A single payer system is a step in the right direction, however, there are deeper issues with the American healthcare system.
The unit cost of healthcare is so much higher than in other developed countries.
In British Columbia, physicians bill at total of around $31 CAD ($23 USD) for a standard office visit. They pay all their overhead out of this fee. Typically doctors keep 65% of their billings and the offices take 35% for overhead. From what I can tell, a similar visit in Washington State will run between $60 and $200 USD when billed to insurance.
Why is this the case? What are the factors in the American system that prevent reasonable pricing?
It's the insurance companies dance with the healthcare providers. Over many decades, the insurance companies have negotiated payments much less than the quoted payment. In turn, the healthcare providers raise their rates in order to make sure they can still make money even with the discount they give insurance. When the time comes for the insurance companies to renegotiate, the same thing happens, and the healthcare providers raise their rates. This works fine for those of us who have insurance, but for non insured individuals, they have to pay the "actual" rate - which has been inflated because of the insurance company discount! This has been going on for many decades.
> ver many decades, the insurance companies have negotiated payments much less than the quoted payment. In turn, the healthcare providers raise their rates in order to make sure they can still make money even with the discount they give insurance. When the time comes for the insurance companies to renegotiate, the same thing happens, and the healthcare providers raise their rates. This works fine for those of us who have insurance, but for non insured individuals, they have to pay the "actual" rate - which has been inflated because of the insurance company discount! This has been going on for many decades
This is close to correct, but a subtle correction:
Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate). As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.
A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".
It's really ridiculous, too. I went to the ER for stomach pains in california for 3 hours (ct scan, IV, and morphine). It was $3500 (no healthcare). I was in college and talked to them and paid around $800. I went to the ER in Japan overnight (12 hours) ct scan, IV, and it was $40 (insurance covered 70% so it was about $130).
How can you say that? When an arbitrary law creates artificial markets and restricts the choices of consumers, you really think that prices aren't affected?
Because health insurance is not about scarcity or moving goods across state lines. Setting up insurance is much more complex than that and I think that is why people get caught up in thinking that allowing insurance to be sold across state lines will help.
When an insurance company sets up in another state, they have create a network of doctors, hospitals and medical providers. The doctor network does not just pop up over night.
What are the factors? Number one is that doctors in the US are paid too much. Why is this? Because health insurance is purchased by employers, not individuals, so most people don't see or care how much it costs. This also explains number two - the price gouging by pharmaceutical companies and hospitals.
People will try to say it's because of malpractice insurance or because the US invents all the drugs (they don't) and bla bla and while those are contributing factors, it's very clear to me as a UK expat that key players in the medical system here just take too much money off people.
A simple example is that Paracetemol (Tylenol), available since the 1950s costs about 10x as much in my local CVS as it would in an equivalent British pharmacy (Boots). Why? Because the US market is already used to paying far too much so they have no idea what a rip off is.
Mostly agree but I think you misrepresent this argument:
>People will try to say it's because of malpractice insurance or because the US invents all the drugs (they don't)
It's not that the US invents all the drugs, but that US customers bear a disproportionate share of the drug development costs because drug makers (whichever country they originate in) can actually charge above marginal price in the US, compared to the monopsonist discount that other countries can secure.
For one, doctors educational costs are astronomical in the U.S compared to other countries. The amount of people able to become doctors is artificially limited. Drug prices are unregulated. The cost of developing drugs is high and has been getting higher.
Hospitals have little price transparency and the cost of same procedures at different hospitals is wildly different. The same bag of saline can cost 10x more at one hospital vs another. In markets where there is price transparency, like Lasik surgery or other elective procedures, the prices are far more sane.
One thing that spending double as a percent of GDP on health care and getting worse outcomes proves is that THE SOLUTION TO THE PROBLEM IS NOT TO SPEND MORE MONEY. Unfortunately, this is the only thing American politics knows how to do as more money means more money for every special interest with their hand out.
