Employer health plans are getting pricier and skimpier - <AUTHOR> https://www.axios.com/2019-employer-coverage-workers-premiums-deductibles-ea2cbdf3-91bd-4b4d-9611-71fd72b1140c.html <comment><USER2> Imagine if grocery stores forced us to choose one of a few dozen grocery "insurance" memberships to buy groceries, and negotiated directly with the insurers. No prices are labeled in store, they just detect whatever you take and send you a bill at the end of the month. (Differing brands of the same food product are not available in store of course.) Individuals are charged 3-100x more per product than negotiated rates, but can't find out until afterwards. Grocery "insurance" would then become a necessity. People would trade away disproportionate amounts of their salary to get good grocery benefits from their employers, i.e. to not get price-gouged by virtue of being an individual on the market. Stores would run discount programs for the very poor, which they could point to when people get outraged (as drug companies do now.) When politicians would threaten the system, grocery stores would fund ads about the "long lines" and limited food availability that would occur. Instead laws would get passed reinforcing the system by making sure everyone gets grocery insurance, as its a necessity (and it would _be_ a necessity).

I'm not saying that health care _could_ be exactly like grocery stores, with many alternatives, transparent pricing, and customers making the final decisions, but that it would have to be much _more_ like grocery stores to call it a free market. What we are working with now is just a system of pricing cartels supported by fear and lobbying. It needs to go.

<comment><USER3> Then imagine that there are some people who can't afford the food they need in the grocery store and are going to die.

Alternatives and transparent pricing isn't going to make brain surgery affordable to the average consumer.

<comment><USER4> According to Wikipedia, there are only .5% of all physicians in the US who can perform neurosurgery. So it's probably safe to say the demand for brain surgery is much higher than the supply.

This incentivises people to become doctors that perform such complecated procedures as it takes a lot of time and a lot of money to be able to do those things.

If you were to force doctors to perform work on people that can't afford it, then presumably they will earn less money. If they earn less money, there is less incentive to do that kind of work as they will pick something easier and more profitable.

You will end up with fewer people to do brain surgery.

<comment><USER5> If money were the only incentive to life no one would become a schoool teacher. Your summary is missing something.

<comment><USER4> That is true, but if you're the type of person that likes to help others it's much easier to become a teacher than doctor.

Also, if you are a doctor and your primary motivation is helping people, wouldn't you want to help many people with simple problems, than few people with highly complex problems (which most likely have a higher risk of failure)? There is already a shortage of doctors doing the easy stuff.

I just don't see the incentive for doing difficult procedures other than with money.

<comment><USER6> > Also, if you are a doctor and your primary motivation is helping people, > wouldn't you want to help many people with simple problems, than few people > with highly complex problems (which most likely have a higher risk of > failure)?

Your analysis completely falls flat here. Not all doctors are motivated by the same things and yet most of them would consider their primary motivation helping people.

Neurosurgeons are a prime example. They would very much prefer few complex cases (not everyone gets a brain tumor thankfully) as their way to maximize benefit rather than manage cholesterol meds for 100s.

Speciality surgeons by their nature are motivated by a certain degree of risk.

The incentive for doing difficult procedures is often because they are challenging. Compensation for doctors in the US isn't fully correlated with difficulty either... with no offense to my dermatology colleagues making more than most general surgery sub specialists.

<comment><USER4> > Not all doctors are motivated by the same things and yet most of them would > consider their primary motivation helping people.

That's fair. I probably over-emphasized the money part of it.

> The incentive for doing difficult procedures is often because they are > challenging.

We can assume that since doctors aren't doing this for free or at least cheap already, that they require at least some amount of compensation. To return to my original point, if you force doctors to perform procedures on people that can't afford them, and the amount they receive is less than they want, then there be a greater shortage of such doctors.

> Compensation for doctors in the US isn't fully correlated with difficulty > either... with no offense to my dermatology colleagues making more than most > general surgery sub specialists.

Not directly anyway, it's probably more supply/demand. Low supply of neurosurgeon means high cost. Whether that's from artificially suppressing the supply of these doctors or because it's very challenging is up for debate.

I'd guess dermatologists make so much because people are more willing to spend money on that sort of work.

</comment></comment></comment></comment></comment></comment></comment><comment><USER7> The problem is that there is not a _single_ reason that healthcare is so expensive. Even if you list the top 15 reasons, you still have to apply the "5 whys" to each of them to find root causes and possible solutions.

\- Doctor's are paid too much... why? \- Well they need to be paid a lot because medical school debt is 250k or more... why? \- Medical schools/the AMA are artificially limiting the number of students and residents for their own ends (keeping wages and scarcity high) so they need to charge a lot... why? \- I honestly don't know.

But the current political climate in the US is incapable of dealing with any kind of multifaceted problem.

One thing that will not make healthcare less expensive is "Medicare For All". It will just shift the bill to different people. Now, you can argue it's the morally correct course of action, or those people who will be forced to foot the bill (upper middle class taxpayers) are more capable of doing so, but you cannot credibly claim with a straight face that it will make anything cheaper. In fact, the opposite will occur.

(I don't want to hear one thing about negotiating power. That is a debunked line of reasoning. Medicare/Medicaid cover more people than many single payer systems in other countries, and their costs are still outrageous)

<comment><USER8> > One thing that will not make healthcare less expensive is "Medicare For > All". It will just shift the bill to different people. Now, you can argue > it's the morally correct course of action, or those people who will be > forced to foot the bill (upper middle class taxpayers) are more capable of > doing so, but you cannot credibly claim with a straight face that it will > make anything cheaper. In fact, the opposite will occur.

Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down. Don't want to pay what the government says it is going to pay? Good luck finding customers then, because the government is bargaining on behalf of all of the customers in the US.

People who say this stuff are the same people who proclaim there is no solution to a problem that the only occurs in the US. Literally, every Industrial Nation has addressed this problem for much lower costs with better out comes.

<comment><USER9> > Having every person under the same plan that has the negotiating power of > 327.2 million people will definitely drive costs down.

Why do you think this would be true? Why do you think the bargaining power would work the way you think it would?

If you were correct, then cop cars must be fairly cheap compared to normal cars. Is this the case?

What about other goods? Laptops? Cruise missiles? etc.

Actually is it true for _any_ good which the US Gov is the _sole_ buyer? Can you think of even a single good where your supposition is true?

<comment><USER10> Perhaps this is a good reason:

>Literally, every Industrial Nation has addressed this problem for much lower costs with better out comes.

<comment><USER9> But why those nations have lower costs isn't so simple. If you remove all profit and admin overhead from the US system, its _still_ something like $5000/person more expensive than other countries (I think that that was vs Canada).

A large component of healthcare cost in the US is simply healthcare use. We are deeply, deeply unhealthy with 75% overweight rates and absurd levels of pre/diabetes, which are the largest comorbidities of all, and comorbidities of each other. Costs will never be comparable until overweight/obesity rates and usage are comparable too. They are not.

High prices in the US are very unfortunately largely explained by usage, and no amount of profit-reducing or cost cutting will work unless you are cutting usage itself:

[https://randomcriticalanalysis.com/2016/09/25/high-us- health...](https://randomcriticalanalysis.com/2016/09/25/high-us-health-care- spending-is-quite-well-explained-by-its-high-material-standard-of-living/)

<comment><USER11> In the UK the NHS negotiates prices for drugs. NICE have to approve all drugs and if a drug is too expensive, the manufacturer either has to lower the price so that the benefit outweighs the cost, or they lose a large market.

This is why hand waving away "bargaining power" ignores one of the sources of high costs.

The other is that our doctors are mostly either employed by the NHS, or employed by a private provider who is paid by the NHS ... yes, there are doctors who do private only work, but they are fairly small in number.

Perhaps our student loans system also helps - fees are £9k a year, but you start paying them back at 9% of income over £25k ... so it's essentially a graduate tax and they are fully written off after a set number of years if you don't pay them off.

<comment><USER12> The difference in drug spending between countries amounts to a small fraction of overall healthcare spending. $1200 a year in the US versus $900 in Switzerland or $800 in Germany, Canada, and Japan.

<comment><USER13> It's incidental what the numbers are. Given how effed the US system is, I would fully expect that $1200 being spent on the entirely wrong things, like a few super expensive drugs, and a lot of antibiotics which should have been dirt cheap getting a ridiculous markup, or on Oxycontin.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER14> Yep, and what people don't always realize is that because employer health plans get more expensive every year for employers, it negatively impacts wage growth. You are paying for it even if you don't necessarily feel it.

<comment><USER15> This is really important. Pulled from the underlying study[1], employers cover 82%/70% (individual/family) of the cost of healthcare. Those numbers are down just slightly from 86%/73% in 2019.

Or, put another way, employers have borne 69%/80% of the cost of healthcare increases. You complain because your individual plan has gone up by $986 in 20 years? Your employer's cost has gone up _$4,005_. Oh, and that's _with_ cutting the underlying coverage ("skimpier").

It negatively impacts wage growth because that extra $4k is a bottom-line _benefit_ (or cost of employment, if you want to think about it that way).

Finally, note the disparity between individual and family plans. Employers are offering 2.5x more benefit—nearly $9,000 more—to workers with families.

