiss work permit; it's triple that for an international student.
So yeah, when we say "university is crazy expensive in the USA (and probably UK too)", we're actually talking about the $30-40k numbers you're looking at. $200k and so are almost inconceivable to us.
> $30-40k debt for a new graduate of an average university sounds crazy expensive to virtually everyone outside of the USA
That's the cost over 4 years. Most people will be able to get financial assistance to help pay for that and you easily manage to make 30k (or less with grants) in 4 years to pay for school. People making below 35k per year are going to pay practically zero taxes. You can work about 15 hours a week making $10 per or full time over the summer to pay for that.
There's no need to take on any debt.
People in the US make considerably more money than those in the EU and, generally pay less taxes so there's a lot more disposable income available. I think people here prefer to be able to just get what they can pay for rather than hope the government will let them pursue the education they want (there are aptitude tests and quotas in some EU countries).
It's not really better ir worse, it's just different.
There are aptitude tests of some kind and quotas for all good universities everywhere in the world. Harvard won't admit 100k students in a year if they randomly decide to join, nor will they accept a student without a stellar record (apart from legacy admissions, of course). And I would bet you whatever you want that you'll get a much better salary fresh out of college in Europe with a bachelor's from the Technical University of Munich (total cost: around $2000 if you're a citizen of an EU country), or TU Delft in the Netherlands (total cost: around $9000) than you will in the states with a degree from a random college that doesn't even have to bother with admissions tests.
Sure, if you're a brilliant young mind and can get into Harvard and qualify for assistance with your tuition, you're set for life, basically, in a way no EU university can match. But for the vast majority of the population, the outcomes are significantly better with the EU system.
Also note that the gigantic tuitions at US universities are actually a relatively recent phenomenon (and a similar thing happened in the UK). Even in the 50s and 60s, tuitions were much closer to the current EU norm.
Any good university will have a limit to how many students it can absorb. A professor can't teach 1000 students in a class, not well. So you either have a university that can accept ~any number of students and function as mostly a diploma mill; or a university that actually cares about teaching students and thus must have a selection process.
Of course, there is some room between these extremes, especially for unpopular subjects where you hardly even get enough students to fill up a professor's time. And in those cases, you'll also see that EU systems will essentially accept anyone. Typically, for uncompetitive universities and subjects (majors), the only condition is to have passed (gotten at least 50%) for the local equivalent of the SATs - a very low bar.
> almost nobody actually pays those mind-blowing $60K/year tuition prices
This is not true at all.()
You quote tuition at the school with the highest endowment in the country. The college cost situation is absolutely still high at the less endowed second tier, and “ordinary” (non-generational wealth, two full time earner) families are paying full price.
() Except in the sense that “almost nobody” goes to any of these schools, comparing to the 50k enrollment at large public institutions.
If this were true, the number of Americans I have known who moved to Europe would be roughly equal to the number of Europeans I have known who have moved to the US. That's not data, that's anecdote. But what is the European country where more people go there from the US than come to the US from there?
USAians are not exactly famous for commonly speaking most European languages at a level that would allow them to resettle to the respective European countries. This makes for a considerable barrier that essentially doesn't exist in the opposite direction.
I have never heard this term before, but to clarify what I mean (it's so weird to bring race into this!): I have worked with dozens of native born dutch, german, french people etc. and lots of latin people etc. But I know almost very few that I grew up with, went to school with, who moved from the US to another country. I am not saying this is good, the US is good etc. I am saying you have to understand the revealed preference vs what people tell you.
I wouldn't be surprised if this changes in the future, I am talking about the period of my life to date.
> I am saying you have to understand the revealed preference vs what people tell you.
And what they're saying is that this isn't just an indication of how awesome the US is compared to other places, but also of how averse Americans are to learning other languages compared to other people.
Very uncharitable way to phrase that, American second language prevalance is similar to other English dominant countries like the UK or the Australia.
Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.
If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.
> Very uncharitable way to phrase that, American second language prevalance is similar to other English dominant countries like the UK or the Australia.
No. Yours is uncharitable because it has got nothing to do with how many languages you speak. This is not a multiglot competition. The only point being made is that someone with a fair amount of American exposure will have a head start emigrating to America compared to say an American to Latvia. Or France. Or Germany. Just on the language front in isolation/alone.
> Americans in general don't speak as many languages as Europeans because they already speak arguably the most useful language. I've lived in 20 countries, and in every single one for them I've been able to find someone who speaks English. People are so ingrained with the need to know the language that I've actually met people who are embarrassed about their English talking to me in their own native country.
Here’s an alternative explanation. These people were so gracious and willing to communicate with you, a foreigner, that they were flustered and embarrassed that their command of the English language did not allow them to express themselves as clearly as they could. Or maybe they were really just embarrassed to have insufficient command of the Master Language, I don’t know, maybe your version is correct.
> If you grew up speaking Greek, Romanian, or even something like Italian, this absolutely would not be true. Maybe you could find a person or two to talk to, but definitely not dozens casually in everyday situations. So you have to learn multiple languages by necessity. And since European countries are so small, close together and all have their own languages, you also end up picking up your neighbors languages.
For someone having lived in twenty countries you seem as wordly as a North Dakotan having travelled abroad three times. All to Winnipeg.
"No. Yours is uncharitable because it has got nothing to do with how many languages you speak. This is not a multiglot competition."
I was referring to this specific part of the comment I replied to: "Americans are averse to learning languages as opposed to other people". My response is a very accurate explanation of the reasons why this is a) an unfair way of looking at things, and b) not unique to Americans. What aspect of my response is uncharitable? I'm not saying things should be one way or another, just explaining how they are.