> The amount of people able to become doctors is artificially limited.
It is not artificially limited, and this is a common misconception that simply won't go away.
The bottleneck is currently the number of people who can complete residency training. Residency programs are not self-sufficient, so most of them are funded by Medicare. That's not an artificial limit - that's a natural one (the sheer economics of the process).
And (per previous discussion [1]) that doesn't explain it. If there is still excess demand for MD degrees, then there is still room for potential MDs to borrow any shortfall that residency subsidies won't cover.
The argument is like saying that Hamilton showings are limited by how much the government will pay in subsidies for the tickets. No. The demand is enough to cover expansion.
And even if it weren't there's still the issue of how much training is actually required to fill the functional role of a doctor. I'm pretty sure that there's some fat to cut out when you're making someone go all the way through a bachelors before they can even start.
> If there is still excess demand for MD degrees, then there is still room for potential MDs to borrow any shortfall that residency subsidies won't cover.
Because the amount of loan debt physicians have to take on is already massive, and very few want to increase that by an additional $112,000 (which is the amount Medicare provides). There are some, but empirically, not many.
The term of that loan is comparable to many mortgages, and there's enough uncertainty at this point in the expected payout that many qualified would-be doctors are incentivized to choose other professions instead, where they can make a pretty good living (and, possibly, a better one) much sooner and without the risk of taking out an additional series of six-figure loans on top of whatever may be outstanding from undergraduate education.
> The argument is like saying that Hamilton showings are limited by how much the government will subsidize ticket prices by.
Broadway ticket prices are a really bad analogy, because prices are intentionally sold below market-clearing rate for a whole slew of reasons that aren't directly comparable to the medical profession.
>Because the amount of loan debt physicians have to take on is already massive, and very few would want to increase that by an additional $112,000 (which is the amount Medicare provides).
Sure, you think it's expensive, but the demand is still there, people are willing to work for (net of costs) less than they currently are. That supports the claim that the service is priced above the market clearing level. (Edit: and they wouldn't be increasing debt by that full $112k; they could simply provide 80% of the existing subsidy per slot instead of the current 100%.)
>Broadway ticket prices are a really bad analogy, because prices are intentionally sold below market-clearing rate for a whole slew of reasons that aren't directly comparable to the medical profession.
No, that makes it a better analogy, because it's a case of good sold below it's market clearing price but which has excess demand capable of paying a (much) higher MCP, and where it's more obvious that the bottleneck isn't (and can't be) insufficient subsidies.
> Sure, you think it's expensive, but the demand is still there, people are willing to work for (net of costs) less than they currently are. That supports the claim that the service is priced above the market clearing level.
* There are more people who apply for publicly-funded GME every year than there are positions available, yes.
* However, almost nobody (roughly speaking) applies for self-funded residency positions (which do exist).
I don't know how those two facts combine to say that "the demand is there" - there is not excess demand at market-clearing rates. There is only excess demand at a subsidized rate. People are not willing to work for less than they currently are; the supply is highly substitutable, and we're already seeing the effects of that.
I added an edit that there is plenty of room between full current subsidy and 0% subsidy.
You're doubling down on the strawman of adding new slots at 0% subsidy, and you're not considering the possibility that the requirements are too stringent to begin with. (Full bachelor's plus MD plus full residency.)
Edit: Also, it wouldn't be "seeing the effects" of it until the number of med school applications = number of med school slots.
There is no "full current subsidy" - the existing contributions from Medicare are already a partial subsidy.
But this is kind of a meaningless debate after a point, because the number of unmatched residents is already an upper bound on the number of additional matches (you certainly wouldn't have more people interested when you increased the price to them). And even then, we wouldn't see a huge difference - the number of unmatched domestic applicants isn't enough to make a meaningful dent in the labor supply of practicing physicians - and that's assuming all of the unmatched doctors are as properly qualified as their matched counterparts.
In other words, no, we're not at the exact market-clearing rates for the medical education market, and we consistently bias in one direction from that equilibrium, but we're measurably not far off from it.
