Taken from JRE #1961 w/Peter Attia:
https://open.spotify.com/episode/6x9k7KcvhAV44Ik0fX2oeu?si=7a7691e4705347c8

did you see the thing I posted a couple weeks ago about this bill we got from when my, Jill was with our middle son in San Diego visiting a friend and he was sick, So she had to take him to an ER, right?

Like, we don't, our doctor's not there, right?

So they did like regular chemistry lab on him.

That's like about a $12 blood test and gave him like, I don't know, 250 to 500 CC of IV fluid.

I don't remember it because I'd have to look at the post I put up.

I think the bill was 6,000 of which we owed 2,000.

$6,000 bill, our insurance somehow picked up, maybe $3,500, we were stuck with $2,500.

Now juxtapose that with the following fact.

Fewer than 50% of Americans today, if given 24 hours, can produce $2,500 in cash.

So when we say healthcare is the leading cause of personal bankruptcy, it's the first, second, third, fourth, fifth, like there's nothing else matters besides healthcare when it comes to personal bankruptcy.

I sometimes think, is there any other problem I would ever be interested to devoting my full attention to besides the problem I work on now?

If that problem was really tackled by our government and they did it in an efficient way, 1 of the ways they would have to do it, 1 of the ways they would have to address it in order to be efficient would be to encourage people to become metabolically healthy Of course, we have 0 encouragement 0.

In fact, there's is actually the opposite there's there's encouragement for people to have body positivity and to not be fat phobic and to not fat shame.

And there's 0 discussion about healthy diets and vitamin supplementation and the benefits of that.

Imagine if the government was responsible for our healthcare and they realized, hey, guys, guys, guys, we got a real problem here.

We're spending too much money and we're losing money because...

What if the amount of money that they made was dependent upon the percentage of money that was spent on health care.

Like, imagine if politicians, if their salary depended on the, like, if there was

See, but I fear that that would still get screwed up, because then they would just cut costs, right?

We have to cut costs, this is the problem, right?

We're spending, we're probably up to $10,000 per capita, which is, I mean we're actually probably more than that.

We're probably $12,000, $14,000 per capita.

So we're at 2 to 5x every other developed nation and what we spend on health care.

OK, so the big reason comes down to made up numbers.

The blood test cost, the actual cost of ordering that blood test is $12.

It's because they play a shell game with the insurance company.

So they say, we negotiate different rates with different insurance companies.

And we're going to build up the price enormously, but we're going to offer you a really big discount.

And we're going to make you our preferred network.

And there's a quid pro quo here, which is the price is enormous, but you don't actually have to pay that much.

But if somebody comes in out of network, which we were, right, we were out of network, because probably our network is optimized around being in Austin and not in San Diego, you're going to get screwed.

And of course, if you don't have insurance, forget about it.

A real injury, you need surgery and you're not insured.

The other thing is we don't have the same laws around like drug pricing, right?

So drug, you know, the United States basically subsidizes the rest of the world in drug pricing.

So we, in exchange for getting first dibs on the best drugs, we pay a higher price for them.

And other countries are basically not going to pay that because you also have better purchasing power.

So if you look at Canada, for example, like the government is buying the drugs, not the payer.

And the challenge is no system is going to be perfect, but what really bothers me about the discussion is we're missing the point that there are 3 variables that need to be optimized around.

And everybody just talks about their favorite 1, but you can't talk about 1 without talking about the other 2.

Because if you pull on 1 lever, you got to let up on 1 of the other levers.

How much does it cost to deliver this care?

So if you look at the United States, we're very good on quality.

There's a reason people come from all over the world here when they need their cancer surgery, right?

We are certainly at or in the, you know, at or above the best for everything that would be done in medicine.

There's literally no country that pays more than we do for a given service.

And on access, we're horrible for a developed nation.

On cost, like what is the difference between like say United States

And that's not like a third world country or something like that.

So Canada is killing us in cost, they're killing us in access because everybody's covered, but we have better quality.

I mean, I do talk about how my mom is getting largely veterinary medicine in Canada.

I mean, her healthcare is horrible as far as I'm concerned.

had many friends in Canada that have complained a lot.

But at least everybody gets it, and it doesn't cost you

And is it bad care because the physicians are not incentivized to provide better care because they don't make as much money?

So first of all, I mean, at least I don't know if I don't want to speak out of school because I'm so far removed from it.

But when I was growing up, they had introduced salary caps.

So When you hit your cap, you stopped working for the year.

So high-earning surgeons would retire, not retire, would stop working in August because they'd hit their set.

Like, let's say the salary cap was $300,000.

If you earned $300,000 by August, you weren't going to

So they would just sit down and sit out the rest of the year.

would create this real problem where there was a bottleneck.

But the bigger issue is just that the government is in charge of what gets done and what does not get done.

So if you, like things that you and I take for granted, right?

If you tweaked your knee at jiu-jitsu tonight, you could get an MRI tomorrow.

In fact, in certain provinces, it's illegal to have private clinics where you can go pay out of your own pocket to get an MRI expedited Illegal I think Ontario is 1 of those provinces by the really yep, so Toronto in Toronto I do not believe it is legal to have private medical clinics where you can pay out of pocket.