"Here’s an alternative explanation. These people were so gracious and willing to communicate with you, a foreigner, that they were flustered and embarrassed that their command of the English language did not allow them to express themselves as clearly as they could. "
The situation I described has occurred to me more then once, even after I tried to communicate in the local language. English speaking is a flex in a lot of the world and poor English is embarrassing. The desirability and prevalance of English may upset you, but it is objectively true. You can get English teaching jobs and find plenty of English speakers all over the planet. The same is not true for any of the other languages I mentioned in my post.
"For someone having lived in twenty countries you seem as wordly as a North Dakotan having travelled abroad three times. All to Winnipeg"
Lmao, why are you so angry? I grew up in Australia and south east asia.
> I was referring to this specific part of the comment I replied to: "Americans are averse to learning languages as opposed to other people". My response is a very accurate explanation of the reasons why this is a) an unfair way of looking at things, and b) not unique to Americans. What aspect of my response is uncharitable? I'm not saying things should be one way or another, just explaining how they are.
Okay that’s fair. I glossed over that part.
> The situation I described has occurred to me more then once, even after I tried to communicate in the local language.
Your interpretation of the chain of events perhaps.
One person goes to a country and meets kind strangers. “Wow, these people are nice to strangers”. Another person has the same experience. “Wow, these people must love me or X attribute.”
> English speaking is a flex in a lot of the world and poor English is embarrassing. The desirability and prevalance of English may upset you, but it is objectively true. You can get English teaching jobs and find plenty of English speakers all over the planet. The same is not true for any of the other languages I mentioned in my post.
I’m very upset that I speak English fluently. It really inconveniences me.
> Lmao, why are you so angry? I grew up in Australia and south east asia.
Do you know what a comparison is? I did not call you an American. There’s no reason to take offense.
> > In Spanish, the Diccionario panhispánico de dudas (English: Pan-Hispanic Dictionary of Doubts), published by the Royal Spanish Academy and the Association of Academies of the Spanish Language, recommends the genderless term estadounidense (literally United Statesian)
The two things are not equals. The US has for a western country, relaxed standards for immigration[0], in particular if you were coming from Europe, it's quite a bit easier to establish residency here.
The reverse is not true. European nations aren't very immigration friendly by comparison. On top of that, the US government, assuming you keep your citizenship, does not make it easy to live abroad. US government tax policy for citizens who live overseas is much more aggressive than any other western country, from what I understand.
Combined with the fact its alot harder to go the other way, and the US government does a fair amount to discourage it, I'm not shocked more US citizens aren't moving to Europe.
[0]: At least before Trump returned to office, I'm unsure how much of this has changed.
> The US has for a western country, relaxed standards for immigration
My comments will only concern skilled migration, e.g., you are a computer programmer or something STEM'ish and you want to work in a different country.
First, let's start with the "Anglo-American sphere" (my term): US/UK/CA/AU/NZ. Of those five, US is the hardest to get a working visa for skilled individuals. The rest are "points-based" system where you can apply for a working visa even before you have a job (95% sure about this -- pls correct if wrong). They are much more friendly. Also, the rules are simpler, clearer, and applied more consistently.
I know much less about other OECD-level (and G7-level) nations, but anecdotally, overall, the process is much more straight forward compared to the US. What the rules say, the rules do. Not so much in the US where they randomly delay or reject applicants without good reason. (Also: Google to find horror stories of what happens when you lose your job in US as a foreigner who does not have PR. Fucking nitemare.) You hear this much less in (to name a few): Ireland, UK, France, Germany, Belgium, Netherlands, Denmark, Norway, Sweden, Finland. (I don't hear as much about Portugal, Spain, and Italy, but quality of life looks awesome!) All of those countries are wealthy, highly developed and have excellent quality of life. All of them welcome skilled migration and have clear programmes (you can Google about them) to get a working visa. Again, strictly anecdotal: The US immigration system is much more adversarial compared to all of the other countries that I mentioned. Oh, and I forgot to add Japan: After PM Abe changed the rules, it is way easier these days to get a skilled worker visa in Japan.
Last point:
> European nations
I see this over and over again on HN. I want to repeat: Europe is enormous -- like continent-sized -- with ~50 countries. It doesn't say much to say "in Europe". Are we talking about Belarus, Albania, Germany, or Italy? All of them are culturally and economically much more different than anything in the US (comparing US states / regions). Immigration/healthcare/public school/public safety/retirement all looks very different in those nations. Advice: It's better to say something like: "the Nordics" or "Benelux" or "GBR/FRA/GER/ITA" (the four economic giants of Europe). The best comments are when people comment about specific European nations, like "I lived & worked in Belgium for 7 years and this happened."
>My comments will only concern skilled migration, e.g., you are a computer programmer or something STEM'ish and you want to work in a different country.
This circumvents the original predicate, which did not have such a limitation. I know many countries have priority / helpful pathways for STEM career individuals as well as capital investors, but that wouldn't apply to everyone.
Even the US has very different pathways to citizenship depending on various factors. Last time I looked into it as research in depth, there alot of common limiting factors across Europe. Their policies are much more strict once you dive into the nuance.
That said, the US immigration landscape is extremely lopsided, thats a fair point.
>Europe is enormous -- like continent-sized -- with ~50 countries.
I realize, though as a US citizen I also realize that when most US citizens say this, they mean a much smaller contingent of countries, rightly or wrongly. I'm sure Europeans dislike how loose we use the term, but as a US citizen, it usually means cold war boundary countries, so Germany and what was considered western Europe before the iron curtain fell. Thats been my experience. People also generally forget about Portugal and a few island nations. Its a safe bet most people mean the Nordics, France, Germany, the UK, Netherlands and Denmark most of the time, conceptually.
However to be specific, France, Germany, Switzerland, the Nordics, all have strict general requirements to have a path to citizenship. I don't think the average US citizen would be able to meet them.
