I am a retired Fed so I "pay" (through my retirement) the same premium I paid as a Fed. To be honest I am amazed at the efficiency (and courtesy) you received in Malaysia. Your most recent pamphlet (The Elysian Manifesto) in the US would fix this! If we received shoddy expensive healthcare in one state (country), we could move to the state next door! Sign me up!
You can't separate the medical system from everything else in any given country, in this case Malaysia. Would you want to live there all the time? I don't know your race, but if you are white, you might have a hard time getting used to the nonwhite culture, and I am not criticizing them at all. They have a right to be whatever they are.
I wonder if it is at all possible to transfer only a medical system into the USA. Keep in mind that Malaysians as a group may not be as sickly as most Americans are where degenerative disease is concerned. Also, certain ethnic groups in the USA are over-represented with certain kinds of sickness.
US govt spends countless billions, maybe trillions, on supporting bases (over 700) all over the world + waging war constantly where it has no business. This has been going on since the end of WW II.
Venezuela seems to next in USA govt's crosshairs. Consider the amount of $$$ handed over to Ukraine and Israel, and that is just for starters, as the best known recipients of US taxpayers' largesse. And there is no end in sight.
The difference is that in the US, the vertically integrated healthcare provider = the most expensive BY FAR.
Look at your nearest city, the big name brand hospitals/health systems with all the services (and all the marketing at sports events) will be the most expensive in the region (charging private insurance >3x more than Medicare). And staying out of these health systems is nearly always the cheaper (and many times higher quality) option.
I guarantee it.
Why? In the US, vertical integration = monopoly pricing leverage.
...enabled by employed sponsored healthcare >> creates fractured insurance plans >> who lose out on leverage battles against monopolistic health systems >> thus hammer independent providers on prices to make up what they lost to systems >> those low-cost independent providers can't support themselves after getting hammered, so join systems >> systems get bigger >> systems have more leverage against payers >> systems also use all that $$$ on lobbying to help with a range of stuff >> etc. etc.
Integrating health systems does NOT lower costs in the US... it raises them. The solution is to change the incentives for health systems and providers overall.
*Former healthcare insider here
**Late edit: in Malaysia, prices are regulated by the government (public hospitals = national fee schedule like Medicare, but private = regulated with fee caps). In the US, the national fee schedule = Medicare, but all private insurance is negotiated between healthcare provider and insurer/employer/individual (i.e. fragmented). Plus, "non-profit" in the US is the biggest bullshit label ever, don't even get me started...
No doubt there are a lot of things wrong with US healthcare that dominos the whole system. It would take a book to write about that and propose a fix (and then we’d have to hope US actually wanted to build that fix which it doesn’t seem keen on doing.)
I guess what I was trying to tackle with a small post on a very small subset of that problem is: get rid of the gatekeepers and stop requiring referrals for everything. Why do we have a system that boomerangs us around and never lets us even get the care we are requesting when we make an appointment. And look, there are places where we can get that!
But yes, I totally get your point that it’s all part of a much bigger and more expansive chain of events clogging the whole thing.
Totally understand with what you’re saying and agree the referral process is horrific (going through same deal for me and back issues).
Where I’m coming from is that in the US, cost (and incentives around it) is problem numero uno, esp the value we get for it.
For example, prices are terrible here, so insurers create HMOs, prior auths, denials, etc. (the barriers) to try and slow down high cost specialty care. Removing these barriers would actually increase costs, even more than they are.
And since our system has enabled system monopolies to proliferate, there isn’t a lot of local competition to cause systems to improve their side.
So cost problems created by both providers and payers, create the bad experience.
FYI I was head of value-based care for one of the largest independent provider (PCP oriented) orgs in the country… and was directly responsible for lowering cost of care and improving quality, and one of our main problem areas was referrals and specialty care
The cost difference between US medical care and Malaysia medical care is shocking and the level of customer service is also shocking. I spent a couple years in Penang as an expat. My 80-something year old father took a fall on a nature walk. We took him to Penang Adventist Hospital. 2 nights in the hospital, multiple CT scans, full diagnostic workup, neurologist consultation and more cost just over 3k USD. That would likely be close to 6 digits in US.