>There is no "full current subsidy" - the existing contributions from Medicare are already a partial subsidy.
In the context, I meant "100% of current level"; I didn't mean to imply that it was "full" in that sense (and my point didn't depend on such).
>t this is kind of a meaningless debate after a point, because the number of unmatched residents is already an upper bound on the number of additional matches (you certainly wouldn't have more people interested when you increased the price to them)
You wouldn't have enough doctors if residents had to bear $1 extra in costs? That is implausible.
With respect, this exchange does not feel productive.
>> For one, doctors educational costs are astronomical in the U.S compared to other countries.
Doesn't this apply to all US educational costs (at the college level)? On the other hand doctors in the US seem to get paid a lot more than in, say, the UK.
Insurance companies acting as profit-seeking middlemen between doctors and patients create a perverse incentive to drive up costs on both ends. It's a terrible feedback loop caused by treating health care (which is ultimately a cost center) as a for-profit enterprise. Every other modern country has managed to figure this out except the United States.
Not really the same thing. Insurers in a purely for-profit marketplace will always be incentivized to reject coverage for people with pre-existing conditions and drop coverage for people who become sick, because both groups are unprofitable to treat. The only way to avoid this is with strict regulations preventing insurers from doing what's in their own best interests at the expense of everyone else.
Why is single payer better? Genuinely curious. I just don't have any solid proof of the American Government doing a better job than the private industry enabled by competition.
It's hard to quantify 'better' but there are some major advantages to a single payer systems in terms of efficiencies. For example, a single standard for billing is in itself a major win.
One problem is that "private industry enabled by competition" is not really an option. Deregulating healthcare would be close to impossible politically.
assuming you're asking in good faith, the answer is pretty simple. A larger population has more leverage, and if all of the citizens bargain as one bloc (i.e., if the government does so on their behalf), it drives the market. Note that a tremendous chunk of the market needs to be involved for this to have maximum effect -- if a physician can "opt out" of Medicare/MediCal and make more money, they will, by and large. (There's a reason that being on call instead of waiting for referrals is called "service")
Most physicians in (e.g.) the UK do participate in the single-payer market (there are a small number who make a living offering pay-as-you-go services, but they are the vanishing minority), since it dominates demand. In the US there are a great many physicians who simply won't accept Medicare rates (they're viewed as too low by most) and since there are alternative sources of patients, that's who they treat (typically privately insured). This leads to the cases that show up at County or the ER being a hell of a lot more expensive than necessary as they tend not to be survivable for long. (A running joke at most county hospitals is that conditions believed "incompatible with life" routinely walk or roll into the ER and clinics.)
If you have 1-3 insurance companies and MediCal/Medicaid and Medicare then you have different rates for different groups, almost all of it horrendously opaque, and the 3rd party insurers are not incentivized to pay for anything.
As far as private vs. public, the issue here is the same as for schools, a private insurer or school can choose not to insure or educate a "customer", the government by law cannot. In the handful of cross-over studies of charter schools or vouchers, after controlling for subject-specific effects, the children who switched from public to charter or private tended to do slightly worse than expected based on their test scores from public schools. (It is a difficult experiment to run for numerous reasons.)
Medical care, unlike most goods and services, is stunningly inelastic in demand -- you either need it and will do whatever is required to get it, or you don't and won't, by and large. (Elective surgeries for cosmetic purposes are a separate matter; nobody goes in for a stent "just because" or visits the trauma unit just to poke their head in) Furthermore, a substantial amount of the cost is centered on the first and last few years of a person's life. Unless you would like the "market driven solution" of even higher infant mortality and elderly culling to proceed, 3rd party insurers don't have the incentives to make it go.
> In the US there are a great many physicians who simply won't accept Medicare rates (they're viewed as too low by most)
Right there is the big problem, though: Medicare reimbursement rates are already below sustainable levels for providers, which actually results in providers charging private insurers for the difference.