That's a fair point. But until recently you could move to a lot of countries in Europe for an investment less than a house in California. But I accept that could be the true reason.
>That's a fair point. But until recently you could move to a lot of countries in Europe for an investment less than a house in California.
That alone is enough to put most people out of grasp of doing this, for a multitude of reasons, of which not having the capital is only part of the equation, as you would also need to have a suitable investment on the other side to put said money, not a promise. I'm sure there are other nuances involved too.
Thats before the fact that the cost of a house in California would price most people out of the equation to begin with.
All the benefits OP lists are at or below mandated minimums for Western EU countries. It’s trivial to lookup and confirm for yourself.
In software the money difference you still end up ahead of where you would be on an equivalent salary in the EU. Also last time I was considering a move to the EU job market was weaker than the US. Also you still need to get all the necessary work visas which aren’t automatic. Even as a dual citizen I can’t just show up to work at a company in the EU.
High fractions of Europeans speak English, eg Poland has 50% of population speaking English (for those of working age it’s probably much higher) whereas the fractions of Americans speaking non-English European languages is much lower (0.25% for Americans speaking Polish).
If 50% of Americans spoke Polish by the shake of a wand, I bet there’d be more Americans in Poland than Poles in Poland.
OK, but by that logic lots more USA citizens should be moving to the UK, Ireland, Spain than the other way around. That's just not the case, at least until very recently.
I could see that the appeal of Ireland can be increasing and Poland sounds cool. I'm not saying that the USA is great, it has tons of problems.
UK numbers yes, though maybe gloomy weather plays a role? Just kidding. That said, Brits are slightly more likely to move to Spain than US despite it being a tiny country in comparison and not necessarily easier to move to after Brexit.
Spain, not sure. It’s tricky to compare since non immigrant Spanish speaking population in US is probably significantly lower than Spaniards speaking English. But yeah, you probably have a point on that one.
Your wand would also need to erase the reason people speak (or don’t speak) the languages they do, otherwise what you said would already be true for the UK, Australia, etc.
Would it? People don’t exclusively learn English to migrate to the US.
What language do you think Germans and Spaniards use to do commerce with each other? There needs to be a common language, there’s no bandwidth to learn all languages, so due to historical and modern reasons, English prevailed.
Re Australia, Australians have highly preferential options to move to US which is not reciprocated.
So you are already saying it isn't just language, your wand would also need to erase "preferential options" facilitating the direction of migration. Which is what I said but in different words.
> If this were true, the number of Americans I have known who
People only live in one unvarnished (more or less) reality at a time. Americans live in America and get told stuff about “Europe”; Europeans live in Europe (or their respective countries if we want to get anal about it) and get told stuff about America. Only a very very small number of people get to live in multiple places and for long enough stretches of time to be able to compare them pretty fairly.
In what kind of dream reality do people come to have such perfect (I’m being hyperbolic) information about other places that they then are able to base their move-or-not decisions on? This is just not reality. People know what their own place is like. They “know” other places through propaganda, mostly.
But Americans are so propagandized that you have to teach them about their own propaganda.
Can you be more specific? What sort of thing could you say in the US that would cause government action if you said it in Canada? Those freedoms are fading fast under this administration at any rate.
Basically explaining to Armenians at home why their relatives who moved to America don’t send better remittances back home despite their $X pay rate. Here’s why …
Is it? I pay 13.5% of my income as healthcare 'tax' for public healthcare. Overall, it is cheaper than US healthcare (as a percentage of GDP), but individually it is still a significant expense.
Ha! I wish. It's not free. You will pay the same that Americans pay for Uni over your life many times over since tax rates in the EU are really high. Healthcare isn't exactly cheap either.
And everything you wrote is just the result of decades of prosperity that are now coming to an end. This will be a shock for many.
In tech, 3-4 weeks vacation not usual for senior roles. Often “unlimited” but in practice far more than 10 days. That might be for new/inexperienced hires in crappy companies.
While healthcare is brought up all the time this is usually ignored. The idea of parents saving a 'college fund' for their child is something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).
> something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).
Like most things learned from movies, you're not getting the full picture. Most US universities charge on a sliding scale based on family earnings. For larger universities, tuition can actually be free depending on parental earnings. At the extreme end, some Ivy League universities like Harvard have $0 tuition for families earning less than $200K/year.
We also have community colleges and state-run universities with subsidized in-state tuition. It's still more expensive than free, but the tuition is in the range where as long as you're smart with your degree selection the ROI of getting the degree will more than make up for any loans you have to take on. That said, you can get yourself into trouble if you take out loans to study for a degree that doesn't translate to a job.
And, in fact, the median amount of college debt for adults who don't hold degrees is sharply lower than the overall median (it's around $10k). It's not nothing, but it's also not a life-changing amount of debt.
(By way of policy bona fides: I'd strongly support forgiving student debt for all for-profit schools, but would oppose forgiveness for degree-holders from universities, which would be a sharply regressive policy).
Implicit in all these stories is that "education" means "access to highly selective universities". In-state tuition at Directional State University is much more manageable.
Both my kids went to UIUC and we paid about $15k/yr, and both my kids graduated within the last couple years. And UIUC isn't a Directional State University; it's the flagship of the UI system. You can just look this up: tuition numbers aren't secret.
You just cited the out-of-state cost of the flagship state university in Illinois as if it were the in-state cost of a Directional State University in Illinois. Again: you have an argument here that depends on people not Googling list prices (the prices that nobody actually pays) and seeing what they actually are.
They in fact differ wildly between students and between colleges! UIC and NIU are commuter universities where students generally don't live on campus. Students at UIUC live in campus-provided housing for their first year, but not generally for subsequent years. Everybody, whether they're in school or not, pays for housing. So no, the cost comparison you're offering here is not very useful.