So this is where when people say, oh, we should just be like Canada, I'm like, no, we should do something Canada does.

But would that be sort of like public defenders versus a really good attorney?

No, I think 1 of the things you have to do is provide primary care and emergency services for free.

Because that's where 90% of your care would be delivered.

And is the problem that because of these made up numbers that you discussed earlier, that these people, in this country at least, are accustomed to charging these exorbitant fees, like $6,000 for a bag of IV?

Oh yeah, I mean I had my, I get a colonoscopy every 3 years, so I had my last 1 this time a year ago.

And you know, because, it's funny, that 1 should have been covered, I don't remember the details on it, but because I was over 45 at that point, so it's counted as a screening colonoscopy.

But I've historically always had to pay cash for my colonoscopies, because I started doing them when I was 40.

And the cash cost of getting a colonoscopy at like 1 of the best guys in New York City, who I've always gone to, is $2,000.

That means that's covering the facility fee, the anesthesia, his fee, et cetera.

The 1 I got here in Austin, where I did it through insurance, the fee was $6,000.

I got the bill and my insurance picked up...

Anyway, my point is my cash out of pocket was almost as bad as the cash I paid for just a full up cash 1.

I actually called my gastroenterologist, the guy who did it, and I was like, you gotta walk me through this.

Because I'm struggling to understand these costs.

But everybody has sort of a different amount.

You know, it's like being at like a bazaar where it's like, oh, I have special price for you today.


Speaker 0: The Joe Rogan experience. And then healthcare. Like,

Speaker 1: did you see the thing I posted a couple weeks ago about this bill we got from when my, Jill was with our middle son in San Diego visiting a friend and he was sick, So she had to take him to an ER, right? Like, we don't, our doctor's not there, right? Obviously we live here. So they did like regular chemistry lab on him. That's like about a $12 blood test and gave him like, I don't know, 250 to 500 CC of IV fluid.

That was it. That was it. What do you think the bill was? $1,200. I don't remember it because I'd have to look at the post I put up.

I think the bill was 6,000 of which we owed 2,000. That's insane. That's problematic.

Speaker 0: That's a real problem.

Speaker 1: Yeah, it might have been more than that. $6,000 bill, our insurance somehow picked up, maybe $3,500, we were stuck with $2,500. Now juxtapose that with the following fact. Fewer than 50% of Americans today, if given 24 hours, can produce $2,500 in cash. Jesus Christ.

So when we say healthcare is the leading cause of personal bankruptcy, it's the first, second, third, fourth, fifth, like there's nothing else matters besides healthcare when it comes to personal bankruptcy. I mean this does infuriate me to no end. I sometimes think, is there any other problem I would ever be interested to devoting my full attention to besides the problem I work on now? That's the

Speaker 0: only other problem that would tempt me. You know what's interesting too? If that problem was really tackled by our government and they did it in an efficient way, 1 of the ways they would have to do it, 1 of the ways they would have to address it in order to be efficient would be to encourage people to become metabolically healthy Of course, we have 0 encouragement 0. In fact, there's is actually the opposite there's there's encouragement for people to have body positivity and to not be fat phobic and to not fat shame. And there's 0 discussion about healthy diets and vitamin supplementation and the benefits of that.

Imagine if the government was responsible for our healthcare and they realized, hey, guys, guys, guys, we got a real problem here. We're spending too much money and we're losing money because... What if the amount of money that they made was dependent upon the percentage of money that was spent on health care. Like, imagine if politicians, if their salary depended on the, like, if there was

Speaker 1: a surplus. See, but I fear that that would still get screwed up, because then they would just cut costs, right? Like I feel like.

Speaker 0: What if that wasn't an option though? What if like there

Speaker 1: was like a standard of care? We have to cut costs, this is the problem, right? We're spending, we're probably up to $10,000 per capita, which is, I mean we're actually probably more than that. We're probably $12,000, $14,000 per capita. So we're at 2 to 5x every other developed nation and what we spend on health care.

But why? And we get worse outcomes. OK, so the big reason comes down to made up numbers. Look at my ER example. The blood test cost, the actual cost of ordering that blood test is $12.

The bag of IV fluid is probably $38. So Why do they inflate the cost so much? It's because they play a shell game with the insurance company. So they say, we negotiate different rates with different insurance companies. And we're going to build up the price enormously, but we're going to offer you a really big discount.

And we're going to make you our preferred network. We're gonna be your preferred network. And there's a quid pro quo here, which is the price is enormous, but you don't actually have to pay that much. We're gonna discount it to you. But if somebody comes in out of network, which we were, right, we were out of network, because probably our network is optimized around being in Austin and not in San Diego, you're going to get screwed.

And of course, if you don't have insurance, forget about it. You're paying the fake money price.

Speaker 0: Especially if there's a real injury. Oh, yeah. A real injury, you need surgery and you're not insured. Oh my God.