To @Rachel Ooi's point it's not all roses. I found medical care to be far more cash-and-carry in SE Asia. But at least it's not 6 digits US every time you go to the hospital.
I just had prostate cancer surgery in US. I have not seen the bills yet but I'm expecting well into the six digit range for that. I was in and out of the hospital in 7 hours.
It really is wild the difference. Just the last month alone, I had to go to the ER in the US for a sinus infection and received a bill for $9,000+. Then my niece broke her arm on Halloween and went two weeks without a cast because they needed “sign off” by the surgeon who had a full schedule.
Thanks for sharing your experience. I'm from Malaysia, and I am curious—were you in a private or public hospital? Because they do make a difference—in price, and in care. For urgent cases and state-of-the-art equipment, one should go to the public hospital, which costs almost nothing for Malaysians, an ironic fact, I know. For routine checks, such as yours, or simple illnesses, the public system may be overwhelmed by sheer numbers, and wait times could be incredibly long. Therefore, if one can afford it, they often opt for a private hospital. However, the majority of Malaysians cannot afford them, so they wait. But I am not a fan of the private hospitals because all they care about is their bottom line, and if a case becomes dire, they'll quickly just ship the patient off to the public hospital to "die" there.
We went to a private hospital, though I think we would have had to pay either way as foreigners? I know the system isn’t perfect (none are), but it’s pretty impressive that Malaysia lets patients decide what they need rather than having this horrible referral process we have to go through to get anything done. Though that’s not good that they outsource to public if things get dire!
Thank you! God forbid a specialist spends more than 15 minutes with you (gasp… the inefficiency). We have so many gatekeepers guarding the actual doctors (insurance companies, triage, referrals, policies like step therapy) and the cost they add seem to just eat up any savings (not to mention harm patient care). If the problem is overworked doctors, a simpler solution is just have more doctors. But that gets into a whole other basket of problems (edu costs, length of study, limit spots both in edu and residency). Medicine also seems burdened by the inefficiencies of over specialization. If a problem becomes too complex for a GP but a specialist can’t diagnose it as an ailment within their speciality, you are SOL, and are adding costs as you bounce from specialist to specialist trying to figure out what is happening. Assuming you are even getting the referrals needed to keep pursuing the issue.
My experience this year with an emergency need in NZ was free, even the medicine. I have also had to visit a doctor twice in this century in China. Total cost one time was $5.oo, the other time $7.00. A friend who had an emergency in Inverness, Scotland, had no cost as a visitor to their country. I have friends who have gone to Thailand for treatment, Canada for medicine, and now your story in Malaysia. It is ridiculous that the system in the USA is so terrible, and we have enough bright people who could change this. When?
Elle - I've followed you for a long time, I love your writing. This is so eye-opening. You come up with the most wonderful ideas and expose so many inefficiencies.
Hi Meredith! Hope you’re well!! And thanks for the kind words about my work. I do have some ideas about schooling, though I’ve never fully developed them. I’ll have to go back to the drafts folder. Any ideas you’ve been wanting to explore there?
- Outdated curriculums - history class was generally about learning every war that ever existed lol - do we really need to be memorizing war dates?
- The fact that we don't really learn real life skills like how to pay taxes, how to get a job, how to be an entrepreneur, how to write a resume and cover letter etc.
- How many people actually need to use for example, calculus skills in their life or work after highschool? Maybe some but probably not a huge percentage, especially today with the internet and Ai.
- Funding of schools - seems like other countries may have better systems than we do to go about this
I'm mostly thinking about public school k-12, but even in a 4 year college degree there was not a lot of information about real life and work skills that jobs today need people entering the work force to know, that I feel were lacking.
I think there are very obvious ways we could reform the system (that other countries already have done), but all of this would require the ability to make policy changes federally (which I see as not very feasible at the moment), I wonder if there is a local way, or state level reform that could be made to change this place by place?
in the US, they call the idea of all the care providers under one roof a" hospital ". so I'm not sure this diagnosis tracks. Something else is going on
The US does have facilities like this. Surgery Center of Oklahoma is one. they tend to not take insurance
US citizens can’t just go to a hospital and get everything they want done like I did in Malaysia. I can only go to a hospital through the ER, or with a referral for whatever specialist I need to see.