Shortly later
I also think you might have to ask around to find a student paying full price for books.
It's evident that you're saying this as a non-European, as there's no "European healthcare".
Many (most?) European countries have private healthcare systems. Switzerland has it and offers some of the best healthcare in Europe and in the world. Similar systems work great in many other European countries as well. The problems with American healthcare are not because it's market-based, it's because how that market is managed.
Some other countries have public universal healthcare. It can work well, but it requires a high-income country with both wealth in abundance and significant government efficiency. It only truly works well in Scandinavia so far. This is not "socialist healthcare" as some will dubiously claim, it's sort of the opposite, which is why it works.
> University is expensive as fck. Health care is expensive as fck.
University isn't near as big of a problem. That's not something the blindsides you like health care expenses. Nobody is making you spend $300k on university. Got my engineering degree at a public university for ~$100k in total and had it paid off 5 years after graduation. But a $195k hospital bill is something I'd never be prepared for. Nobody chooses to go to a hospital.
For $100k, you could pay the tuition fees for 4-10 (depending on exact school choice) of the best universities in Europe outside the UK combined - and I'm talking of the foreign student fees, not the much lower tuitions that EU citizens get.
That's great, but you've missed my point. I get payed more in the US, so I can afford the extra cost for university. And once that university bill is paid, I can pocket the extra.
There are still reasons why high university costs can be a problem. Teachers, for example, don't get paid near enough to be able to cover university costs in a few years like I was able to. But becoming a teacher requires just as much investment.
But even then, the cost of college loans is far more manageable for even teachers than an unexpected $195k visit to the hospital. University cost is a problem in the US, but I don't think it's comparable to the problem we have with health care costs.
That's true for a handful of jobs, but not so much in general. Sure, in CS and medicine and Wall Street you get salaries that are huge compared to typical EU salaries. But this doesn't apply at all to all white collar work - certainly not at the 10x - 100x difference in college tuitions.
Not to mention, I also gave the example of the tuitions for a Swiss university, and Swiss salaries are typically at least comparable to US salaries, even in CS.
> certainly not at the 10x - 100x difference in college tuitions.
The full time tuition rate at the university I got my engineering degree from is currently $11k /yr. I can't imagine that's even 10x a typical EU university - let alone 100x.
My local community college's full time tuition is currently $5.8k /yr. Either way it's a lot of money, but lets not exaggerate things too far. We're worried about affordable access to education here - not getting everyone into Harvard.
> So like these are less serious issues if you are paid an extra $1-200k/ year
Ok but to be fair most people in the US aren't making "extra $1-200k / year" over a person in Europe. They aren't even making $100k / year to begin with.
Almost 40% of the USA is on medicare, medicaid, or entitled to VA benefits or military healthcare. It's only a narrow majority that depends on unsubsidized private healthcare, and those people skew in the upper income levels.
You believe the top 60% of the nation skew in the upper income levels? Median pay is $61k a year for the entire country. The top 1% skews to the upper income levels. The rest are charged $30 for a dose of aspirin and can't afford it.
There are numbers on this, and their comment is probably directionally correct; the median household with private insurance earns more than 400% of household FPL (KFF). By subtracting Medicaid and fixed-income seniors from the picture, you are sharply biasing the median upwards.
I would say if you ignore the poorest 40% of the population, you've got quite the slim margin to go before you are no longer talking about "Most" Americans, which the OP was pretty explicitly talking about.
He was saying "Most people in the US" don't make 100-200k more, and that they probably don't even make 100k. This was in response to the generalization that "people from other countries ... underestimate how well paid people in the US often are".
Now there was talk of getting the political motivation to change things, so I guess everyone is assuming Medicaid/Medicare/VA recipients don't want to change the system, but that wasn't really established, nor was that really being refuted.
I don't think I could be any clearer that I am (1) talking about Americans with private health insurance and (2) not making a normative judgement about which system is better, but rather a positive claim about the political challenge of changing the system (its large group of stakeholders who are better off under it).
Oh I'm clear about the demographic you are trying to discuss, my point was I'm not sure this all stemmed from a discussion about that specific demographic. It started at "people in US", then went to "most", then by the time you got involved in the thread you were defending a statement about people with private health insurance.
I could have made this comment at the level where it went off the rails, but I thought making it at the leaf level would help everyone involved see the deviation between what was said and what was being argued.
i think in this case, if you're at all familiar with what US hospitals charge for the small stuff, it's a safe assumption that when someone says aspirin costs $30 a dose, they're not talking about buying it at a CVS. of many folks on hacker news dot com i trust you to bridge that gap instead of nitpicking!
That's an odd argument to make in this thread, because whatever the drivers of burdensome consumer health spending are, they're not overpriced hospital aspirin.
So what about this? It is a question, not meant as a counter.
Although I have to say the rosy picture some paint here about the high incomes is counter to anything I ever heard - and saw, although I left the US in the early 2000s, after having lived there for almost a decade (still mostly paid from Germany, never ready to make a complete move).
By the way, Europeans don't quite all have a "nationalized healthcare system". Germany, for example, has "Krankenkassen" but also private insurance, and the "Krankenkassen" are private organizations.
We pay health insurance and get to choose the provider, those with higher incomes can switch to complete private insurance. We also have lots of our own problems and increasing costs because of immigration but more so aging population.
However, I personally know several people who had severe illnesses for a long time, and their normal "Krankenkassen" insurance never made any problems. One person with plenty of money, whose wife was dying, even asked US medical experts if he should come to the US with her, and those US experts said he should stay where he is, the German univ3ersity hospital right next door had some of the leading therapies in the field. She lived five more years instead of dying after less than half a year with the standard therapy, every single expense paid for with the standard insurance, additional private insurance unnecessary. Similar with my stepfather, who had soooo many severe conditions, and yet every single item down to the special medical bed brought into our house so that he could finally die at home was paid without question.