If Medicare were expanded to everyone, either Medicare would have to increase its reimbursement rates, or you'd see providers close up their practices (which is already happening, and which is one of the current problems with providing affordable care outside urban areas).
> Medical care, unlike most goods and services, is stunningly inelastic in demand
That's actually not true at all - medical care is highly elastic, as evidenced by the utilization differences for people who have plans with high copays and deductibles compared to those who don't.
> As far as private vs. public, the issue here is the same as for schools, a private insurer or school can choose not to insure or educate a "customer", the government by law cannot. In the handful of cross-over studies of charter schools or vouchers, after controlling for subject-specific effects, the children who switched from public to charter or private tended to do slightly worse than expected based on their test scores from public schools. (It is a difficult experiment to run for numerous reasons.)
But we actually do have a point of comparison here, because Medicare does have both privately managed and publicly-managed plans (as does Medicaid). Consistently, the privately-managed plans come in under budget while delivering superior medical outcome metrics and patient satisfaction scores compared to Original Medicare (or the publicly-administered Medicaid plans).
This is interesting -- suppose that the choke point of negotiation was handled by the government on behalf of citizens, but the administration of programs was privatized? That could be interesting.
Lord knows I've had about enough red tape for several lifetimes from NIH, NSF, and similar organs; Medicare as it now stands somehow manages to result in both medicine-at-a-loss and also fraud on a spectacular scale. I'm not a big fan of government but between consolidation and fragmentation, I don't think the current medical care solution is working, nor is it sustainable.
> Medicare reimbursement rates aren't necessarily too low if healthcare providers are currently overcharging. They could be perfectly be fair.
No, Medicare reimbursement rates are about 7% lower (in the aggregate, not individually) than COGS - the marginal costs of providing care. That is, if a test costs a provider $100 to purchase wholesale, Medicare reimburses $93, which doesn't cover the cost of the supplies, let alone covering overhead (wages for staff, office rent, etc.)
> If that's true, why does any single doctor in the entire country take Medicare patients then?
Well, independent private practices have been dying out for precisely this reason, and outside of Critical Access regions (which have a higher fee structure), many don't anymore. Some view it as an act of charity (the way lawyers might take on pro bono cases), but the laws regarding insurance segregation have gotten stricter and the logistics of it have become so burdensome that many just view Medicare as too much of a liability. It's one of the reasons Medicare patients have such horrific wait times to see doctors, particularly specialists.
Hospitals take Medicare because many of them are legally required to. If they're part of larger hospital systems, they can also play interesting tricks to manage the respective patient populations without explicitly discriminating based on insurance provider, which has been another major force behind the massive consolidation of hospital systems that we've seen over the last decade.
The other major force, incidentally, is that many of them have been going bankrupt, and are being bought out either by other hospital groups or by insurance companies.
yeah the doc-in-a-box practice is rapidly becoming a thing of the past. However the corporatization of medicine is not doing anyone any favors save for the administrators, and even then only the executives make out like bandits.
Private insurance is a big once since the Dr bills $xx with the expectation that insurance will only agree to pay a % of that amount(but different amounts from different insurers and clients). In BC doctors know up front what they'll get back so they don't have to play pricing games.
> What are the factors in the American system that prevent reasonable pricing?
One major factor is the administrative cost for medical providers when dealing with insurance. That's why the cash price for medical services is often much cheaper
There's lots of development, but it takes time to see the effects of that. The recent spike in prices has been extremely fast, up by 20% in 2015. Also, the city has to approve any increases in density, which doesn't happen overnight. Faster than silicon valley, though.
The first issue is that it's extremely difficult to run a long term controlled study on nutrition. Adherence to diet interventions is difficult to measure and it drops off over time. As a result most nutrition studies are epidemiological cohort studies which are not particularly good at determining causality.
The second issue is a question of funding. Diet and exercise interventions are not something that are typically monetized be the pharmaceutical industry. As such there is little private sector funding going into nutrition studies. Couple that with the fact that they're extremely expensive and you have a serious deficit in studies.