\-----

[1] [http://files.kff.org/attachment/Report-Employer-Health- Benef...](http://files.kff.org/attachment/Report-Employer-Health-Benefits- Annual-Survey-2019)

Fig. 1.10 shows premiums increasing from $2,196/$5,791 in 2019 to $7,188/$20,576. (Note also that 72% of that is attributed to premium increases vs. inflation and worker earnings, per Fig. 1.14.) Fig 6.1 shows % of premium paid by workers going from 14%/27% to 18%/30%.

<comment><USER16> > Finally, note the disparity between individual and family plans. Employers > are offering 2.5x more benefit—nearly $9,000 more—to workers with families.

Interestingly, my employer discloses the full premium that they pay to the health insurer every year. As an employee without a partner/dependents (I just graduated college/started my career), my employer spends ~$17k/year less on my health/dental/vision benefits than employees with a partner/dependents.

That effective pay difference makes me mildly salty.

<comment><USER15> It's an interesting topic, particularly as it relates to employers being women/family-friendly. How do you feel about parental leave, for instance?

Of course, this is a benefit that's within your control: just get a partner/dependent! And the flip side is that even individual employees might value knowing that the company "has your back" as your family situation changes.

Or, more bluntly, your company _has_ to offer disparate benefits, because other employers do, and no employee with a family would work for your company otherwise.

Of course, all this masks the REAL problem that employers and healthcare are so intertwined. Even this article puts some of the blame on employers, when really it's the healthcare companies and the overall rising cost of care.

</comment></comment></comment></comment><comment><USER17> This is absolutely the biggest story in America, and most people aren't talking about it.

An entire generation is draining their savings to keep up with premium costs.

Not to mention the millions of people locked into careers they would otherwise get out of, if not for the health coverage.

This situation is probably going to lead to unbelievable outcomes.

<comment><USER18> > An entire generation is draining their savings to keep up with premium > costs.

Knock on wood but, myself and pretty much everybody I know has insurance covered ~75% through our full time employers. I think my portion of my insurance is about... $100/mo? I've never had to use it way/shape/form in the past... 5-10 years.

Isn't the truth that the most unhealthy people are what drives health care costs?

It'd be interesting to see a visual of who uses their insurance and how much of it they use. Let's not forget that lack of exercise, obesity, and heart disease are rampant in America.

<comment><USER19> Yeah, I really wonder where that $10,000/person figure comes from when you remove obesity and smoking related illnesses, so, the two highest and most preventable causes of death in this country.

I always believed you should be able to qualify for lower costs (or be charged higher) depending on how you take care of yourself. Annual physical fitness test. I'm a little sick and tired of paying high premiums for people to have healthcare that don't take care of themselves.

<comment><USER20> Many of us who won the genetic lottery are sick of paying for those who didn't

Where do you draw this line ?

If someone cannot afford to eat or live a healthy lifestyle do you kick them while they are down ?

<comment><USER18> The brotherhood of "we can all band together to pay for each other" falls apart when the line to McDonald's is wrapped around the corner in my eyes.

If you take in over 3,500 calories a day of pizza, soda, cheeseburgers, or candy then follow it up with little to no exercise/movement, you are contributing to the "health insurance crisis".

</comment></comment></comment></comment></comment><comment><USER21> The sooner we can completely divorce healthcare from employment, the better.

<comment><USER22> I hear this statement all the time...but what does it mean?

If employers didn't provide health insurance to employees wouldn't we just wind up with 40% of the insured uninsured? Its not like Corporate America is going to make up the difference and start paying cash to compensate for the lost benefit, at least thats what happened as pensions got stripped away from the workplace. Even if the employer's did make up the cash difference, its not like that will bring pricing down, individuals can't negotiate individual insurance rates, pools of employees can negotiate group rates, so if anything costs would probably go up.

How will this help: 1) insured more people; or 2) bring costs down?

<comment><USER23> Getting insurance as an individual is expensive because you're not part of a group plan. With a group plan the insurance company has some reason to believe you're not collectively a bunch of dying people committing moral hazard, you're just one of a generally similar looking company workforce.

If employers stopped providing it, I think it is presumed that the mentality towards individual plans would change

<comment><USER24> Well, one way of looking at it is that the general population is the biggest group possible :-)

<comment><USER23> Sort of. This is true if everyone is required to participate in the system. And there's only one provider. If you imagine there being a cheap plan and an expensive plan, you would probably expect that the expensive plan is a way better return on the dollar because there are fewer poor people on it weighing it down (because poor people are likely to have more health issues).

True meaning it averages out to a reasonably healthy person _

<comment><USER22> >you would probably expect that the expensive plan is a way better return on the dollar because there are fewer poor people on it weighing it down

It is unfortunately true in the US (probably everywhere) there is worse health/higher incidences of chronic conditions in the poor (mostly because all chronic conditions are diet related). However, in the US the biggest weight would be the elderly who have chronic conditions at a higher rate than any other demographic (generally due to a lifetime of poor diet combined with irregular care over their life to treat the conditions until they are Medicare), but thats the irony these are the people already covered by Government healthcare (and they seem fairly happy with it. Its time to extend it to everyone.

</comment></comment></comment></comment></comment></comment><comment><USER25> It seems like a strange omission for this article not to mention that the reason health insurance is so expensive in the US is that health expenditures are so high. The US spends more than $10,000 per year per person on health care[1], more than any other country. Clearly, on average, premiums clearly must be higher than the amount paid out on behalf of the customer.

If you want lower premiums, you somehow need to lower the amount spent on health care. The problem is that, perversely, health insurance companies are incentivized to spend _more_ on health care rather than less. By law, they must spend at least 80% of the money collected as premiums on health care costs[2]. The more they pay, the larger the 20% they are allowed to keep.

So if you want to reduce the cost of health insurance in the US, you need to reduce the cost of health care. If you want to reduce the cost of health care, you somehow need to change the incentives so that the big players benefit when the cost of health care goes down rather than up. Failing that, you need to change the system so those big players are no longer in control.

[1] [https://www.healthsystemtracker.org/chart- collection/health-...](https://www.healthsystemtracker.org/chart- collection/health-spending-u-s-compare-countries/)

[2] [https://www.healthcare.gov/health-care-law- protections/rate-...](https://www.healthcare.gov/health-care-law- protections/rate-review/)

<comment><USER26> Only the latter option is a feasible solution. If you look at countries with mixed systems (like South Africa), a great deal of the cost savings disappear. Tim Faust has a great new book that breaks this down. Also, recommend his interview on the Death Panel podcast.

[https://www.mhpbooks.com/books/health-justice- now/](https://www.mhpbooks.com/books/health-justice-now/)

[https://deathpanelpodcast.com/2019/02/02/all-care-for-all- pe...](https://deathpanelpodcast.com/2019/02/02/all-care-for-all-people-w-tim- faust/)

</comment></comment><comment><USER27> I would love if everyone that seems to be in support of a single player system would make a mental note right now that they were in support of it, and then years later after the US moves to such a system (seems pretty likely?) they review how much it helped.

I grew up in a single payer system and I'm theoretically in support of it for the many reasons people already listed in the comments (larger negotiation position, spreading the risk to more people, because it's humane, because it removes an incentive to stay in the wrong job, etc). But while I agree with those arguments I also have a strong conviction that if such a system were to be adopted in the US, it will NOT result in better care and more efficient and overall reduce the costs in the system. Not without many other changes in other laws and even cultural changes. Just because something works in Germany for example it doesn't mean it will work in the US, there are different demographics, different mentality, different service expectations, different tax system and a largely different legal and law system. Not to mention we were just discussing a few days back about the increasing national debt and this needs to be done without increasing the deficit.

<comment><USER28> I'm in the UK, and have unfortunately had all too much experience of the health care system here.

My view is that it's optimised for the majority, and for the "easy" things. For example, all the NHS endocrinologists I've seen have only really known about diabetes, the dieticians I've seen only really know about weight loss, the pain specialists I've seen have a narrow and fixed list of mess they prescribe, and the neurologists I've seen only really knew about... well, not much TBH. I can only guess it's because they're over-stretched and simply don't have time, but it's also been my experience that consultant's knowledge is way behind the times; almost like they haven't read a paper since they left medical school. Oh, and waiting list times are often ridiculous.

The NHS fails many, but I know helps far more than it fails, and if you have the money you have the option of private medical insurance or self-funding private medical care.

I'd still take our "sort of works for most people" system over that of the USA any day.

</comment></comment><comment><USER29> I see alot of the proposed solutions to the US healthcare system boil down to some form of "Medicare for all". I think a single payer system would be great and I am all for it.

That said, I doubt it would solve all the problems in the US healthcare system at this point. It seems to me the biggest one is that providers, i.e. doctors, hospitals and drug companies all bill way too much. I think it is just politically less palatable though to go after doctors than after a big anonymous insurance company.

I do remember when I had an appendix operation a few years ago and was billed $50,000 for it, including some gems such as $4,400/night just for the hospital room and $50 for 2 tylenol that the Walgreens down the road would sell you for $5 a 24-pack.

I know several doctor acquaintances making >$1m and even $2m a year - I know they get together regularly where they actually discuss techniques to bill their patients the most money. One dermatologist discovered that removing 2 skin lesions on the same day was a bad idea - he got paid about 50% less for the 2nd one that way. Sending the patient home and telling him to come back next week for the 2nd one would however double the bill. So that's what he does! More patient inconvenience and added expense - but who cares?