The problems are with more mundane expenses, e.g. glasses, or the dentist, where only some of the treatments are covered. The really expensive illnesses seem to be better covered than the more common and much simpler problems.
Careful there, thats a rightwing propaganda point. Immigration into an aging society does not raise healthcare costs, it lowers it. See https://archive.is/XxfTH (and note that this is a NZZ article, a right-wing publication by now, so not slanted towards being immigration friendly).
I did not try to make a political statement, what happened here, anyway???
I have no idea what there is to defend - even if you assume they will all get high-paying jobs some ay, for the first few years costs will increase while they either learn the language, are not allowed to work (status pending), or get minimum wage jobs (food delivery and parcel services at least in my city now is dominated by immigrants).
Even with your most positive outlook, initially there will be lots more people and the same system (number of doctors), and the numbers of payers increases slowly.
I even wrote "but more so aging population", conveniently overlooked in this strange politicized discussion.
I am NOT against immigration!!! Don't make stuff up people.
You are misreading this exchange. You just got a fact wrong, but thus repeated a lie that is planted often by nazis - and it's easy to get mislead. Anyway, you did not get criticized for an imagined stance on immigration, but those answers are to a comment I assume you missed, the one by nxor?
You wrote, incorrectly:
> We also have lots of our own problems and increasing costs because of immigration
As the NZZ article explained, health care / Krankenkassen are the area where it is the clearest that immigration is an economic benefit. Look at statements like the section title "Krankenkassen profitieren", followed by "Ein grosser Profiteur der Zuwanderung sind dagegen wohl die Krankenkassen." and the ending paragraph of said section:
> Laut dieser Analyse gab es in diesen sieben Jahren einen Wanderungssaldo aus dem Ausland in Höhe von 4,7 Millionen Menschen in das System der GKV. Für das Jahr 2019 ergab sich daraus eine Entlastung der GKV über etwa 8 Milliarden Euro (umgerechnet 0,6 Beitragssatzpunkte). Seit 2019 hätten sich die Rahmenbedingungen aber deutlich geändert, heisst es dazu von der TK.
So the numbers we have do not support that part of your statements. And I'm not aware of newer numbers that say the contrary - the recent cost increase sees completely different reasons for example, as in https://www.mdr.de/nachrichten/deutschland/panorama/krankenk..., the "but more so aging population" part of your comment fits there.
> Of course, far-left demagogues like you would advocate for flooding a country with uneducated criminals
We've obviously banned this account. Please stop registering accounts just to keep breaking the guidelines. It's boring and a waste of everyone's time.
And while European countries have various forms of nationalized welfare, their salaries are so low that they would be automatically eligible for the US' welfare too!
our blocs aren't that different
except in the US middle class and upper middle class
It's hilariously out of touch, but it's what you should expect from the HN bros. They live in a bubble.
I'm from the eu and earn far less than these American techbros do, but far more than my American friends who work normal jobs. They work at the DMV, a supermarket, or general office work. You know, normal people. The vast majority.
Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.
So when you're talking about how bad the American system is, you're really talking about a minority of its users. That doesn't make everything OK, but does highlight the political difficulty of enacting seemingly-popular changes.
> about how bad the American system is, you're really talking about a minority of its users
It sure seems that way if a wealth family with top level insurance can still get bankrupt by medical bills. Examples of that are right here in comments.
>the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.
If you had said the median tech worker? I might have believed you, but the median family? No way.
The median family of 4 with private health insurance has a household income of around $115k not counting the gross cost of their employer-provided health care. Remember: being on private insurance puts you in a cohort that:
* Excludes everybody on Medicaid
* Excludes fixed-income seniors on Medicare
* Makes it overwhelmingly likely you have subsidized employer-covered health insurance.
Figure your employer "covers" half the gross cost of your $24k/yr health insurance (they aren't, really: that's money they'd be paying you directly without the distortion of employer-provided health care). Do the take-home pay math. Put them in, like, Ohio, or Iowa, or Colorado; just not SFBA or NYC.
Now move that same family to Manchester, take the wage hit for moving to the UK labor market, and work out the take-home pay. They'll of course pay $0 for the NHS.
Are they better off or worse off?
I'm not valorizing the arrangement, I'm making a point about how political tractable changing it is.
You’re moving the goalposts. How many families have private insurance? Considering both families with and without private insurance, is the median family better off in the US?
Idk, speaking as a big Medicare-for-all supporter, this would definitely explain why MfA always polls well at first, until people start asking if they can keep their current plan. I know at this point in the debate we’re supposed to write those people off as either innumerate, a minority, or too risk-averse for their own good, but honestly if it turned out that that stat was true, that would explain a lot.
And it would be exactly the kind of political engineering minmax scheme large corps in the US are great at: petition legislators to cut regulations so you can cut costs and maximize profits, but keep juuuust enough of the right perks in the right places so that a slim majority of people in Wisconsin, Michigan and Georgia oppose shaking things up.
The people who want to keep their own plan are almost definitionally not innumerate! They would be worse off financially under M4A.
That doesn't make M4A bad policy (I think it's bad policy for other reasons), but it does take "people are being irrational" off the table in a discussion like this.
Even if you keep your plan it's getting enshittified every year.