Speaker 1: The other thing is we don't have the same laws around like drug pricing, right? So drug, you know, the United States basically subsidizes the rest of the world in drug pricing. So we, in exchange for getting first dibs on the best drugs, we pay a higher price for them. And other countries are basically not going to pay that because you also have better purchasing power. So if you look at Canada, for example, like the government is buying the drugs, not the payer.

So it's a totally different system. And the challenge is no system is going to be perfect, but what really bothers me about the discussion is we're missing the point that there are 3 variables that need to be optimized around. And everybody just talks about their favorite 1, but you can't talk about 1 without talking about the other 2. Because if you pull on 1 lever, you got to let up on 1 of the other levers. So the 3 levers are cost.

How much does it cost to deliver this care? The second is quality. How good is the care? And the third 1 is access. How many people fall through the cracks?

So if you look at the United States, we're very good on quality. When we deliver care, it's the best. There's a reason people come from all over the world here when they need their cancer surgery, right? We are certainly at or in the, you know, at or above the best for everything that would be done in medicine. On cost, we are absolutely the worst.

There's literally no country that pays more than we do for a given service. And on access, we're horrible for a developed nation. Horrible, right? The number-

Speaker 0: On cost, like what is the difference between like say United States

Speaker 1: and- And Canada? Yeah. 2 and a half X, I would bet. Wow. Maybe 3 X.

Speaker 0: Wow.

Speaker 1: Yeah.

Speaker 0: That's so crazy. And that's not like a third world country or something like that.

Speaker 1: So Canada is killing us in cost, they're killing us in access because everybody's covered, but we have better quality. So that's the trade-off. I mean, I do talk about how my mom is getting largely veterinary medicine in Canada. I mean, her healthcare is horrible as far as I'm concerned. Totally unacceptable.

Yeah, I've

Speaker 0: had many friends in Canada that have complained a lot.

Speaker 1: No, no, it's totally unacceptable.

Speaker 0: So they have bad care, but

Speaker 1: it's more accessible. But at least everybody gets it, and it doesn't cost you

Speaker 0: any money. And is it bad care because the physicians are not incentivized to provide better care because they don't make as much money?

Speaker 1: No, no, no, no. So first of all, I mean, at least I don't know if I don't want to speak out of school because I'm so far removed from it. But when I was growing up, they had introduced salary caps. So physicians' salaries were capped. So When you hit your cap, you stopped working for the year.

So high-earning surgeons would retire, not retire, would stop working in August because they'd hit their set. Like, let's say the salary cap was $300,000. If you earned $300,000 by August, you weren't going to

Speaker 0: get paid anymore. So they would just sit down and sit out the rest of the year.

Speaker 1: And then it

Speaker 0: would create this real problem where there was a bottleneck. Shortage of docs.

Speaker 1: Yeah. But the bigger issue is just that the government is in charge of what gets done and what does not get done. And there's sort of shortages, right? So if you, like things that you and I take for granted, right? If you tweaked your knee at jiu-jitsu tonight, you could get an MRI tomorrow.

That doesn't happen in Canada. In fact, in certain provinces, it's illegal to have private clinics where you can go pay out of your own pocket to get an MRI expedited Illegal I think Ontario is 1 of those provinces by the really yep, so Toronto in Toronto I do not believe it is legal to have private medical clinics where you can pay out of pocket. So this is where when people say, oh, we should just be like Canada, I'm like, no, we should do something Canada does. We should have universal coverage.

Speaker 0: And then have the option.

Speaker 1: And then you have the option to bolt on.

Speaker 0: But would that be sort of like public defenders versus a really good attorney? Like some public defenders just suck.

Speaker 1: Yes, of course. No, I think 1 of the things you have to do is provide primary care and emergency services for free. Because that's where 90% of your care would be delivered.

Speaker 0: And is the problem that because of these made up numbers that you discussed earlier, that these people, in this country at least, are accustomed to charging these exorbitant fees, like $6,000 for a bag of IV?

Speaker 1: Oh yeah, I mean I had my, I get a colonoscopy every 3 years, so I had my last 1 this time a year ago. And you know, because, it's funny, that 1 should have been covered, I don't remember the details on it, but because I was over 45 at that point, so it's counted as a screening colonoscopy. But I've historically always had to pay cash for my colonoscopies, because I started doing them when I was 40. And the cash cost of getting a colonoscopy at like 1 of the best guys in New York City, who I've always gone to, is $2,000. That's the fully loaded cash cost.

That means that's covering the facility fee, the anesthesia, his fee, et cetera. The 1 I got here in Austin, where I did it through insurance, the fee was $6,000. I got the bill and my insurance picked up... Maybe this is the 1 I'm... Anyway, my point is my cash out of pocket was almost as bad as the cash I paid for just a full up cash 1.

It had a whole bunch of made up numbers. I actually called my gastroenterologist, the guy who did it, and I was like, you gotta walk me through this. Because I'm struggling to understand these costs. And he couldn't really explain it. He's like, I mean, I don't know.

I don't really understand it. But everybody has sort of a different amount. You know, it's like being at like a bazaar where it's like, oh, I have special price for you today.

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Why Healthcare Costs Are So High in America