<comment><USER30> Everything in American society is done the way it is done because it's making someone very, very rich.

Healthcare. Education. Defence. Incarceration. Taxes. Bank Transfers. Telco. Roads. Infrastructure.

Patient convenience, Overall society happiness - whatever you want to talk about. It's a money machine. And the money is more important than the people.

</comment></comment><comment><USER31> This is why I feel the "most Americans like their health insurance" cliche is complete garbage.

<comment><USER32> Nobody does. The real translation is old people don't want to change doctors.

<comment><USER33> It's worth pointing out that for the vast majority of people doctors != insurance. The payer is not the provider.

The refrain of "people like their health insurance" deliberately conflates the two. People like their doctors, not their insurance. Doctors accept multiple insurance companies.

<comment><USER34> > Doctors accept multiple insurance companies.

Some do, but not all. One of my providers takes exactly one insurer, which I do not have, so pay out-of-pocket.

Luckily most insurance companies allow you to submit receipts to receive credit towards your deductible.

</comment></comment></comment></comment><comment><USER35> I just got my renewal quote: $2,372/month for a family of 4 is going to $2,883/month. That's a ~20% increase, to $34,595 PER YEAR.

(And this is while benefits continue to be cut back: $150/month for many prescriptions, etc.)

As others have written, there's no _single_ reason. But, I think there's a major unintended structural problem: under US law, insurance companies are required to pay a high percentage (like ~90%) of their premiums out to service providers. The intent is to cut administrative overhead.

The effect: it's very hard for an insurance company to invest in technology or administrative improvements. So, the status quo persists.

WORSE, the admin overhead is pushed onto the providers, so the overhead cost gets hidden. It's not uncommon for a family medicine general practitioner to have a back office of _3-5 people_ dealing with billing and insurance paperwork.

<comment><USER36> > WORSE, the admin overhead is pushed onto the providers, so the overhead cost > gets hidden. It's not uncommon for a family medicine general practitioner to > have a back office of 3-5 people dealing with billing and insurance > paperwork.

My old doctor from when I was a baby till he retired had a practice with three to four other doctors. They had a nurse and one of the doctors wives did all the office work, billing, and answering phones. Current doctors practice has two doctors, four nurses, and eight office staff.

Old doctors office could would take x-rays and set a simple fracture. Or stitch up a simple cut. New doctor won't do any of that.

</comment></comment><comment><USER37> Insurance companies need to be expropriated. The entire thing needs a restructure from the ground up, there are too many critical path issues that will keep things expensive if we try to have two systems at once (medicare for all + private)

the US should get real medicare, then move to a public/private system where you get base coverage through medicare and pay extra for fancy coverage.

<comment><USER20> Simply removing insurance and letting the free market adjust would fix the issue.

When I was a kid no one worried about hospital bankrupting the family. Now anything larger than a paper cut has the chance to bankrupt most families.

Combine that with the accident rate in cars you have an almost certain chance for a large percentage of the US to be bankrupt

<comment><USER37> Free markets don't work with the information asymmetries involved in healthcare.

<comment><USER20> Odd how it worked before insurance took over the healthcare system.

Care to share what you see would be different ?

<comment><USER38> 50 years of medical innovation leading to the propagation of procedures, medicines, and equipment costing upwards of tens of millions of dollars to procure and maintain.

 _Nobody_ is equipped to try to make an informed purchasing decision on if they want the $50k or $100k option to try to save their life while bleeding out of a gurney after getting hit by a car.

</comment></comment></comment></comment></comment><comment><USER14> I think another thing about employer-based healthcare that few think about is that if you work for a large company then it is almost certainly self-insured, meaning that you or your employer is paying premiums into a fund that it is managing itself.

How crazy is it to think that not only does Apple or Ford or Trader Joe's need to manage it's own business but that it is also hiring actuaries/insurance specialists/consultants etc to manage a complex insurance program for all of its workers? I'm not sure many people that work at large companies realize that their employer knows every diagnosis, procedure, and prescription you've ever picked up, and actively trying to incentivize you to use as little healthcare as possible.

<comment><USER34> > I'm not sure many people that work at large companies realize that their > employer knows every diagnosis, procedure, and prescription you've ever > picked up, and actively trying to incentivize you to use as little > healthcare as possible.

I work for such a company, and it's great. I pay about $30 per month for a plan with a tiny deductible ($2,500), and they offer great wellness perks like weekly classes (yoga, kick-boxing) in-office, partner with a local CSA that does a bi-weekly produce truck out in the parking lot. They do encourage folks to get yearly wellness screenings, and basic dental cleanings by increasing your plan by about $2 per week if you don't.

This is a single, no dependents rate. I believe the comprehensive plan, with families runs about $70 per month.

As it were, the plan is employer funded but we have some type of partnership with a major provider for administration so the employer itself isn't hiring actuaries / specialists / consultants. Perhaps your personal experiences differ here?

<comment><USER14> I don't understand your comment. If the company is large it is likely self- funded, so it is taking on the risk, whether they are doing it in house or hiring a benefits consultant to do it for them.

I didn't say anything about the quality of a self-funded plan, simply just pointing out that a self-funded plans means your relationship with your company is not merely just a worker but you morph into this insurance risk that they now have to actively manage. I am pointing out how strange it is to ask a company to have to do that, which is unlike any other country in the world.

<comment><USER34> > I don't understand your comment. If the company is large it is likely self- > funded, so it is taking on the risk, whether they are doing it in house or > hiring a benefits consultant to do it for them.

Because they partner with a larger provider for the doctor / hospital / pharmacy networks and specialist support. This is a very common pattern insofar as I'm aware.

Has your experience differed?

<comment><USER14> The network of providers available to you is a separate issue from whether your company manages the risk or an insurance company does. Didn't mention anything about provider networks.

<comment><USER34> > The network of providers available to you is a separate issue from whether > your company manages the risk or an insurance company does

What I'm saying is, my company manages the risk. We partner with a larger insurer company that provides A) network B) specialists for the roles you've claimed a company would normally hire. Because of this we don't have inside actuaries and specialists and such. As a result, there is no inside man looking at my claims.

I will ask for for a third time, have you experience that differs here?

<comment><USER14> What you've described is the self-insurance model for large companies. That doesn't conflict with any of my earlier comments. Companies can decide whether they want to administer it internally or use a consultant.

You seem to believe that just because a company uses a consultant that no one in HR or Finance or management would be privy to viewing your claims history via the consultant? Not sure what would lead you to believe that. Just because your company is outsourcing the task doesn't mean it is shielded from the data.

</comment></comment></comment></comment></comment></comment></comment><comment><USER39> Sharing this idea in order to gather critique. The cost of healthcare in the USA is insane. Could we look for insight into the US Military? Example: This morning, a coworker told me she's going to have an operation on her back. The "cost of the tray" (I have no idea what this is) is $14,000. She has to pay $8,000 up-front two days before the operation, and the remainder will be financed over two years.

To me, it's insane to think the US Military pays $14,000 for this same operation in US Veterans' hospitals. Why don't we look into the military to see how they're doing it?

Or am I completely off-base here? Thoughts?

<comment><USER40> The insurance companies are for profit corporations who pay politicians so they can keep taking your money when you're healthy and cutting you when you're not. The army is not, as far as I know, a for profit enterprise.

<comment><USER41> This is the one and true answer with regards to insurance companies.

</comment></comment></comment><comment><USER42> Healthcare is expensive and getting more so because of over reliance on insurance and government imposed restrictions on supply. See "Overcharged" for a detailed summary of the issues: [https://www.amazon.com/Overcharged- Americans-Much-Health-Car...](https://www.amazon.com/Overcharged-Americans- Much-Health-Care/dp/1944424768)

</comment><comment><USER43> In no other country is your healthcare tied to your employment but the US. Germany has had a national healthcare system since around 1880 (after the country was unified, based on what Krupp did for their employees). Why is the US the outlier (also in cost per capita)?

<comment><USER44> During World War II wages were frozen to focus on the war efforts so employers used ancillary benefits to attract workers. Then things carried on from there. [https://www.nytimes.com/2017/09/05/upshot/the-real-reason- th...](https://www.nytimes.com/2017/09/05/upshot/the-real-reason-the-us-has- employer-sponsored-health-insurance.html)

</comment></comment><comment><USER45> Even at famously generous employers they will try very hard to push you towards high deductible plans by giving you 1-2 thousand extra dollars per year in your HSA. Of course the high deductible plans discourage you from seeking care so it saves your employer peanuts it can add to its war chest in Ireland

Some of this probably has its roots in the ACA adding extra taxes onto "Cadillac insurance plans" though which I didn't even learn about until recently. Yes, apparently you may need to pay extra taxes for extra good insurance

<comment><USER46> I manage a health plan for our smallish business of 19 employees. We offer "pretty good" health insurance, meaning, we pay around $600 per employee per month for health and dental. It gets worse every year. I am considering moving toward a HSA based plan, because upon analysis, it's actually probably better for everyone involved. The max out of pocket per year is the same, but instead of a $1000 deductible you have a $5k deductible. This works for our business (and I am assuming a bunch of other tech businesses) because our employees are generally young and in good health. It's a cheaper plan, the worst case scenario for an employee is the same, and I can give raises for the difference in price, and once every few years someone will need more than a $1k deductible, but the raise from the last couple years greatly exceeds the one time cost.