Once I found out that food calorie count today is still determined by literally burning the food in a calorimeter and measuring the heat, a practice started in the 1800-s, I realized that I am on my own.
I get that the laws requiring calorie content on labels have lead to finding an efficient way to measure and provide the numbers, but it is obvious to me that the measuring system is completely broken or very inaccurate at best.
I'm not sure what your problem with this method is, given that the amount of heat given by burning is the definition of a food calorie.
That's like saying "once I learned that voltage was measured by the deflection of a coil in a current (a practice started in the 1800s)" or "once I learned that heat was measured by the expansion of a liquid in a glass tube..."
You could argue that the heat definition of calorie doesn't really reflect the health function of the food (for example, maybe glycemic index is more useful), but I'm not sure why complaining that a calorie isn't a calorie is really insightful.
My problem with this method is that my body does not burn the food in the same way. And, it doesn't burn every food in a way similar to every other food.
I get that it's the best scientists could think of 100+ years ago. But putting averaged numbers derived from this absurd method on labels as if they are how my (!!) body works, and deriving all kinds of "food science" conclusions and recommendations from it is imo willful ignorance in the name of convenience.
Your body isn't actually burning the food. Therefore, why is this an important measure, other than it is easy to measure?
Bioavailability / metabolizable energy varies not only in the small, ie composition and cooking of food, but in the large, as long run diet choice changes gene expression.
Actually, respiration is burning the food, it's literally the same energy release, and the methods of calculation take into account the portion of the food that's burnable but non-digestable. If you're saying that the corrections for indigestible food are the subject of scrutiny, that's true, but that has nothing to do with the fact that "burning" is a problem for calculating caloric content.
I used to work in aquaculture, where we measured the amount of food going into a fish (via the bomb calorimetry that we're talking about, directly), the amount of energy spent by the fish in respiration (by measuring carefully increases in water temperature in their tank), and then we measured how much energy the fish had at the end (by burning the fish).
And quite simply, calories in was equal to calories out. It was a good relationship within very acceptable experimental error.
Now of course, the fish were growing very rapidly and we could control their food exactly. Humans, growing over a longer period, can be subject to different metabolic pathways, and we can't measure their respiration directly of these pathways [Edit: this is where the gene expression you mention comes in] - this is a far, far bigger source of error than the calorimetry, so calories alone can be less predictive of outcome. But this doesn't take away from the basic definitions of thermodynamics.
1) respiration is burning the food, but it's not burning all the food; "calories in" refers to calories absorbed, not calories put in your mouth; and the proportion between those two varies depending on all kinds of things, including e.g. gut microbiome and temporary changes to that due to various drugs; so if you strictly count calories put in mouth you still get a hard-to-measure variability in actual "calories in" (unless you put a respirator on the subject and measure it that way).
2) All other things being equal, changing "calories in" will make you lose/gain weight. The trouble is, all other things are not equal - simply changing how much you eat will significantly change those other things, it has an effect on your metabolism and eagerness for physical activity, thus directly affecting also "calories out" if you don't carefully monitor that and work to keep that stable.
3) All other things being equal, changing "calories out" will make you lose/gain weight. The trouble is, all other things are not equal - simply starting/stopping working out will significantly change your natural appetite, how hungry you are and how often you're hungry, and which types of food you have cravings for, thus directly affecting "calories in" unless you carefully track what and how much you eat everything and actually do keep that schedule exactly the same.
Ok but if my body takes for example an amino acid and uses it as a building block for repairing a muscle, that building block hasn't been burned, correct? So that "calorie" is functioning in a completely different way than as an energy source.
It's like we didn't burn the wood or store it for fuel, we used it to repair the walls of the house.
Yep. Though it's still counted as a "calorie" that's stored in your body as a certain number of grams of protein. If your body later decides to lose that muscle, then the calorie is spent.