It's that time of year again - enroll for 2026 benefits. My employer raised employee premiums by 10%, raised the deductible, added more administrative burden such as "step therapy" (the insurance company denies your claim for a drug until you've tried a cheaper but less effective drug, even if you've already done "step therapy" while on another health plan!) Your employer will change the plan premiums and structure every single year. They can lay you off, exclude expensive drugs, exclude doctors, etc. Some specialties like anesthesiology and psychiatry are usually not in network. In extreme cases an employer can change health administrators mid-year and your deductible will reset.
There are countries that have single-payer systems and widespread supplemental insurance. But if you universalized Medicare, you'd immediately do at least two big things to the market:
(1) You'd eliminate the system of advantages and supports that cause employers to offer private insurance, which is where most people get their insurance from.
(2) You'd create a huge adverse selection problem --- the more effective/useful Medicare is, the fewer families will want to spent $24k/yr on private insurance, meaning the families left on private insurance have a reason to want it, meaning the composition of the risk pool would shift dramatically.
Like, if we ever did M4A, we'd probably end up with a widespread system of supplemental insurance; we already have it with Medicare! But that's not the same thing as keeping your existing plan.
I don't understand the obsession some people have with keeping your existing plan. Lots of people can't keep there plan under the current system. Insurance companies update their plans regularly. Sometimes they remove plans or exit markets entirely. An existing plan will get small changes over time. If Theseus has an insurance plan for 10 years and the insurance company makes changes every year can we still call it the original plan of Theseus?
If M4A plus supplemental insurance gives me about the same coverage I have now for a reduced total cost that sounds like a win to me. Even if it ends up costing me the same amount the net improvement from everyone having access to basic health care would still be a win.
Every policy is easy to enact if you just define away anybody who'd object to it. But, more importantly: it's unlikely that M4A by itself (let alone with the supplemental plan you'd likely end up with) would reduce your total cost!
> Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.
The US spends nearly as much in taxpayer funds as a share of GDP as other developed countries (and vastly more on a per capita basis), with even more in private costs on top of it. It is simply dishonest to say that the "wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays", because neither the US wage premium nor any lower tax burden are attributable to differences in healthcare systems, but rather are in spite of the far greater burden of the US healthcare system.
OTOH, it is true that a major challenge is that people respond with this line to any proposed major structural changes to the US system.
Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance. That family would likely (in fact, almost certainly) be worse off in a single-payer system.
I'd appreciate if you'd avoid using language like "simply dishonest" with me in the future. It's easy to tell me I'm wrong about something without accusing me of commenting in bad faith. This is in the guidelines. Thanks in advance!
There is a middle ground here. Many European countries do not actually have single-payer, but still perform better than the US.
It's a bit out of date now but the book The Healing of America found that Germany, France, and Japan had world-leading healthcare results, measured by things like survival time after major disease diagnosis, but spent much less of a percentage of their GDP on healthcare. None of them had single-payer. Their systems were pretty close to the ACA, with private insurance companies and a mandate.
They were also different than the US in certain ways. Probably the biggest was a national price list for services. A lot of healthcare isn't really a functioning market; in many cases you're in no position to comparison shop. A result of the price lists was that doctors made a lot less money, but this didn't seem to affect quality.
Other differences included: no claim denials allowed for anything on the price list (which saves a lot of administrative staff), effective national digital records systems (ditto), and the insurance companies had to be nonprofits.
All three countries actually got better bang for the buck than Canada's single-payer system. Japan was the cheapest, spending only 5% of their GDP on healthcare, despite an aging population of heavy smokers. Germany was the most expensive at 13% (compared to US 18%) but covered things like week-long visits to the spa for stress relief.
The author did a spot check on the user experience by seeing a doctor in each country for a shoulder problem, and those three countries worked out really well for him. In Japan the doctor offered surgery the next day, at a very modest cost. They did make do with simpler equipment; the MRI machines were bare-bones but they got the job done and a scan cost $100.
I agree. I'm a fan of the non-single payer European systems, and, especially, of the Australian system. Nobody can look at the American system and say we've got it right! I do like the private->Medicare compromise we have, but we also have the original sin (a strange and I think unintended consequence of the mid-century tax code) of employer-sponsored coverage.
> Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance.
Yes, you can just do the math, and changing nothing about the US except transition to a European style universal system, the median family would face lower aggregate tax, out-of-paycheck, and out-of-pocket costs than they do now, with less health insecurity around unexpected events (either health or employment), unless the tax increases necessary were deliberately and perversely targeted to avoid that.
That’s a direct consequence of the difference in the macro-level costs: they aren’t separate, orthogonal concerns. People just have a hard time accepting that the US health care system is structurally constructed right now to waste vast hordes of money preventing people from accessing health care, but that’s exactly what it does.
Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.
I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.
> Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.
Not tax penalizing non-capital income is sort of an essential reform in the era of increasing automation anyway; I'm not sure what point you are trying to make there. The average middle income family isn't making a substantial share of their income in forms taxed as long-term capital gains, so that seems...unrelated to the focus of your argument.
> I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.
It does both (particularly, in the “actual care” angle, as regards low-benefit, high-cost measures near the end of life.) We have a system based on denying and economically incentivizing younger people to avoid and defer care, but then doing much less of that with (most of) the elderly.
You're contradicting yourself. You took me to task earlier for factoring in the wage penalty for working in the UK market --- fair enough, though really I'm making the simple descriptive point that people in the US are accepting of a dysfunctional status quo in part because they would be worse off in Europe.
But taxing capital gains at the level of ordinary income would be an immense change our tax code. All sorts of things the broader economy would change as a result. If you accept Sanders plan, you're not holding to your original constraint of changing only the health financing system.
I want to be clear that I'm not stipulating that families would be better off under M4A if you didn't do this: I still think your argument has the fuzzy end of this lollipop. I think it's unlikely that you will come up with a set of numbers for any proposed single-payer health system that leaves the median family with private health insurance better off on a take-home basis. I'm making a strong claim, so you should be able to knock it down straightforwardly if I'm wrong, and I'm interested to see if you can.