Anyway, just trying to frame my logic here, because I don't consider myself an evil employer trying to skimp on health insurance for my employees (which many I consider friends), but an employer that has to approve health plan changes annually which each increase cost by a considerable amount. If this trend continues, each employee will cost $900 a month within 5 years, and the coverage will be half as good. That's $5k a year per employee that I could put into their salaries, while not screwing anyone over on the worst case scenario.

<comment><USER45> From my perspective, I am unlikely to hit the out of pocket maximum but quite likely to spend more than $1k/year. All the high deductible does is discourage you from seeking care for things before they become serious. Not sure how it worked from the employer's end, but $5k/year will get taxed at roughly 50% before I see it so it's not clear whether that will be greater than my out of pocket costs

<comment><USER47> The missing link here is premium savings. HDHP plans exchange higher deductibles for a nontrivial premium discount. Insurance companies like to assure employers that employees will bank this discount into a tax-advantaged HSA. So the theory goes, a reasonably healthy subscriber will have sufficient savings to meet their deductible.

This falls apart in practice when employees, who are already spread thin financially, elect an HDHP but can't or won't set aside cash to cover expenses.

</comment></comment></comment></comment><comment><USER48> There aren't many industries where price shopping is as hard as healthcare. When you remove the cost of a good so far from the actual beneficiary costs become incredibly hard to control.

Not many here will remember when the insurance markets started in the US, but the original deal was that people pool their resources and get a discount vs street rates. However now that everyone is pooled, what possible metric can you use to determine if you are actually getting a good deal?

Sure, we hear stories of outrageous bills that are sent to patients that their health insurance "covers". However, the reality is the insurance company expects a discount which has caused an opposite effect to uninsured patients. Costs go up so that the "deal" the insurance company gets looks good. All the stories about $20 pill of Advil, is all pointing to the leverage hospitals and doctors used to fight cost cutting at insurance providers.

I think there are only two ways to resolve this at this point. Build a free market solution where price transparency is required and make it easier to shop for non-emergency care, while the government continues to cover emergency visits or full single payer healthcare with the government footing the bill.

Based on the moral logic that many U.S. citizens see healthcare and life savings services as fundamental right, I think we inevitably will need a single payer system in the US. I know the desire is to see something federally mandated but I am quite surprised that not one state has taken up the idea of single payer and made it a system available to all residence who prove they have resided in their state at least X days. I'd like to see the different solutions presented in each state and let the state with the best healthcare solution win and eventually become federal.

</comment><comment><USER49> The U.S. is supposed to be immune to this in principal due to the nature of states being test beds of policy. The only reason this is happening in all states is because of federal policy that has destroyed the ability of states to experiment in this area.

When you ask for zero risk, you are asking for infinite cost.

</comment><comment><USER50> If you want to blame anyone, blame the RAND institute with poor studies that pump up the hype around high-deductible plans: [https://www.rand.org/pubs/technical_reports/TR562z4/analysis...](https://www.rand.org/pubs/technical_reports/TR562z4/analysis- of-high-deductible-health-plans.html)

My last reading of their work was years ago, but at the time the study found that folks will use fewer health resources when on a high deductible plan. However--the study allowed folks to revert to their old insurance (i.e., lower cost insurance) if they got sick. Meaning the study would show those in high- deductible plan would use fewer resources only because the people in that plan who used more resources quit the study.

</comment><comment><USER51> The entire health insurance industry makes ~$25B in profits a year, correct? That doesn't seem overly large considering it is the entire insurance industry.

<comment><USER52> It's not only profit. They also cause a lot of administrative overhead. For example if doctors had to deal only with one insurer or at least one coding system they wouldn't need four billing assistants as I have seen. In essence insurance companies do a lot of unnecessary stuff. Their profit is only a small part of that cost.

<comment><USER53> There are two coding systems (ICD - for diseases, and CPT for procedures) that are mandated to use by medicare/medicaid and all the insurance companies use them as well. Most of them even accept the same forms. They need those billing assistants for other reasons.

<comment><USER52> "They need those billing assistants for other reasons."

Whatever it is they do exactly it deals with insurance companies. Germany also has private doctors but they have much smaller staff and dealings with insurance are very straightforward. American insurance companies cause a lot of friction. I don't know exactly why but they do.

<comment><USER53> Insurance companies are mainly trying to combat fraud. They kick back claims if they are formatted wrong (why did you code an operation on the left knee when the right knee was the problem), or they deem that the work done was improper, unnecessary or does not fit the standard of care. Billing staff also handle accounts receivable and collections.

The biggest problem IMO is how we structure payment for health services in the USA. The fee for service model is highly inefficient and disincentivizes preventative care. All of the current proposals for universal healthcare do not address this fundamental problem, and so long as this remains in place we will continue to have the highest costs in the world. (disclosure, I am working to try and solve this problem)

If you were to pick countries to emulate, I would pick Singapore, Japan, the Netherlands, and Switzerland instead of Canada and the U.K.

</comment></comment></comment></comment></comment><comment> non-entity I was just thinking the other day. Every job I've had has offered health insurance through the state BCBS. Those plans are ways a little over $100/m (for a single worker)

Meanwhile, I've had people brag to me about paying $10/ for damn to near full coverage. I'm starting to wonder if BCBS employer plans are just garbage

<comment><USER54> The average health insurance monthly premium for individuals is a couple hundred dollars ($321 in 2017 per [https://www.cnbc.com/2017/06/23/heres-how- much-the-average-a...](https://www.cnbc.com/2017/06/23/heres-how-much-the- average-american-spends-on-health-care.html) ; it'll be higher now). $10 or $100/month both mean the employer is chipping in a bunch, they're subsidized via the exchange due to low income, or they've got absolutely garbage coverage that won't actually pay for anything significant.

This is why the linkage to employers for coverage is so insidious - it hides the true cost of the system in lowered salaries. People look at an unsubsidized exchange plan like mine, with its $2,144/month premiums, and go "holy shit, I only pay $10/month for mine at work, that's horrible!"

<comment><USER55> My wife just took a job at a place that has a 'good' health insurance plan.

If she opted into it, her contribution would be ~$300/month, her employer's contribution would be $900/month.

If she wanted to cover me with it, her contribution would be $1,500/month, and her employer's would be $900/month.

Unsurprisingly, we did not take advantage of this, and she remains on my insurance (Since my employer handles 90% of the premium for both of us.)

When we were still dating, I had a good look at what the $300/month health plans provided. Absolutely flippin nothing. Deductibles of $8,000/year, and co-pays of 25%. If all you can afford is a $300/month plan, there's no way in hell you can afford an $8,000/year + 25% medical bill.

Meanwhile, Canada provides universal healthcare for $5,200 USD/year/person, with similar health outcomes.

Edit: fixed a typo in the employer's contribution.

<comment><USER56> Coinsurance is paid only until the out of pocket maximum is met, no?

I have a plan on the state exchange for around $300/month and an out of pocket max around $8k (I'm 34 years old).

I just budget $12k/year for healthcare and move on. This seems reasonable for people who can afford to take the risk of potentially having to pay anywhere from $4-12k/year.

</comment></comment></comment></comment><comment><USER57> Definitely feeling this during my company's health insurance renewal this year. I used to think that I had it pretty alright, but over the past few years, things have gotten worse and worse. This year, for our "gold" plan, which was sold as the equivalent of the previous year's "gold" plan, our insurance provider increased our monthly cost by approx $120/mo, and increased our deductible by $5,000, up to $15,000.

I used to be against single payer, but now I'm rooting for any politician that thinks they can pull it off. I'm willing to pay a bit more tax in exchange for no longer having the "best" health insurance plan that I can afford that, quite frankly, I am terrified to use. Health care costs in this country are completely out of control. We need to have the system burned down and rebooted.

</comment><comment><USER58> The American health insurance system is not insurance--it's a long-term payment plan. Why does insurance need to get billed when I go for a yearly checkup with my doc, or when I pick up some prescription-strength ibuprofen? My auto insurance company doesn't get billed when I get the oil changed in my truck. My homeowners insurance company doesn't get billed when I have to recharge the refrigerant in my heat pump. The insurance companies have taken all the monetary interactions between clinics and patients away, except for the (oftentimes criminal) balance billing that occurs when your claim was denied for some ass-hat reason like "You didn't tell your insurance company whether or not you had other insurance."

</comment><comment><USER55> Of course they are, healthcare costs are growing in an unbounded manner, way ahead of inflation.

<comment><USER59> Why is this? Are there more sick people or just more people?

<comment><USER60> The healthcare system has become a symbiotic relationship where providers and insurance companies work together to funnel money from just about every business in the US into their pockets.

Hospitals increase staff to justify billing more, then insurance companies use increased costs to justify raising rates. Internally, hospitals and insurance companies are also in a tug of war over their slice of the pie. These conflicts introduce even more people-hours into the treatment of patients, in the form of revenue cycle managers, lawyers, medical coders, etc.