Right, but not because they're housed under different roofs or aren't integrated. If you ever have an emergency, you realize that they really can do all of the things immediately in the same place (including MRIs and STAT bloodwork).
The reason is more complex than inability to act as an integrated whole.
Elle, the statement about wait times in Canada is not accurate in itself. Yes, there are long wait times but there is triage. I have seen both the long wait for some things, and the quick response for others. I know many who face longer wait times in the US for many services, so addressing it as a multi faceted issue would be better. I also have seen no medical bills in Canada in the last 5 years.
It's quite an incredible, albeit stressed, system.
Yes that’s a good point. There’s no doubt the Canadian system is better than the U.S. system, I only mention it because Canadian wait times are often mentioned by U.S. leaders as a reason we shouldn’t socialize. (When that specific result is not caused by socialization)
I’m glad I live in Belgium. I pay 700 euro’s a year, which is probably way more than I should and what most people do, but I’m insured for everything, really everything. The last couple of days I was worried, I have stents, went to the emergency, came out 3 hours later fully checked: bloodworks, lungs, ecg: everything ok, except for my stress level. I relaxed and felt immediately much better. And I only had to open my wallet for my id.
I’m well aware of that. I look at what happens in the States and I do not understand. A healthy population is so much more productive: economically and socially (they are happier). It must be greed over there. Doesn’t every given SNAP dollar produce a return of 1.8 dollars?
I am a retired Fed so I "pay" (through my retirement) the same premium I paid as a Fed. To be honest I am amazed at the efficiency (and courtesy) you received in Malaysia. Your most recent pamphlet (The Elysian Manifesto) in the US would fix this! If we received shoddy expensive healthcare in one state (country), we could move to the state next door! Sign me up!
You can't separate the medical system from everything else in any given country, in this case Malaysia. Would you want to live there all the time? I don't know your race, but if you are white, you might have a hard time getting used to the nonwhite culture, and I am not criticizing them at all. They have a right to be whatever they are.
I wonder if it is at all possible to transfer only a medical system into the USA. Keep in mind that Malaysians as a group may not be as sickly as most Americans are where degenerative disease is concerned. Also, certain ethnic groups in the USA are over-represented with certain kinds of sickness.
US govt spends countless billions, maybe trillions, on supporting bases (over 700) all over the world + waging war constantly where it has no business. This has been going on since the end of WW II.
Venezuela seems to next in USA govt's crosshairs. Consider the amount of $$$ handed over to Ukraine and Israel, and that is just for starters, as the best known recipients of US taxpayers' largesse. And there is no end in sight.
The difference is that in the US, the vertically integrated healthcare provider = the most expensive BY FAR.
Look at your nearest city, the big name brand hospitals/health systems with all the services (and all the marketing at sports events) will be the most expensive in the region (charging private insurance >3x more than Medicare). And staying out of these health systems is nearly always the cheaper (and many times higher quality) option.
I guarantee it.
Why? In the US, vertical integration = monopoly pricing leverage.
...enabled by employed sponsored healthcare >> creates fractured insurance plans >> who lose out on leverage battles against monopolistic health systems >> thus hammer independent providers on prices to make up what they lost to systems >> those low-cost independent providers can't support themselves after getting hammered, so join systems >> systems get bigger >> systems have more leverage against payers >> systems also use all that $$$ on lobbying to help with a range of stuff >> etc. etc.
Integrating health systems does NOT lower costs in the US... it raises them. The solution is to change the incentives for health systems and providers overall.
*Former healthcare insider here
**Late edit: in Malaysia, prices are regulated by the government (public hospitals = national fee schedule like Medicare, but private = regulated with fee caps). In the US, the national fee schedule = Medicare, but all private insurance is negotiated between healthcare provider and insurer/employer/individual (i.e. fragmented). Plus, "non-profit" in the US is the biggest bullshit label ever, don't even get me started...
