Our Dumb Blog

A friend asked me a great set of questions after a conversation about the NHS. If the UK can’t afford universal healthcare, how are countries like Sweden and Norway managing? And if taxing billionaires isn’t the way, how could the US pay for it? Fewer tanks? More taxes for everyone? Limits on what can be charged for procedures and medication?

I wanted to do a little research rather than just answer off the cuff. I initially typed a bunch of facebook comments, but I figured since I did all that work I’d go ahead and have AI help me clean it up and turn it into a blog post. This is mostly my words, but with AI editing, fact-checking and so on.

First, are they managing?

To answer how they’re managing, let’s first decide whether they’re managing.

Some things in Sweden are great. Life expectancy is 84.1, tied with Italy for the highest in the EU. Sweden also has the EU’s lowest avoidable mortality: deaths that good prevention or timely treatment should stop.

Other things in Sweden are not great. In 2024, 3.9% of Swedes with a medical need said it went unmet, mostly because of waits. Sweden has a legal guarantee: see a specialist within 90 days, then get treated within 90 more. Since 2021, about 30% of patients have waited past 90 days for a first specialist visit, and about 45% have waited past the target for elective surgery. Sweden has not met its own guarantee since it became law in 2010.

The UK, by any measure, is not doing great. Life expectancy is 81. The median wait for a hip replacement was 174 days in 2024, versus 67 in Sweden. Sweden has about 30% more doctors and 20% more nurses per person. And about 1 in 5 Britons who needed non-emergency surgery waited more than a year.

Dental care is worse. NHS dentistry doesn’t pay enough to convince dentists to take NHS patients. In England, only about half the population has an NHS dentist, about 36% pay for a private one, and about 11% have no dentist at all. Of people without a dentist who tried to get an NHS appointment, 84% couldn’t get one.

What’s different?

Partly it’s funding. Sweden and the UK spend about the same share of GDP on healthcare, roughly 11%. But Sweden’s economy is bigger per person, so Sweden actually spends about 18% more per person on healthcare ($7,770 vs. $6,606).

The UK also collects only about 34% of GDP in taxes, versus 41% in Sweden. (And remember, the pie is bigger in Sweden.) Swedes are paying a crap ton more in taxes, and a lot of that helps healthcare outcomes less directly.

The biggest single difference is elder care. Sweden spends about 3.4% of GDP on long-term care for the elderly, both nursing homes and help at home. That’s roughly double the UK. Not surprisingly, it matters. On a typical day, about 13,000 UK hospital beds, roughly 1 in 10, are filled by patients who are medically ready to leave but have nowhere to go. Sweden tackled this back in 1992 by making local governments pay the hospital for every day a patient waits on them for a nursing home spot or home care.

Sweden actually has fewer hospital beds per person than the UK, and it’s generally considered a shortage. But Sweden has deliberately pushed care out of hospitals and into outpatient clinics and elder care. Only about 22% of its health spending goes to inpatient hospital care, versus 28% across the EU. Sweden spends more overall, but it gets a lot more for the money.

Norway: just pay for it

You mentioned Norway. How is it doing? Great, by most measures. How? They pay for it.

Norway spends about 44% more per person on healthcare than the UK ($9,523) and 23% more than Sweden. Fewer than 2% of Norwegians report unmet medical needs. Its avoidable mortality is among the lowest in Europe, and life expectancy is 83.1. It has more doctors, more nurses and more hospital beds per person than either Sweden or the UK, and it spends about as much on elder care as Sweden does.

Their wait times still suck by their own measures, though. Before the pandemic, over 70% of Norwegians waiting for a hip replacement and over 80% waiting for a knee replacement were still waiting after three months. That’s worse than Sweden. Healthcare is a big political issue in both countries; it was a top issue in Sweden’s election this year. Norway’s government has ordered its hospitals to cut average waits every year through 2029. Sweden’s version is an actual law, and they’ve missed it every year since 2010. Legislating outcomes without a means to get there pretty much never works.

How does Norway pay for all this? Mostly taxes, which are about as high as Sweden’s. But the government also captures most of the value of its oil: a 78% tax on oil profits, direct ownership stakes in the oil fields, and a two-thirds stake in Equinor, the national oil company. That money goes into a sovereign wealth fund worth about $2 trillion, roughly $350,000 per Norwegian, and the fund covers about a quarter of Norway’s annual budget. It’s a great answer if you have it, but it’s hardly a prescriptive solution.