Each new layer added to the cost onion of healthcare results in the pie growing, since most insurance providers can only take in some percentage of what is spent. So they need to spend more to make more.

<comment><USER61> Incentives. There is no incentive for a doctor that sees a patient to provide a favorable outcome for the patient. Whether the patient stays sick or not, the doctor still gets paid. But here's the kicker: The doctor gets paid even more if the patient has to come back. The payments come from the insurance company.

Take this concept to the level of a very large health care network (but non- HMO). Patient has early signs of serious but uncommon condition, goes to doctor. Doctor checks for common, obvious things. Finds non-specific symptoms, refers patient to a specialist or three, and the patient is diagnosed with "Not-My-Problemitis".

Disease progresses and the patient is now able to tell the majority of the symptoms are vascular in nature, not muscle or bone as previously thought. More referrals are given. The specialist orders a battery of tests, but they yield false negatives as the symptoms are not occurring at the time of the test, and the patient was not advised that the symptoms needed to be occurring during the test for it to be valid. Patient is again diagnosed with "Not-My- Problemitis" and possibly referred to a research institute, where they'll have quite a long wait time.

By this point, the patient may have lost their employment due to the frequent sick time and time off for appointments, and generally being frustrated in general. They can qualify for Medicaid but will have to start the process over again, but much slower as providers have to tread carefully with care received under Medicaid supervision, as if they were treading on thin ice. But oops, the patient has now gone into critical condition and is sent to the ICU, which is statistically likely to be owned by the same health organization that had their hands involved in the patient's earlier care.

Due to the patient's hospital visit, regardless of whether the patient survives, a payout of Six or even Seven figures is rewarded. Ka-Ching! Insurance companies are hesitant to deny those kinds of claims now, if they involve life or death. Too much bad PR. Thanks, Michael Moore! Of course, it doesn't work out as well for the hospital if the patient had lost their job and is back on Medicare, as there isn't much profit to be made there, if any. That's just the collateral cost of doing business.

</comment></comment></comment></comment><comment><USER62> This is the first year I have had to really utilize my healthcare coverage to its fullest due to a cancer diagnosis in my family. I work at a very small company doing its best to provide a decent healthcare plan, but with our numbers we have very high monthly premiums plus a high out-of-pocket maximum for me to reach (which will now likely happen every year).

I can't help but wonder if I am paying WAY more with my current healthcare plan than if I didn't have any insurance at all and negotiated the "uninsured" price per each service myself.

</comment><comment><USER63> They really should offer the employee the option to take the benefit in cash instead of getting the health insurance then you could barter with the healthcare centers. The health insurance and healthcare centers(hospitals/clinics) are a cartel and the only way to bring down prices is through competition and that doesn't happen when you give an arbitrary amount of your paycheck to a clandestine insurance agency that has dubious relationships with the hospitals.

</comment><comment><USER64> Because you can't buy true insurance. You are buying a combination of prepaid healthcare - often including things you don't need - with some insurance features attached.

</comment><comment><USER65> Does anyone know the extent to which this is happening faster or slower than the background increase of medical care costs? I know that historically medical care costs have been outpacing inflation. So it's not altogether surprising that, in an unsubsidized environment, the costs to the end-user of that care would also increase, by roughly the same amount.

</comment><comment><USER66> Where I work (in the USA), we have an employer-paid plan. There are no weekly premiums paid by the employees. There's a minimal deductible, around $500-1500 maximum per year.

The employer gets the bills, they pay them. They belong to a cooperative and get negotiated rates, they have a provider network and everything.

Why isn't this more common?

</comment><comment><USER9> Is there even a single _non-political_ way that plan buyers can, even in aggregate, do something about this?

<comment><USER67> Stop getting sick and having to use the healthcare system. So no, not really, unless we change our living habits as a civilization, but then we get old anyway.

<comment><USER9> Well, I think there's some literal truth to that.

Even though I seem weirdly unable to get sick, and I've been to a doctor once in 15 years (just to get a note! required by other insurance), I still have to pay unfunny premiums. So being super healthy still doesn't help.

AND YET if everyone in aggregate used less healthcare, I bet it would do more to move the needle than anything a politican plans. Americans are deeply, deeply unhealthy and I wish I could convince them all to eat better. To me it is just wild that so many people complain about non-insurance healthcare costs but do not want to invest in better food/behaviors for themselves.

<comment><USER68> I'm a lot less salty because the money I pay is being used to treat everyone who gets sick, including poorer and older relatives and neighbours, and nobody looses their house and life due to healthcare costs.

Even if you pay a lot (because you can, with high income) there is a clear benefit for the people around you, not just cooperations. Basically, everyone around you is safe, and that's a good feeling.

(Germany)

</comment></comment></comment></comment><comment><USER69> It's the supply, stupid.

Congress limits the number of medical school students, thus limiting the supply of doctors.

You see all kinds of programs to introduce more STEM or coding camps into public schools. But you won't see schools encourage more doctors. Why? Because of special interest groups.

</comment><comment><USER70> Hm, 7100 USD for a single person seems pretty affordable. Sounds to me like the US healthcare system is a lot more affordable than they made us believe.

In Germany, with my income level, I pay about 17000 EUR (roughly 18600 USD) per year (of which my employer pays 50%).

</comment><comment><USER71> Our healthcare system is so wildly (and increasingly) inefficient, I don't doubt there will be a breaking point when politicians will finally be forced to nationalize it. Let it keep getting worse. Let them see the bed they're making.

<comment><USER72> They are covered %100, they won't feel the bad they're making.

<comment><USER71> Fortunately, pressure on politicians doesn't come solely from how their policy affects their own lives.

</comment></comment></comment><comment><USER73> If any of y'all have questions about the process for getting a Tier-2 visa in the UK, I know waaaay more about that than I wish I did.

(I'm an American living and paying income taxes in the UK as a software engineer. It is an option.)

<comment><USER74> Genuine question, what is the link between a tier-2 visa in the UK, and the subject of the story. Thanks.

<comment><USER75> GP is implying that us Americans all want to flee our country for his just for their "perfect" healthcare system.

<comment><USER73> Why would a Brit know anything about the visa system in the UK (unless they were a solicitor)?

NHS isn't perfect. But its cost structure is miles more navigable and we've found wait times better.

</comment></comment></comment></comment><comment><USER51> How much of this problem goes away if price transparency is required by regulation?

</comment><comment><USER76> [https://news.ycombinator.com/item?id=21074455](https://news.ycombinator.com/item?id=21074455) is a related article, whose thread we merged into this one.

</comment><comment><USER77> I thought it was fairly common among tech companies to provide 100% paid health, dental, vision for the employee and dependents?

(Current company does, and I've had this at previous jobs also)

</comment><comment><USER78> And here I was expecting that an environment that suppresses price information and and eliminates competitive pressure would just get cheaper and better over time.

Silly me.

</comment><comment><USER79> Is it possible for an American to move to Switzerland?

<comment><USER80> Yes, it is possible. Our health insurance is only slightly less expensive, though (and can only be paid with post-tax money). We hold the proud second place in healthcare costs.

You'll also have some issues with opening a bank account here — Swiss banks are not particularly fond of US customers, because of reasons.

</comment></comment><comment><USER81> If this is the price of living in the land of the free (and the home of the brave), then count me in. Freedom isn't free, folks! /s

</comment><comment><USER82> What makes health insurance cheaper is a larger pool of people. There is no other mechanism by which costs can be reduced.

This is why a single payer system is dramatically cheaper. It ensures complete coverage, reducing the cost of insurance to it's minimum. Furthermore, it leverages the collective bargaining power of all subscribers.

There is no substitute for a national health insurance, and the United States slowly bleeds money, time, and health outcomes every day we continue with our current state.

<comment><USER83> What makes health insurance cheaper is _not paying for as many expensive operations per capita_. While there are a host of factors making US health insurance expensive, the critical factor since 2008 is laws: laws which require that the insurance cover patients who will have very expensive operations, and do so at the same rates as other patients.

The primary advantage of a national health insurance scheme is that it can ration its care for expensive operations, and people won't be able to yell "Greed, greed!" at insurance companies as a scapegoat (ignoring that the profit margins sit at about 4%, which is not exactly the sort of health insurance savings that would fix anything).

<comment><USER84> There is little evidence to support the "US consumes too much healthcare" narrative and some good evidence that our total healthcare spending is inline with our level of wealth [0]. There is quite a bit of evidence to support the "Prices for equivalent healthcare are significantly higher in the US".

[0] [https://randomcriticalanalysis.com/2018/11/19/why- everything...](https://randomcriticalanalysis.com/2018/11/19/why-everything- you-know-about-healthcare-is-wrong-in-one-million-charts-a-response-to-noah- smith/)

</comment></comment></comment><comment><USER85> Stop voting up all these people that don't want to fix it. It's that simple. Just stop it.

</comment><comment><USER86> We have politicians now saying they want to ban private health insurance.

</comment><comment><USER87> Is it possible that it is due to more people becoming insured that are burdensome on the system?

I thought it was pretty expected that as you get more of the unhealthy parts of the population into healthcare, costs will rise for everyone else.

<comment><USER54> Part of the goal of the individual mandate in Obamacare was to force _healthy_ people to obtain meaningful levels of health insurance to offset that.