No doubt there are a lot of things wrong with US healthcare that dominos the whole system. It would take a book to write about that and propose a fix (and then we’d have to hope US actually wanted to build that fix which it doesn’t seem keen on doing.)
I guess what I was trying to tackle with a small post on a very small subset of that problem is: get rid of the gatekeepers and stop requiring referrals for everything. Why do we have a system that boomerangs us around and never lets us even get the care we are requesting when we make an appointment. And look, there are places where we can get that!
But yes, I totally get your point that it’s all part of a much bigger and more expansive chain of events clogging the whole thing.
Totally understand with what you’re saying and agree the referral process is horrific (going through same deal for me and back issues).
Where I’m coming from is that in the US, cost (and incentives around it) is problem numero uno, esp the value we get for it.
For example, prices are terrible here, so insurers create HMOs, prior auths, denials, etc. (the barriers) to try and slow down high cost specialty care. Removing these barriers would actually increase costs, even more than they are.
And since our system has enabled system monopolies to proliferate, there isn’t a lot of local competition to cause systems to improve their side.
So cost problems created by both providers and payers, create the bad experience.
FYI I was head of value-based care for one of the largest independent provider (PCP oriented) orgs in the country… and was directly responsible for lowering cost of care and improving quality, and one of our main problem areas was referrals and specialty care
The cost difference between US medical care and Malaysia medical care is shocking and the level of customer service is also shocking. I spent a couple years in Penang as an expat. My 80-something year old father took a fall on a nature walk. We took him to Penang Adventist Hospital. 2 nights in the hospital, multiple CT scans, full diagnostic workup, neurologist consultation and more cost just over 3k USD. That would likely be close to 6 digits in US.
To @Rachel Ooi's point it's not all roses. I found medical care to be far more cash-and-carry in SE Asia. But at least it's not 6 digits US every time you go to the hospital.
I just had prostate cancer surgery in US. I have not seen the bills yet but I'm expecting well into the six digit range for that. I was in and out of the hospital in 7 hours.
It really is wild the difference. Just the last month alone, I had to go to the ER in the US for a sinus infection and received a bill for $9,000+. Then my niece broke her arm on Halloween and went two weeks without a cast because they needed “sign off” by the surgeon who had a full schedule.
Thanks for sharing your experience. I'm from Malaysia, and I am curious—were you in a private or public hospital? Because they do make a difference—in price, and in care. For urgent cases and state-of-the-art equipment, one should go to the public hospital, which costs almost nothing for Malaysians, an ironic fact, I know. For routine checks, such as yours, or simple illnesses, the public system may be overwhelmed by sheer numbers, and wait times could be incredibly long. Therefore, if one can afford it, they often opt for a private hospital. However, the majority of Malaysians cannot afford them, so they wait. But I am not a fan of the private hospitals because all they care about is their bottom line, and if a case becomes dire, they'll quickly just ship the patient off to the public hospital to "die" there.
We went to a private hospital, though I think we would have had to pay either way as foreigners? I know the system isn’t perfect (none are), but it’s pretty impressive that Malaysia lets patients decide what they need rather than having this horrible referral process we have to go through to get anything done. Though that’s not good that they outsource to public if things get dire!
Hi Rachel, thanks for sharing your insight. Out of my American curiosity what do you consider an incredibly long wait time you mentioned?
Thank you! God forbid a specialist spends more than 15 minutes with you (gasp… the inefficiency). We have so many gatekeepers guarding the actual doctors (insurance companies, triage, referrals, policies like step therapy) and the cost they add seem to just eat up any savings (not to mention harm patient care). If the problem is overworked doctors, a simpler solution is just have more doctors. But that gets into a whole other basket of problems (edu costs, length of study, limit spots both in edu and residency). Medicine also seems burdened by the inefficiencies of over specialization. If a problem becomes too complex for a GP but a specialist can’t diagnose it as an ailment within their speciality, you are SOL, and are adding costs as you bounce from specialist to specialist trying to figure out what is happening. Assuming you are even getting the referrals needed to keep pursuing the issue.