The counterargument is simple - it works in other countries.
Other countries have healthcare systems that don't generate medical bankruptcies, and don't put a slaver's chain around the necks of employees who risk financial destruction if they have to give up an employer-funded plan.
You're essentially arguing that 500k medical bankruptcies every single year, out of a population of 340 million, is a small price to pay for an imaginary financial benefit that you're convinced exists, for some loosely defined demographic, but which you've failed to quantify.
This is, very specifically, the problem that destroys your argument.
Some people in the US are better off until they aren't.
One serious medical crisis - like an extended bout with cancer - is enough to wipe out the benefits, and leave people who used to be prosperous out on the streets.
Literally. Not as an exaggeration, not as rhetoric, but as a cold, hard reality that affects half a million people every year.
You're responding persuasively to somebody's argument, but it isn't mine. I'm talking about the large cohort of American voters who would be worse off under a single-payer system.
I don’t know if the median American would be worse off with a European style system. Certainly the 1% don’t need it. I’ve been on the Google health insurance before and it made me feel like I had $10 million in the bank.
I've been lucky with my health so I don't have a huge list of interactions:
* Free tele psycho-therapy. Not sure what the limit is but it's >= 2 hours per week. I even cancelled same-day once with no fee. The quality of the care was also very high.
* I developed wrist pain from typing, holding a Steam Deck, starting pull ups. I was able to see a physical therapist at the Google office (through an embedded One Medical) after 1 week. No referral needed. Saw them once per week for 5 weeks paying $20 co-pay each time. They fixed my issues permanently.
* I also occasionally used the Google One Medical locations (and public ones) for injuries from a low speed bike crash, vaccines, etc. Don't think I ever paid more than $20 for anything. On a Google income that amount is completely inconsequential.
As with many things, in the US if you're part of the privileged minority you do well. The top 10% of earners in the US earn a lot more than the top 10% in Europe – that covers tech, high end knowledge work, that sort of stuff.
But the bottom 90% do badly. Society is very divided, and most people lack social mobility, they lack a voice on the national and international stage, they lack the security that either a social safety net or high pay would give them.
The UK is similar, although much less pronounced. I moved to Australia about 18 months ago and society here is much flatter, the difference between the top 10% and bottom 10% is much less. There are still problems here, it's not a utopia, but it's very noticeable how most people are struggling less, and how the top 10% of earners aren't living that different a life.
Wrong - sorry. The reason is that politically the US public is very skillfully managed from above via divide and conquer strategies and beaureaucratic techniques (i.e. identity politics, gerrymandering voting districts). The public polling is very clear about US citizen preferences, but US Govt policy is rarely aligned that way.
No, it's not clear at all: it's been tested in actual referenda and failed. What's actually happening is people don't intuitively grok the distinction between opinion polling, where questions are asked in the abstract (and often in the best light preferred by the org sponsoring the poll) versus actual voting, where the questions are very specific and include details like "your taxes will increase by X%" or "you will lose access to your current insurance plan".
Oddly enough the big rhetorical push against a universal system from prior decades was about "death panels" deciding what care somebody would get. And guess what's happened with insurance? Death panels!
The propaganda spin on the health care system in the US has been on overdrive ever since Hillary Clinton wanted to implement some reforms in the 1990s, leading to absolutely massive resistance to any change whatsoever. Even the changes implemented by Obama, which were a HUGE improvement in access, barely made it across the legislative line, and dismantling that access to the health care system has been a huge rallying cry for one of the major political parties. I won't say which one because mentioning that fact results in people turning off their brains and downvoting.
The US healthcare has optimized for availability and higher access to the most treatment options. This does not mean evenly distributed treatment options, but that people have the chance to get access to things more quickly.
And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.
>>> And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.
As an individual who has lived in multiple countries in three continents, I dispute that “the care most people get is better than adequate”. Perhaps better than the world average, but certainly not better than in most first-world countries. And that’s not even counting the impact of delayed decisions and denied care, and the stress of dealing with the system overall.
And if you’re looking for more than anecdotes, there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.
While I don't doubt that there are endless stories of bad care, especially among the non-unionized working class, the bulk of voters with middle class lifestyles do have good care. Which is why it's so hard to make it into an issue that drives political change.
> there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.
Americans aren't dying earlier of diseases that are solvable with a doctor visit, surgeries, pills, or other easy medical interventions. The medically related early deaths are primarily because of overnutrition and lack of exercise leading to pre-diabetes, diabetes, high blood pressure, and heart disease. That comes from public policy mandating car dependence throughout society and huge subsidization of empty calories in the food system. Overeating and lack of exercise are problems that have been stubbornly resistant to the medical system's efforts to change behavior. There's also other heightened early death risks like car crashes, drug overdoses, and suicide, but few of these deaths could be prevented by increased access to the medical system.
>While I don't doubt that there are endless stories of bad care, especially among the non-unionized working class, the bulk of voters with middle class lifestyles do have good care. Which is why it's so hard to make it into an issue that drives political change
This ignores the outsized influence of lobbyists, especially post Citizens United.
The majority (depending on which polls you cite, seems to range anywhere from 57% to over 70%) favor a universal healthcare solution for all citizens. Yet like many other majority opinions, this doesn't translate into legislative action in that direction, in large part thanks to lobbyists and dysfunctional partisanship. None the less policy is not reflecting the majority.
What lobbyists are opposed to universal healthcare?
It seems to instead be merely a wedge issue in culture war. Republicans firmly oppose it, Democratic politicians fight for it, and apparently voters don't care enough to advocate for what they say they want in polls.