</comment></comment><comment><USER88> I think Warren said it right in the last debate I also have never met anyone who likes their health insurance. Medicare for all is supported by 72% of people according to polls. I think it is time we go for it.

</comment><comment><USER89> Where's the regulation?

I'm upset that the democratic party has been increasingly more focused on social issues than worker issues in the last decade. Once neither political party cares about the working man then you'll start to see unregulated capitalism like whats happening with healthcare/insurance costs.

The republicans are starting to care more (or at least pay lip service) for the working person but neither party is fully committed.

</comment><comment><USER90> Cadillac plans getting taxed?

</comment><comment><USER91> The American health insurance and payment system is a huge mess and is only getting worse.

</comment><comment><USER92> Open the market. Liberalize the selling and buying of healing goods and services. Abolish patents. You can even keep some certification of ability and quality, as long as they're on point (no 6 years training for stitches), specific, free and unlimited in number.

Put current psychopats behind the medical industry under death penalty as a warning for future generations. Seems harsh but they killed hundreds of thousands, maybe millions, and all for unjust profit. They deserve it.

80% cancers cured in max 20 years. No more threads on hacker news about people going around like dogs begging for a decent diagnosys. Stem cells for every need at costco, top quality. Problem solved.

</comment><comment><USER93> So many healthcare deniers in this thread. This is, what, the second or third _presidential election_ we've had where the central debate is about the skyrocketing cost of healthcare? Government healthcare has been shown to work in multiple other countries with lower costs, but I guess we can't let facts get in the way of HURF DURF SOCIALBISM HURF DURF.

If only your local MD could cure criminal stupidity.

</comment><comment><USER94> My BCBS plan has a $4,000 deductible per insured person per year.

</comment><comment><USER95> Maybe things would be better if people paid for their own health care? Having workers pay for their own healthcare along with the healthcare of those who are unwilling/unable to work just means that things are going to be expensive for workers.

</comment><comment><USER96> Because medicine isn't paid for as a government-provided service. Insurance companies exist to profit - they defer risk. It is not a public service. I have a pre-existing condition, and I have a very mild case of Cystic Fibrosis: my healthcare at market costs about $500k a year. There's a lot of nuance to how much insurance companies actually pay out, etc, but looking at it in a simplified manner, it takes 25 families at $20k in premiums a year (with no claims to pay out) for them to break even on one of me.

tl;dr Health insurance is a for profit product, not a public service.

<comment><USER97> Time to change that! :)

<comment><USER96> No doubt. The tough questions are around where will the sacrifices be made?

<comment><USER97> Marketing, claims denial, billing and executive compensation budgets that together amount for 20% of the expenditure of an average US insurer after they were legally capped to that level.

<comment><USER96> Even eliminating those expenses doesn't really help much. It just changes the numbers in the headlines. $16k in premiums is still tough for most US families.

<comment><USER97> It's still $0.6 trillion dollars saved per year, and a solid place to start. There's all sorts of other places that a socialized system saves of course. This would at least make the US no longer far and away the worlds worst.

Bringing everyone under a single umbrella should reduce everyone's cost of coverage to the per capita cost, $10K (now $8K after savings). Then as a progressive tax system yields costs that scale according to your income the least able to afford it pay much less than that and the most able pay much more. Done and done. This is what the rest of the world does, no new ground is being broken here.

</comment></comment></comment></comment></comment></comment><comment><USER98> If you think health care is expensive now, wait until it's free.

<comment><USER54> We're just gonna pretend Europe, Australia, Japan, Canada etc. don't exist?

<comment><USER98> Those countries are smaller and most likely have more functional governments than the United States. Having a dysfunctional government is a feature, not a bug, but it does mean that the national government would do a bad job running the health care system.

<comment><USER54> Germany's nearly 90 million people. What about a 90 million person health system can't be done with 300 million? At what point does this magical impossibility kick in?</comment></comment></comment></comment>


EU's answer to AWS hailed as "the most important tech project in a generation" - <AUTHOR> https://tech.newstatesman.com/cloud/gaia-x-cloud-project-peter-altmaier <comment><USER2> Will need very talented programmers, data center designers and excellent management. Good luck with that.</comment>


What we might have to teach before Computer Science - <AUTHOR> http://maxhorstmann.net/blog/2015/10/17/fundamentals/ <comment><USER2> The point of teaching some computer science and _programming_ to children, is EXACTLY to teach them:

\- (very) critical thinking

\- (very) high attention to detail

\- using very precise language

\- navigating multiple levels of abstraction

\- applying logic and reasoning

And definitely NOT to make them professional programmers, or to teach them some programming language or system useful for their professional life.

The thing is that learning programming is the most effective way to teach those skills.

Teaching mathematics (and making them build theorem proof) fails to teach that to most pupils, because they don't see the purpose of maths (it remains too abstract to them). Teaching them any other matter is even worse for this same reason. Also, one problem of maths teaching (and also for other matters), is that the entity that detect errors and correct or help the pupil find a correction, is the human teacher. This error detection and correction made by a human is loaded with human relation interferences that are often nefarious for the learning experience. ("I wasn't good at maths because the teacher didn't like me", or "I didn't like the teacher", etc).

On the other hand, the computer is a neutral tool, and when the computer system signals an error, and give some clues as to how to correct it, the pupil can remain receptive, without any emotional involvement about it. The error is not something that is wrong with the pupil, but really something that is wrong in the program, external to the pupil, and that the pupil can correct. And as importantly, as mentionned above, contrarily to maths, when the program is done and correct, you obtain a concrete result, a running program! Once you've led a pupil to the steps showing him how to write his first program and have it run successfull, they are generally hooked and can't stop making progress.

What's the point of using a precise orthography, (beside avoiding bad grades given by this evil teacher)? But when the computer says invalid token or undefined variable, the pont of using a precise orthography is immediately clear, and the correction gives an immediate positive feedback in the form of a running program.

What's the point of logic and reasoning? (All this mathy stuff, useless!) Well, not so useless, when it allows you to build a program doing what you want in all cases, or when it allows you to find the bugs in it.

What's the point of being attentive to details? Nowhere, in the life a children, do details matters. But when he writes a program, all the details will matter, producing results differing to what he wants to obtain. Here he will learn to be attentive to details.

And where else do you have multiple level of abstraction available to you, for study, creation and modification? Can you play with your cat, and deconstruct it's biological system, enter a cell, and study its thermodynamics, enter the molecule and play with its electron cloud? Can you change the charge of the electron and see what changes two level up for the poor cat? NO WAY! Only when writing programs, you can build such layers of abstractions and there you can learn how to navigate them. There is ABSOLUTELY NO OTHER WAY to teach that to pupils.

And finally critical thinking. While some critical thinking could be taught without learning programming, it is not something that's usually taught early, because it relies on logic and reasoning and knowledge of a lot of historical, sociological, and philosophical data that is available only later. Some stuff could be done with physics or chemistry EXPERIMENTS, but the problem is that it seems that it is much more costly in time and resources to have pupils perform enough physical or chemistry experiments than merely having them program. So here, since programming will teach earlier logic and reasoning, and attention to details, it will also, in the context of programming, but also extending to the wider real world, if they write "useful" programs in relation to the world (a game with a physical simulation, a social application, or any program whose specifications are actually imposed by "users"), they will have to learn at least some form of critical thinking. At the very least, when they'll learn the other matters, they will already have tools to extend their critical thinking to those other domains.

Really, the only thing you need to teach before Computer Science, is reading writing calculating, some maths, some physics, and that's about it. Having to write a program will then motivate them to learn the application domains.

If you want to write a realistic 3D game, you will learn some physics, if you want to write a translation program, you will learn some linguistics and statistics, etc. At this point what teaching programming has done, is basically to introduce the Montessori method surreptitiously.

<comment> loup-vaillant > _Really, the only thing you need to teach before Computer Science, is > reading writing calculating, some maths, some physics, and that 's about > it._

Maybe not even. Alan Kay & co, with Scratch, used to teach physics and Science (with a big S) with the aid of programming. One of my favourite example was the teaching of Galilean physics by filming the fall of a rock. The reported result was that without the computer, almost no child could understand how it worked. With the computer, almost all children were able to _derive a model_ by themselves —I suppose with some guidance.

</comment></comment><comment><USER3> __TL;DR: Want your kids to learn how to code and have a job __? Incentivize it with some cool hardware, and let them run wild. Not every student learns the same way, and not every single one will write perfect code every step of the way. But they are smarter than you think, and you can learn logic and critical thinking on your own. (Though a good teacher wouldn't hurt)

 __TL;DR: Want better teachers?? __Raise their salaries and respect them professionally, like some countries in southeast Asia and Japan do. Don't let parents tell teachers that the teacher should have given them a perfect A+, and their corn-flake special child is perfect and isn't understood by the rest. Teacher, after all, are professionals trained in the art of education, child psychology, etc. Reduce the amount of bureaucracy, or completely reboot the public school system by some disruptive measure.

\-- My full arguments here I think your arguments are on the right track, and I agree that (very) critical thinking should definitely be part of a school's (heck, even federal) curriculum, but in practice, I think mayor's De Blasio's program ([http://www1.nyc.gov/office-of-the-mayor/education- vision-201...](http://www1.nyc.gov/office-of-the-mayor/education- vision-2015-computer-science.page)) is a good policy to effect the kind of change we want to see.