My experience this year with an emergency need in NZ was free, even the medicine. I have also had to visit a doctor twice in this century in China. Total cost one time was $5.oo, the other time $7.00. A friend who had an emergency in Inverness, Scotland, had no cost as a visitor to their country. I have friends who have gone to Thailand for treatment, Canada for medicine, and now your story in Malaysia. It is ridiculous that the system in the USA is so terrible, and we have enough bright people who could change this. When?
It’s crazy that so many countries get it right, and we can’t.
And there's no good excuse.
Elle - I've followed you for a long time, I love your writing. This is so eye-opening. You come up with the most wonderful ideas and expose so many inefficiencies.
Want to do one an article on school systems next?
Hi Meredith! Hope you’re well!! And thanks for the kind words about my work. I do have some ideas about schooling, though I’ve never fully developed them. I’ll have to go back to the drafts folder. Any ideas you’ve been wanting to explore there?
Yes:
- Outdated curriculums - history class was generally about learning every war that ever existed lol - do we really need to be memorizing war dates?
- The fact that we don't really learn real life skills like how to pay taxes, how to get a job, how to be an entrepreneur, how to write a resume and cover letter etc.
- How many people actually need to use for example, calculus skills in their life or work after highschool? Maybe some but probably not a huge percentage, especially today with the internet and Ai.
- Funding of schools - seems like other countries may have better systems than we do to go about this
I'm mostly thinking about public school k-12, but even in a 4 year college degree there was not a lot of information about real life and work skills that jobs today need people entering the work force to know, that I feel were lacking.
I think there are very obvious ways we could reform the system (that other countries already have done), but all of this would require the ability to make policy changes federally (which I see as not very feasible at the moment), I wonder if there is a local way, or state level reform that could be made to change this place by place?
This is an amazing thing to know. Incredible. And the ability of the Dr. to say what he thinks about healthcare here ….
Not here, Dr. are as handcuffed here, it seems, as their patients.
Uplifting info, thank-you!
We could do this but we don’t.
As Laura Logan says, “ if something isn’t fixed, it’s because they don’t want to fix it”.
in the US, they call the idea of all the care providers under one roof a" hospital ". so I'm not sure this diagnosis tracks. Something else is going on
The US does have facilities like this. Surgery Center of Oklahoma is one. they tend to not take insurance
US citizens can’t just go to a hospital and get everything they want done like I did in Malaysia. I can only go to a hospital through the ER, or with a referral for whatever specialist I need to see.
Right, but not because they're housed under different roofs or aren't integrated. If you ever have an emergency, you realize that they really can do all of the things immediately in the same place (including MRIs and STAT bloodwork).
The reason is more complex than inability to act as an integrated whole.
Right, it’s that that process is only available to us if we are deemed in need of it. We have a maze of gatekeepers.
Elle, the statement about wait times in Canada is not accurate in itself. Yes, there are long wait times but there is triage. I have seen both the long wait for some things, and the quick response for others. I know many who face longer wait times in the US for many services, so addressing it as a multi faceted issue would be better. I also have seen no medical bills in Canada in the last 5 years.
It's quite an incredible, albeit stressed, system.
Yes that’s a good point. There’s no doubt the Canadian system is better than the U.S. system, I only mention it because Canadian wait times are often mentioned by U.S. leaders as a reason we shouldn’t socialize. (When that specific result is not caused by socialization)
Fair, I only responded because it's a BS argument and we shouldn't give it more oxygen.
I’m glad I live in Belgium. I pay 700 euro’s a year, which is probably way more than I should and what most people do, but I’m insured for everything, really everything. The last couple of days I was worried, I have stents, went to the emergency, came out 3 hours later fully checked: bloodworks, lungs, ecg: everything ok, except for my stress level. I relaxed and felt immediately much better. And I only had to open my wallet for my id.
You’re so lucky!
I’m well aware of that. I look at what happens in the States and I do not understand. A healthy population is so much more productive: economically and socially (they are happier). It must be greed over there. Doesn’t every given SNAP dollar produce a return of 1.8 dollars?