Since fat and protein each have different amounts of calories stored per gram, that's why if you want to get really accurate about weight loss/gain, you track your body's %fat & %muscle and not just your weight.
Edit: to clarify your analogy, just because we use wood to build a part of the house, doesn't mean we won't take it and burn it if we're desperate for heat and have used all the other fuel.
Are we accepting that the complex biochemical mechanisms of the cells are identical to burning things in an open flame?
And, that every living human's body processes all foods in exactly the same way, regardless of age, ethnicity, gender, time of day etc? Just like the open flame would?
I generally agree with your two issues 100%, but one thing I've found interesting about these discussions is that no one seriously questions the fundamental hypotheses involved, that typical diet bears any relationship to long-term health.
That is, it's assumed it does, but we just can't pin it down because of poorly done studies.
My guess is that that's true, but the other very real possibility is that our bodies are designed to process a very wide variety of foods in a very robust manner, such that as long as you're not eating something obviously poisonous, it doesn't matter as long as you're not depriving yourself of something important nutritionally (as in scurvy).
Similar arguments can me made with regard to weight and exercise, although there it seems like the effects are clearer in certain ways (e.g., I doubt anyone would argue that being in shape isn't better than being physically deconditioned).
> our bodies are designed to process a very wide variety of foods in a very robust manner
There are indications that various health conditions can impair glucose regulation, and those affected would tolerate less dietary carbohydrate than healthy people. I'm aware of two conditions, elevated cortisol [1] and elevated blood iron [2] (which can be caused by regular alcohol consumption, btw).
The third issue is the food categories are way too broad and ill-defined. For example "meat" and "fat". There is meat and there is fat that tastes good (incl. hours later, when the gut had a chance to sample it more thoroughly - there's a "brain" and there are taste receptors down there).
There's meat and also fat that doesn't (taste good). It's not just the meat/fat itself, it's also the combination with other foods and the preparation that can change completely how my body perceives a food. Since those "feelings" have developed for a reason - we didn't have science to tell us what is good to eat for the 1st million years of humans (and pre-humans) - I dare claim it is significant for ones long-term health.
But studies don't make any such distinction. To assume everybody eats what tastes best is a stretch, not just because circumstances in our stressful lives, but also because the brain can only ask for food that it knows, and I remember the stories from that British chef who showed American kids tomatoes and potatoes and they had no clue what that was, they only knew processed food.
So how can you seriously leave it at "they ate x amount of meat" when such a person eats "meat" compared to someone who had opportunity to taste "traditional" (pre-industrial) foods and prepares him- or herself a good piece, including a good combo with other stuff and well-prepared?
Am I seriously to believe a McDonalds burger's "meat" is correctly put into the same place - as "meat" - as a real meal?
Of course, if you acknowledge this difficulty you have to give up on studies because I see now way to reliably collect that information on a scale large enough and long-term enough for a useful study. As the article suggests, actually (to give up going down this path). The story of that guy looking for his car keys under the street light even though he lost them somewhere else comes to mind, in the desire to study this at all this seems to be what happened.
It isn't about giving up as some readers took away from that paragraph, it's about choosing another path. For example, get down to understand what's actually happening instead of high-meta-level studies and see if that gives us new ideas.
Oh and here's a nice article related to the subject: http://www.vox.com/2015/3/23/8264355/research-study-hype(I hope nobody tries to count the dots on each side of the plot to use that to draw conclusions... it's an example and incomplete and even if it had dots for every single study could not be used for that purpose)
There is already some process available to measure this as Canada has tax deductions available specific to your "primary residence". CRA definitely has a way of auditing this. Sharing that information with a provincial level organization may not be possible, though.
But you pay interest on your leverage. So if your asset isn't appreciating faster than inflation + your interest rate then I don't think you're actually realizing any gains.