As someone who has gone through the public education system in the United States, Argentina, and Israel, whose parents are (still) high school teachers, whose wife was a public school teacher, I can tell you first-hand that most school teachers get paid a really crappy salary; in New York City (see charts [http://schools.nyc.gov/nr/rdonlyres/eddb658c-be7f-4314-85c0-...](http://schools.nyc.gov/nr/rdonlyres/eddb658c-be7f-4314-85c0-03f5a00b8a0b/0/salary.pdf) and [http://www.uft.org/files/attachments/secure/teacher- schedule...](http://www.uft.org/files/attachments/secure/teacher- schedule-2009-2018.pdf) ), the starting salary is $45,000 annual, and the current ABSOLUTE MAXIMUM (22 years of experience with a bachelors and a masters degree) is $100,049. There are some ridiculous things about this chart, including the fact that it's set UNTIL freakin' 2018.

Teacher often barely get a 1% salary raise (on a good year), and, to make things worse, are the only professionals in the US where the government tells them exactly what they should teach each day, every day, only so kids could pass some standardized national test (see: the No Child Left Behind act that Bush gave us).

Don't forget that these are just salaries, in New York city, which are unusually high for the rest of the United States. Look up Texas -- the starting salary is $27,540 ([http://tea.texas.gov/Texas_Educators/Salary_and_Service_Reco...](http://tea.texas.gov/Texas_Educators/Salary_and_Service_Record/Minimum_Salary_Schedule/2014-2015_Minimum_Salary_Schedule/)), which is hovering near the poverty line in the United States. And yes, some schools actually give teachers these salaries (usually in more rural areas). Compare that to the average threshold of poverty([https://www.census.gov/hhes/www/poverty/about/overview/measu...](https://www.census.gov/hhes/www/poverty/about/overview/measure.html)) in the US, and you will be embarrased to live in this country, and awed.

That means that, those really smart people you want to be teaching your future children are going to, by an large, opt-out and become lawyers, doctors, or, case-in-point software developers, but not teachers.

I have seen this at every step of my education, where my teachers often told me that I had a lot of potential, but they often failed to really challenge and in the math and logic department. (e.g.: If it hadn't been for my middle- school physics class in Argentina (Jesuit schools for the win), I would have failed college physics, because my public US high school teacher couldn't really teach it.)

This is why private and charter schools exist. The US public school system is cyclical with its policy (more testing, 10 years pass, do less testing), slow to move, inefficient, beaurocratic, and by and large broken. Even Zuckerberg tried to donate some money recently, and I believe it didn't really work out very well in that regard.

But hey, some of us made it out of there and did okay.

On the flipside: English teachers (in my experience) generally do a good job at teaching critical thinking and writing because there is a large number of people with degrees in the language arts, so there's plenty of healthy competition there. Not so many CS graduates go straight into teaching.

 __\-- Arie Litovsky, Co Founder of Teaching Table [@arie_speaks]([https://twitter.com/arie_speaks)**](https://twitter.com/arie_speaks\)**)</comment>


Apple's Samsung Apology Hits the UK Newspapers, Doesn't Seem Any More Heartfelt - <AUTHOR> http://www.gizmodo.co.uk/2012/11/apples-samsung-apology-hits-the-uk-newspapers-but-doesnt-seem-any-more-heartfelt/

<comment><USER2> What are Apple and Samsung.. two primary school children who have to apologize to each other 'properly' for an altercation in the playground?

Nonetheless, the amusing thing is that by all this playing around, the story is getting _far_ more press and reaching readers who wouldn't otherwise be hearing about it.</comment>


Simplifying the Data Access Layer with Spring and Java Generics - <AUTHOR> http://www.baeldung.com/2011/12/08/simplifying-the-data-access-layer-with-spring-and-java-generics/ Simplifying the Data Access Layer by using a single, generified DAO, will result in elegant data access, with no unnecessary clutter. Yes, in Java. <comment><USER2> verry good info

</comment><comment><USER3> nice article.

</comment><comment><USER4> very challenging</comment>


The Harmful Consequences of Postel's Maxim - <AUTHOR> https://tools.ietf.org/html/draft-thomson-postel-was-wrong-00 <comment><USER2> While this doesn't settle any of our debates, it's interesting to note that there's a real question about whether today's debates have anything to do with what Postel originally meant: [http://www.cookcomputing.com/blog/archives/000551.html](http://www.cookcomputing.com/blog/archives/000551.html).

The robustness principle is so compressed that it invites the reader to project an interpretation onto it.

<comment><USER3> Great point.

The original Usenet _comp.mail.pine_ newsgroup post [1] by Mark Crispin (father of the IMAP protocol):

      This statement is based upon a terrible misunderstand of Postel's
      robustness principle. I knew Jon Postel. He was quite unhappy with
      how his robustness principle was abused to cover up non-compliant
      behavior, and to criticize compliant software.

      Jon's principle could perhaps be more accurately stated as "in general,
      only a subset of a protocol is actually used in real life. So, you should
      be conservative and only generate that subset. However, you should also
      be liberal and accept everything that the protocol permits, even if it
      appears that nobody will ever use it."

[1] [https://groups.google.com/d/msg/comp.mail.pine/E5ojND1L4u8/i...](https://groups.google.com/d/msg/comp.mail.pine/E5ojND1L4u8/iYunDY6h_xMJ)

<comment><USER4> I don't give this reminiscence ANY credit. The very first version of Postel's law makes it VERY clear that Postel intended his law to deal with non- compliant behavior in a tolerant or "liberal" way: "In general, an implementation should be conservative in its sending behavior, and liberal in its receiving behavior. That is, it should be careful to send well-formed datagrams, but should ___accept any datagram that it can interpret_ __(e.g., __ _not object to technical errors_ __where the meaning is still clear). "

See my potted history of Postel's law: [http://ironick.typepad.com/ironick/2005/05/my_history_of_t.h...](http://ironick.typepad.com/ironick/2005/05/my_history_of_t.html)

<comment><USER2> Nice to see that so well documented: I'd only seen the one most common reference, RFC 793.

That said, it's still unclear how far this extends: the example given is of an unknown error code, which might lead you to think that the requirement is "syntactically well-formed input where you can't 100% determine the semantics." That's a far cry from the way browsers handle malformed HTML. Similarly, you have to apply some judgment concerning what an agent can interpret the meaning of.

</comment></comment></comment></comment><comment><USER5> I have a hard time not to be sarcastic about the author's naivete.

He does acknowledge that Postel's Maxim might be essential to any widely deployed protocol that wants to be successful. He also acknowledges that his alternative is inaplicable to the early life of a protocol.

The main two flaws in tghe reasoning is that incompatibility or bugs are not intentional and that success is contingent on something 'just working'. For a thousand-feet views, you want errors, whatever their source, to propagate as little as possible and affect as little of a network as possible. Postel Maxim provides that effect. Being strict ensures that some process somewhere over which you have no control will affect your system.

Fortunately, it's being applied everywhere, notwistanding purists. Your house electrical input gets filtered and aim to provide a standard volatge. Your computer power supplies filters that and aims to provide a stable voltage and amps. Your electronics are surrounded by capacitors... wand it goes up the stack. It's just good engineering.

<comment><USER6> Fortunately, Postel's law is not applied everywhere. Electrical deviations are formally specified so engineers design smaller error bounds, resulting in lower cost of the end-product (or lower weight and size). Your computer power supply will still produce magic smoke when connected to 330V or when subjected to strong fluctuations. The 'liberal' part is actually the 'strict' part: your electricity provider is obliged to provide you with an electric potential within certain boundaries.

The reasoning of the author is simple: we want a POC of an idea ASAP (lacking formal specifications of anomalies and error bounds) and when successful, error bounds and boundary conditions including specifications thereof should be communicated and implemented. That seems like a cogent and professional point to make, given the complexity of our systems.

<comment><USER7> Plenty of computer power supplies will produce magic smoke at 175V too! They interpret 'substantially less than 240V' as 'switch to 115V mode' and then happily blow up with the excess voltage as input.

</comment></comment></comment><comment><USER8> I've argued in the past for an intermediate position, especially for HTML. Browsers should be moderately tolerant of bad HTML. But rather than trying to handle errors invisibly, they should revert to a simplified rendering system intended to get the content across without the decorative effects. After the first error, a browser might stop processing further Javascript, display a red band indicating defective HTML, and display all text in the default font. It might also report the error to the server in some way.

Read through the error-recovery specification for HTML5. It's many pages of defined tolerance for old bugs. Then read the charset-guessing specification for HTML5, which is wildly ambiguous. (Statistical analysis of the document to guess the charset is suggested.) The spec should have mandated a charset parameter in the header a decade ago. If there's no charset specification, documents should render in ASCII with hex for values > 127.

<comment><USER9> You've got two browsers to chose from. One that handles every site you visit without a problem, one which throws a bunch of obscure error messages on about 20% of the sites you visit.

Which do you think most people will chose?

