Why None of Us Understand Healthcare

America’s healthcare system: We all know it’s broken.

We pay too much money, still get terrible outcomes, and, along the way, get stuck in endless bureaucracy.

How did this happen? How did the wealthiest country in the world get this so wrong?

Well, it’s obviously all the fault of the big corporations that are trying to exploit our sickness for profit.

Wait, sorry. What we meant to say is that it’s all the fault of the government bureaucrats who gave us socialized medicine.

Wait, what? Neither one of those things is really accurate? And no one actually knows how the healthcare system works? And you can’t even call what we have a “system”?

All right, folks. Guess we’re figuring this one out together.

[OPENING SEQUENCE]

There are two things — and, look, maybe only two things — you can say for certain about the healthcare system of the United States. (1) We all hate it and (2) None of us have any idea how it actually works.

For nearly 30 years, polling has consistently shown that somewhere between two-thirds and three-fourths of Americans think that our healthcare system has major problems.ⁱ And one of them might be that no one has any idea what the hell is going on.

A study in the Journal of Health Economics found that only 14 percent of patients understand even the most basic aspects of their insurance plans. ⁱⁱ Which, ok, this stuff is complicated. Maybe it’s too much for patients to wrap their head around. But at least we can rest easy knowing that the people who provide our medical care know how everything works.

Right?

Well … about that. Research has found that 92 percent of doctors agree that they have a responsibility to control costs for patients … but that only about 37 percent of them have any real idea how much things are actually supposed to cost.ⁱⁱⁱ

Isn’t this kind of weird? A system we all have to use and yet none of us knows what’s going on? Well, at least part of the problem is that even the most basic talking points we hear about American healthcare … are themselves often wrong.

For instance, depending on who you listen to, the problem is either that our healthcare system is heartless, dog-eat-dog capitalism … or that it’s bureaucratic, government-run socialism.

And honestly … it’s adorable that anyone thinks we have a system that coherent.

In reality, we have something you might call … capitalocialism?

Here’s what we mean: On paper it looks like there’s a tidy distinction. In 2021, over one-third of Americans got their healthcare from government sources: Medicare, Medicaid, or the VA.^iv The other two-third, meanwhile, had private plans.^v Simple enough, right?

NO! NOTHING ABOUT HEALTHCARE IS ALLOWED TO BE SIMPLE!

In reality, the public and the private are always blending together. Medicare, for instance, may be “government healthcare” but there’s a whole class of plans called Medicare Advantage in which the government is paying for people to use private insurance.

This works the other way too. Because even if you have “private” insurance, the specific rules around your plan — what’s covered, how much it costs, even what kind of treatment you receive — are themselves heavily shaped by government rules and regulations.

Not public. Not private. Just kind of a mess.

Speaking of messes, another claim we hear all the time is that America spends way more on healthcare than the rest of the world and still gets worse outcomes.

And that claim is … well, it’s complicated.

Why? BECAUSE IT’S HEALTHCARE, ALL RIGHT?! IT’S ALWAYS SO … DAMN … COMPLICATED.

It is the case that the U.S. spends more per person on healthcare than other wealthy countries and that we nevertheless have the lowest life expectancy amongst those countries.^vi

But here’s where it gets tricky. While the natural assumption is that those terrible numbers are a reflection on the quality of our healthcare, the data suggests that a lot of it is actually a reflection of our own behavior. Because Americans lead riskier lives than people in those other countries.

Obesity — we’re #1.^vii

Smoking deaths — we’re #1.^viii

Murders — we’re #1.^ix

Suicides — we’re #1.^x

Opioid overdoses — we’re #1.^xi

Auto accidents — we’re #1.^xii

Fatal selfie accidents — we’re #1. Don’t actually have a source for that one,^xiii but feels like it’s gotta be right.

Now, regardless of what exactly the problem is, it’s still the case that a lot of Americans would like to see the country move to a different healthcare system. After all, we hear all the time that America is the only advanced nation without universal healthcare^xiv and that claim is…

…painfully, soul-crushingly complicated. Maybe we should go back to the days where we just paid doctors with chickens.

Here’s why it’s so confusing. Americans often think that being like those other countries would mean moving to a single-payer system where the government essentially runs healthcare. But, here’s the thing: A lot of those other countries have universal healthcare — they cover everybody — but they do it without single-payer systems run by the government.

Single-payer does exist in countries like Canada and the U.K. But it can have real drawbacks. Those systems tend to be plagued, for instance, by long wait times.

As of 2021, the wait for neurosurgery in Canada was nearly a year.^xv In 2022, nearly 40 percent of patients in Britain were still awaiting treatment two months after being diagnosed … with cancer.^xvi

And it’s not as if they’re necessarily getting better care once they come off the waiting list. The survival rate for Americans diagnosed with breast cancer is actually higher than in either Canada or England.^xvii

So, what have other countries done differently?

In places like France and Australia there are mixed systems: The government provides some healthcare, but — since they can’t afford to cover it all — there are also options for private insurance.^xviii

Meanwhile, in countries like The Netherlands and Switzerland, the healthcare system is privately run, with the government merely adding subsidies to make sure it remains affordable.^xix In other words, lots of countries have been able to make sure their citizens have healthcare without turning the whole system over to the government.

So, is healthcare easy to understand? Absolutely not, we’re going to need a nap after this. But if we can cut through these misconceptions, we can start finding our way towards making it better for everyone.

Except the selfie people. Honestly, guys, that problem is on you.