Not necessarily true because you are covering your need for housing at the same time as paying the mortgage. So even if it appreciated exactly at the same speed as inflation(as one would expect if housing prices were flat) you are only paying the interest rate but gaining an asset at the end of the mortgage. Also, that asset theoretically allows you to cover your housing needs for the rest of your life(with appropriate maintenance), so it should be valued as potential sale price + the value of owner's equivalent rent for the rest of your natural life.
This is what is different about real estate from all other investments -- you have you put your money towards it, whether it's an investment or not. You might not realize any gains on a mortgaged property, but it could be a better hold of money than rent.
You need to subtract the rent you're saving from the interest and also need to take into account if you can deduct the interest from your taxes [1]. If that interest rate ends up lower than inflation, you're realizing gains.
Even then, this assumes you'll have enough deductions to not take the standard deduction. I did this analysis once. I took the cost of a rental I was considering, figured out how much I claimed on long-form taxes. Then I re-calculated using the standard deduction (loss of housing interest deduction meant standard deduction was better for me). Then used the tax difference spread out over 12 months to calculate the "true" cost of my mortgage. It turns out the mortgage was quite a bit cheaper.
Even still, though, I am taking on a risk of not being able to sell the house if I ever change jobs. It's appreciating rapidly right now, but everyone knows this can change in months.
Note that primary residences in the US also have very preferential treatment as far as taxation of capital gains goes. That means that owning a house is a lot better than owning pretty much any other asset that only appreciate at the inflation rate.
That's only true if you just let the property sit there without taking advantage of the potential ways it could produce income for you (e.g. rent). On the flip side, you also need to consider property taxes, maintenance, insurance, etc.
Good point! I meant for your primary residence, you're paying that interest regardless of if you own a home or rent. So I don't factor that in when it comes to a primary residence. This is a different story for investment properties.
We Vancouverites are spoiled. I just finished an 18 month stint in the Bay Area. One of the biggest inconveniences was the driving time (especially with traffic) to get to the mountains.
In Seattle now and it's a great compromise. Similar wages to the Bay Area but similar geography and outdoor access as Vancouver. And even with the exchange rate housing is cheaper than Vancouver.
I spent a summer in Seattle and did more hiking, kayaking, and biking than I did in the year prior. It's an amazing place to work if you like the outdoors.
One thing that stood out to me is that immigration from Canada nearly stopped altogether in the mid 1890s. I wonder if the klondike gold rush was a factor here. I know it spurred a mass migration to the North.
As a collateral effect, even Vancouver's population skyrocketed growing from around 13,700 in 1891 to over 100,000 in 1911.
Probably one major factor was completion of the trans-canada rail road to British Columbia, finished in 1885 by CPR. This allowed free movement of immigrants from Coast to Coast, lowering immigration to the US and moving that migration to Western Canada.
The more time I spend in this industry the more I realize how many software engineers leave salary on the table.
It's great to see a tool like this which both encourage software engineers to negotiate their salary, and help them strengthen their bargaining position.
It's an interesting hypothesis but unfortunately a cohort study with no randomized control and n=236 isn't really meaningful. There's no control at all here and the sample size is tiny.
236 is a massieve sample size and it is more than sufficient for showing an effect here. The p-values are below 0.001, and while p-values aren't everything, it's a strong indicator that the result is statistically significant.
Particularly since one of the connections they postulate is between antibiotics and asthma, I'm curious how they control for respiratory infections which seems like a much more likely common cause.
p-value is almost irrelevant if you don't know how many overall statistical tests were performed. Finding a p<0.001 "significant" result after testing 1,000 different variables is far less meaningful than finding one after testing 5 variables.
The unit cost of healthcare is so much higher than in other developed countries.
In British Columbia, physicians bill at total of around $31 CAD ($23 USD) for a standard office visit. They pay all their overhead out of this fee. Typically doctors keep 65% of their billings and the offices take 35% for overhead. From what I can tell, a similar visit in Washington State will run between $60 and $200 USD when billed to insurance.
Why is this the case? What are the factors in the American system that prevent reasonable pricing?
http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/med...