<comment><USER10> I think this would have been great if done from the beginning, but even in early versions of Mosaic malformed HTML would still appear "correct" visually, and since once it _looked_ ok most people figured it _was_ ok we've been buried under broken HTML from the beginning. The idea that the browser "handles every site without a problem" is slightly misleading though, since even if everything looks ok the user is paying a price of lower performance and a slower pace of innovation as browser developers devote huge amounts of time, money, and attention to not puking on all that broken HTML.

<comment><USER11> To a large degree this is it. Nobody bats an eye if a misplaced quote somewhere in a Python program causes the whole program to fail to start, but XHTML breaking pages on syntax errors was considered a terrible idea because the old way worked fine(tm).

However, Python source code is not typically dynamically generated, while HTML is, increasing the probability of errors the site author could not trivially predict and the user can do nothing about.

</comment></comment></comment></comment><comment><USER12> _groan_ …

"Fail early and hard, don't recover from errors" is a recipe for disaster.

That principle applied to critical systems software engineering leads to humans getting killed. E.g. in aerospace the result is airplanes falling out of the sky. Seriously. The Airbus A400M that recently crashed in Spain did so, because somewhere in the installation of the engine control software the control parameter files were rendered unusable. The result was, that the engine control software did fail hard, while this would have been a recoverable error (just have a set of default control parameters hardcoded into the software putting the engines into a fail safe operational regime); instead the engines shut off, because the engine control software failed hard.

In mission and life critical systems there are usually several redundant core systems and sensors, based on different working principles, so that there's always a workable set of information available. Failing hard renders this kind of redundancy futile.

No, Postel's Maxim holds as strong as ever. The key point here is: "Be conservative in what you send", i.e. your implementation should be strict in what it subjects other players to.

Also being string in what's expected can be easily exploited to DoS a system (Great Firewall RST packets anyone?)

<comment><USER13> _E.g. in aerospace the result is airplanes falling out of the sky. Seriously._

You're misinterpreting 'fail fast' \- it doesn't mean 'entire system should fail catastrophically at slightest problem' or 'systems should not be fault- tolerant'. It just means that components should report failure as soon as possible so the rest of the system can handle it accordingly instead of continuing operation with an unrecognized faulty component leading to unpredictable outcomes.

<comment><USER14> In particular, "Just Sort Of Keep Going And Hope It All Works Out Eventually" is also a great way to crash planes and kill people, if we're going to pretend that everything's safety critical.

</comment></comment></comment><comment><USER15> I have always felt that Postel's Maxim combined with network effect leads to complications in long term while it promotes interoperability in the short term.

It's game theoretically successful strategy to get your implementation to work with everyone. When you accept sloppy input, this allows sloppy implementations to become popular.

Eventually de facto protocol becomes unnecessarily complicated and you need to understand quirks in popular implementations.

</comment><comment><USER16> Like the equivalent rule for human interaction, this is a coordination problem and it fails in the same way - when you're nice to people, you get overrun by assholes. People who don't care about being "conservative in their sending behaviour". This rule is really great _if_ you can make everyone stick to it. In a competitive environment, it's impossible without some additional way to ensure assholes will be punished.

</comment><comment><USER17> Basically, we shouldn't issue standards or RFCs without test vectors and tests that are meaningful, and updated if bugs are found in them (or the RFC).

Expecting someone to (say) read the HTTP spec and write a compliant implementation without tests that everyone else is using as well is lunacy, and leads to the nightmare we have today.

Standards without engineering to back them up are bad.

Side effect: Committees that produce "ivory tower" standards that are unimplementable will find that their work is ignored.

Another side effect: Standards will get simpler, because over-complex nonsense will be obvious once the committee gets down to making an exemplar actually work.

Not that it will ever happen...

[I helped write an HTTP proxy once. The compliant part took a couple weeks; making it work with everyone else's crappy HTTP implementation was a months- long nightmare on rollerskates]

</comment><comment><USER18> What is missing from this is the ability to toggle a "strict mode" with a browser, or even a "reference implementation browser". Right now developers have to rely on their knowledge alone combined with the simple fact of whether or not their work seems to render correctly on the major browsers. That is where you run afoul of Postel's Maxim, because it should be possible to use these tools (like browsers) in a way that provides the sort of "hey, don't do that" feedback during development even though during normal operation the browser should do its best to make due with whatever it's given.

That same pattern exists elsewhere too, so often people need to do "API science" to figure out how to use various tools. With the common result being the discovery of how to use those tools seemingly effectively, but incorrectly.

</comment><comment><USER19> I think both of these philosophies represent extremes.

This means Forgive all mistakes: _Be liberal in what you accept, and conservative in what you send_

This means forgive no mistakes: _Protocol designs and implementations should be maximally strict._

I would suggest an alternative, Forgive most mistakes, but always let them know they did made mistake:

 _Be conservative in what you send, and as liberal as possible in what you accept but always let them know what they could have done better_

<comment><USER20> Does that solve interoperability though? If you accept it and let them know, you're still accepting it, meaning you're still going to tolerate that protocol implementation continuing its bad behavior in the future. And if the protocol implementation becomes widely-used, then we have the exact same maintenance issue as we do with Postel's Maxim.

</comment></comment><comment><USER21> My take on this: [http://www.win-vector.com/blog/2010/02/postels-law-not- sure-...](http://www.win-vector.com/blog/2010/02/postels-law-not-sure-who-to- be-angry-with/)

Though I am beginning to think it coming down to "do you want to make it easy to run on a dev-box or easy to run in production?"

</comment><comment><USER22> Being liberal in acceptance did not discount the conservatism in output. If diligently only one side of the maxim is followed, there would be less issues. For example, if many implementations were conservative in sending, that alone is sufficient. After that allowing for liberal handling of input is to compensate for those who did not follow the conservatism in output. Postel can't be easily blamed for long term entropic outcomes, accelerated by the abundance of implementations that ignore both sides of the maxim.

</comment><comment><USER23> "Conservative in what you accept" works fine if the first implementation shipped is complete and bug-free. If you have two implementations that have incompatible bugs then third parties have to detect who to be bug-compatible with. If your system is not backwards compatible (easily achieved in HTML by ignoring new elements), then you have to do version detection as well.

</comment><comment><USER24> So, if the original spec for HTML rejected ill formed pages and enforced nesting and end tags, would the web be better today?

I think the lack of formality actually hurt non-technical users because it made tool harder to program.

<comment><USER25> But you then end up with OSI instead of TCP/IP and the internet would look very different.</comment></comment>


Stop Equating Women in Tech with Engineers - <AUTHOR> https://medium.com/thelist/stop-equating-women-in-tech-with-engineers-e928e9fa1db5

<comment><USER2> Maybe someone can clear up my misconceptions - but I always thought that most VCs (the ones that aren't started with tech money) come from Finance. For example Jim Swartz, founder Accel (first firm I could think of that I wasn't sure if it was founded by a entrepreneur), in his bio states came from a finance background - I thought this was the story for most partners.

If this is the case, then I'm unsure this is a problem that the tech industry has to face facts with, but a problem that the finance industry has to acknowledge. The stereotype is (not sure if its still completely true) is that finance is still a huge boys club, and I think the tech industry has made far more strides in diversity than the finance industry has. If the problem really is "VCs don't invest in women" or "there aren't enough female partners" it would help to know 1.) the career path to be a VC partner and 2.) the percentage of women that qualify.

</comment><comment><USER3> We all know LinkedIn is a 'match.com' or 'tinder' or 'okcupid' for the majority of folks. "We only hire hot chicks..." a quote from the article, is very truth telling. Lets be honest folks.

</comment><comment><USER3> Until we are honest with ourselves about the sexual dynamics (including what our wives or SO's think) that exist, we will go no where on this issue.

<comment><USER4> The fact that your assumption is that everyone reading this has wives says a lot...</comment></comment>


Apple Fanboy = Religious Fanatic? - <AUTHOR> http://www.neurosciencemarketing.com/blog/articles/apple-fanboy-religious-fanatic.htm?utm_source=feedblitz&utm_medium=FeedBlitzRss&utm_campaign=neuromarketing

<comment><USER2> This isn't unique to Apple; there have been several studies over the last few years about how certain brands have passed some threshold of triggering the same brain waves as cultists have. I don't have any citations, and for that I apologize, but one show my wife and I watched said a very few have done this. The brands mentioned were, if I remember correctly, Apple, Linux, Nike, Volkswagon, and Coke.</comment>


Scientists create first solar cell with over 100 percent quantum efficiency - <AUTHOR> http://www.engadget.com/2011/12/19/scientists-create-first-solar-cell-with-over-100-percent-quantum/

<comment><AUTHOR> Original article:

[http://phys.org/news/2011-12-scientists-solar-cell- electrons...](http://phys.org/news/2011-12-scientists-solar-cell-electrons- photocurrent.html)</comment>


Identification of molecular cause of inherited microcephaly - <AUTHOR> https://medicalxpress.com/news/2020-07-molecular-underlying-rare-genetic-disorder.html <comment><AUTHOR> >Haploinsufficiency of X-linked intellectual disability gene CASK induces post-transcriptional changes in synaptic and cellular metabolic pathways

[https://www.sciencedirect.com/science/article/abs/pii/S00144...](https://www.sciencedirect.com/science/article/abs/pii/S0014488620301503?via%3Dihub)</comment>