Life expectancy tells you basically nothing about the quality of health care in the US. It's dominated by car accidents, homicide, and then CVD --- but CVD varies dramatically across the United States (from states in the south with drastically worse CVD outcomes to states in the north with outcomes on par with the Nordics) despite the same health care structure across all those states.
Like Ticketmaster, health insurance companies get paid to be the "bad guys". This is a reasonable function since Americans can't seem to understand that someone must decide where limited resources go. However, there's no reason their cut should be so large.
I don't know how to answer that. I think the system is pretty inefficient in a variety of ways. If you universalized Medicare, eliminating insurance entirely, you'd get costs somewhere in between Medicare's current admin overhead and the overhead of private insurance (you mechanically would not get Medicare's current overhead, because the majority of your customers would have much lower claims than Medicare's all-seniors patients do, and overhead is a ratio).
But the largest inefficiencies are all on the providers side. We simply pay practitioners too much, enforce artificial scarcity of practitioners, and prescribe too many services.
So if we're talking about "The American System" as a whole --- which is what the thread is about --- it behooves us first to consider the question "how much better would things be if we simply zeroed this category of expense out". The answer is, to a first approximation, we would get a 6.5% price break. I would not drive even a couple blocks out of my way to get a 6.5% price break on a pack of chicken breasts.
That's true, but it's a problem single-payer doesn't fix; that's my big issue with it (it locks in rapacious rates and preferences for the health provider industry, making them palatable to consumers by hiding the payer).
The complexity is far higher than credit card processing, including extensive price negotiation with individual health care providers. Though we call it "insurance" it's just as much a "buyer's club" for health care services.
Large employers (e.g. Google) are also generally "self-insured" meaning that the "insurance" component is offloaded to the purchaser, the employer of the insured individuals. In those cases, the health care insurer processes the claims from health care providers, determines if they were justified, or if the treatment/diagnostic/drug is justified by coverage determinations of the provider, etc, but the employer (e.g. Google) just pays the claims in the end too.
Health insurance companies have had their profits capped at a percentage of revenues. That means that to grow profits, they must increase revenue. Which means incentives to increase care and increase costs.
Oddly enough, all the plots I have seen of cost increases don't show a massive skyrocketing of costs since the profit caps were introduced. If anything, they have been somewhat reduced.
However a reckoning must happen at some point, health care can not consume the entire economy's efforts.
You could offer me 10x my current salary and I wouldn’t take it if it meant I had to stress and be terrified about the life of my 6 year old daighter because a company wants to make more money.
> people know it is a problem but ideologically they really disagree about what to do about it
Can we really say this is true about individuals in the US?
I think it's pretty clear the propaganda machine has successfully privatized health care to the great detriment of the populace and have the clamps on it.
After all, if you told everyone you had a solution where insurance rates would be cheaper, their healthcare system would cost less overall, and the health outcomes would be superior, they would all be like "sounds great". Then, when you reveal this solution is the complete destruction of the insurance "industry", insurance payments are "tax", and the health provider is the government, they would balk, scream about socialized healthcare, and say how they don't trust the government.
In fact, US Americans are paid so well, the GDP per capita of the poorest state (Missisipi) is about the GDP per capita of France. In fact, the gross average wage of Missisipi is just barely lower than the average salary in Germany. Americans are paid really, really well.
There's already a soft alternative many people use, which is the deregulation option via geo-arbitrage, go to Mexico and get the same thing for 10 cents on the dollar.
Universal healthcare is a very different thing from controlling costs.
Obamacare attempted to make the US healthcare system into a universal system by mandating that people purchase coverage, heavily subsidized to become affordable to every income level, in addition to massive expansion of Medicaid to those with the lowest levels of income or no income at all. Automatic enrollment in health insurance exchanges, even if people did not make their own choices on the health insurance exchanges, is what would make the US system universal health care.
Universal means that everyone has coverage, that the question to the patient is "what insurance plan are you on," rather than "do you have insurance." And making coverage universal has no connection to lowering costs. We need larger structural changes in the logistics of how care is delivered and how the money flows.
Single payer is another choice to be made, but that doesn't necessarily mean that health insurance is cheap, that all the care gets delivered that people want delivered, etc. Medicare is often cited as one direction for this, but most don't realize that private health insurance costs are partially high because they help subsidize the care of those who are covered by Medicare, because Medicare reimbursement rates are far lower than any of the private insurers have been able to negotiate.
Other routes are full decoupling of insurance from employment, full price controls that normalize Medicare and private insurance rates, which either make health care more free market or less free market depending on how you define those terms.
However every year that passes makes any of these reforms more difficult because administration of the costs and billing is getting more complex each year. ICD codes, PLA codes, all that stuff grows in complexity.
HMOs, like Kaiser, may provide a route towards greater simplicity of administration of health and costs.
But implementing any large change will require political buy-in of people, and when we have our current low-trust, high-misinformation political system there's been no way to make any political traction for changing anything. Until we regain a functional democracy or turn to full dictatorship, it seems unlikely that we will see structural changes that improve anything. Hell, we had Republican states actively trying to prevent poor people from receiving coverage from federal dollars. How can we ever come to terms with a change unless that sort of attitude no longer has traction?
> ideologically they really disagree about what to do about it
I really don't understand this sentiment. It's not like the current state of the US insurance market were based on the principles of a free market. On the other hand, not coupling your health insurance to an employment contract that can be cancelled at will has nothing to do with socialism.
A Princeton study showed over a decade ago that the policy preferences of the vast majority of Americans have no correlation with actual policies. That you put forth these completely detached theories is quite impressive.
I don’t know if this a case of ideological delusion to go along with political impotence or just the usual upper middle class playing their part in obfuscating the on-the-ground realities. Structurally the latter is more likely.
But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.
I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.