• Absolutely. However we have a convoluted and patchy way of paying for it, a litigious society, American attitudes toward health, healthcare perspective, a lot of unhealthy habits, and unhealthy infrastructure

    How we pay:

    We have Medicare for the elderly and disabled. Sure they pay a premium (which comes out of the individuals social security check) and this is supplemented by 2.9% payroll tax. Half of this is hidden as the employee only sees 1.45% taken out but then the employer must “match” that amount so it is really 2.9%. Medicare pays 80% of the medicare “fee schedule” for a medically necessary service. So the patient either pays the other 20% or buys co-insurance. Payment from medicare is just above the cost of the hospital/physician so no doctors really want a lot of medicare patients.

    We have Medicaid for the poor. It is paid by federal and state tax dollars. The ratio is determined by the per capita income of the state. Payment rates to providers vary by state and are very low (lower than the provider’s cost). Most physicians only take a Medicaid patient in an emergency. Some states run clinics for these patients. Mostly the patients use the ER as a clinic (the most expensive form of care, but since the Medicaid patient is not paying for it and cannot get care elsewhere this is one of the patient’s few options).

    We have insurance provided through the employer. Many employers provide insurance and many pay most of the cost. There is often a network of physicians and the pay for the hospitals and doctors is pretty good (though deductibles and costs have gone up since the ACA has gone into effect)

    We have privately purchased insurance policies. These tend to be quite expensive. Prices have risen drastically since the ACA went into effect and deductibles have risen. Families with this may have insurance in name only as the deductible may be $10,000 and the premiums $10,000 before the insurance pays anything.

    We have the ACA exchanges. This is where you input your income, pick a policy and find out a price. The “thought” since everyone was required to have insurance is that the young and healthy would support the older sicker patients. Prices are subsidized but policies are provided through private insurers. Current trends show insurers dropping out of markets and prices rising quickly as the young people choose to pay a tax rather than pay a significant rate for health insurance that they probably won’t use.

    Finally there are the uninsured. Works well if you don’t get sick or injured. A serious sickness or injury can cause bankruptcy as the list price at US hospitals is sky high.

    So in conclusion, we have a mish-mash of the way we pay for healthcare. The privately insured and the ones with employee provided insurance tend to be the happiest, but their costs are rising now quickly to pay for the patients with subsidies.

    A litigious society:

    The US is the only western society that allows for contingency based lawsuits. If a patient thinks something was done wrong or he had a reaction to a drug he may find a lawyer and sue. It costs the patient nothing. The lawyer takes 33–40% of any award as pay. The doctors, hospitals and drug companies must defend these suits. That costs money.

    In 2001 one of the largest malpractice carriers in the US, St.Paul, left the market after 37 years. In 37 years they had never made money in a single year and just could not predict the market. Personally I had 6 claims. None resulted in a payout or settlement. Given my specialty the odds were that I should have averaged 18 in the same period. My malpractice carrier in the interim paid $357,000 to defend me. I paid $1,500,000 in premiums. So I guess they made money from me, but not in the market overall.

    One cannot watch TV in the US for an hour without seeing 3 ads from attorneys about drugs or medical devices offering to sue.

    American attitudes to health care:

    Americans often think that if something is wrong with their health that a pill should fix it. It cannot be that they are sedentary and 50 pounds overweight, eat a high sugar diet and few vegetables. That is somehow not the reason they have diabetes, hypertension and heart disease.

    It cannot be that our portion sizes have grown so that an appetizer could feed a single person. Recently I ordered Chinese take out and thought I bought enough food for myself. There was soup, an appetizer and an entree. 3 days later I was still eating it. The soup would have been enough.

    Unhealthy Infrastructure:

    The US is a large and spread out country. It is huge. Our cities have suburbs and there are only three cities that I think the average person could go without a car. Boston, New York and San Francisco. We don’t do mass transit well mostly because the distances are vast. Train travel works on the East Coast Washington to Boston corridor only. We could have more, but we already have cars and highways.

    The result is that our suburbs and cities have huge streets and distances are long. We don’t walk anywhere much. We get little exercise because we hop in our cars to go to the supermarket or office. It isn’t like the coast of Italy where the lemon farmer fills his basket, goes up 750 stairs, down 750 stairs to the market. He does this 7 times a day. There is no road just a path and steps. I sure he could find a road that went 20 miles out of his way but the road winds and nowhere to park to off load his crop. He probably doesn’t have a car anyway, there just isn’t a need and the infrastructure in his town wouldn’t support it. So every day he climbs those steps and burns calories.

    In many inner cities there really is no supermarket and the US really doesn’t do many small shops. Our inner cities are often poor and the food choices may be really unhealthy (as in fast food).

    Unhealthy Attitudes and costs:

    Americans work a lot. I mean the average person gets 2 weeks vacation. We tend to arrive home tired and cooking a meal may be tiresome. We get processed food from a box or high calorie take out.

    Another costly problem is that since some form of insurance is paying for everything families and consumers demand costly treatments. A chemotherapy drug that extends life 2 months but costs $75,000 is routinely demanded even if those two months are not a very good quality of life. The insurance company pays.

    The US has great technology, great delivery systems, but poor habits and unrealistic expectations of what medical care can do.

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