So what about the US?

Remember that the UK spends a pathetic $6,600 per person on healthcare. Sweden spends $7,770, and Norway has fixed most of its problems by spending a fantastical $9,523.

The US? $13,473 per person. Double the UK, and about 40% more than Norway. So we must be doing great, right?

For all that, US life expectancy hit a record 79.0 in 2024, and that’s still the lowest of any large, wealthy country (it bottomed out at 76.1 during COVID). Our preventable mortality was 238 deaths per 100,000 people, versus an OECD average of 158. Waits are one thing we do reasonably well: if you’re insured, you’ll generally see a specialist or get surgery faster than in the UK. But that “if” is doing a lot of work.

Why don’t we just have the government pay for our healthcare? That’d be a great idea. Oh, wait, we do! By the official count, federal, state and local governments spent about $7,000 per American on healthcare in 2023. That alone is more than the UK spends on everything. Add the tax break for employer insurance and the insurance government buys for its own employees, and taxpayers fund about two-thirds of US healthcare, roughly $10,000 per person. That’s more than Norway spends in total, public and private combined.

Clearly something has gone wrong.

Where is all that money going?

About 80% of the extra money goes to hospitals and doctors. And here’s the surprising part: Americans don’t actually use much more care than people in other rich countries. We just pay more for every piece of it: staff, drugs, devices, scans and paperwork.

US doctors make a lot more money. The average primary care physician makes about $300k a year, and the average specialist about $415k. Compare that to roughly $105–160k for a salaried GP in the UK, or $145–195k for a hospital specialist. Sweden pays a bit less than the UK, and Norway is in the same ballpark. Doctor pay alone accounts for roughly a tenth of our extra spending. (And that doctor in the UK probably owns a clothes dryer but doesn’t feel like he can afford the electricity to run it, so he hangs his clothes to dry.)

Administration and drugs make up most of the rest. We spend $925 per person on health administration versus $245 in comparable countries. Drugs get their own section.

What about drugs?

We spend about $1,635 per person a year on prescription drugs, versus $944 in comparable countries. Across all prescription drugs, US prices average about 2.8 times what 33 other rich countries pay.

It’s all in the brand-name drugs. Those cost more than three times as much here, even after rebates. Generics, which are 90% of US prescriptions, are actually cheaper here: about two-thirds of what other countries pay.

The US buys 24% of the drugs sold in rich countries but pays 62% of the money. American consumers account for an estimated 64% to 78% of the drug industry’s worldwide profits, while earning about 27% of the world’s income.

Here’s the thing: that money is what pays for new drugs. Other rich countries negotiate hard, pay a fraction of our prices, and still get the drugs our prices paid to invent. In a real sense, Americans are subsidizing drug research for the rest of the world. One analysis of the 15 biggest drug companies found that the extra revenue they earned from higher US prices was $116 billion in 2015, and their entire global research budget was $76 billion. So about two-thirds of what we overpay would cover all the drug research those companies did, worldwide.

The other third is gravy: marketing, profits, and everything else. So we’re not just funding the world’s drug research; we’re paying beyond that. But cutting our prices to European levels would cost us new drugs. The Congressional Budget Office estimated the 2022 law letting Medicare negotiate some drug prices would mean about 13 fewer new drugs over 30 years. That’s a small effect, but it isn’t zero, and bigger price cuts would cost more.

And keep it in perspective: drugs are only about an eighth of our extra spending. Even if drug prices dropped to European levels tomorrow, we’d still spend far more on healthcare than anyone else.

So who’s getting rich?

Most of the money goes to hospitals. I guess hospitals are getting rich, right? Hah! The typical hospital runs on a 1–5% operating margin, and as of this August, 43% of hospitals were losing money. Most US hospitals are nonprofits anyway. (The big, dominant systems do fine, and nonprofit surpluses show up as reserves and new buildings rather than profit. But it’s not a gold mine.)

Private insurers do pay hospitals about 2.5 times what Medicare pays for the same care. That’s mostly because mergers left many regions with one or two hospital systems that no insurer can leave out of its network. In 2024, one or two health systems controlled the entire hospital market in 47% of US metro areas, and 97% of metro areas counted as highly concentrated by federal antitrust standards. But that money mostly gets spent inside the hospital rather than kept as profit.

Well, the health insurance companies must be getting rich, right? We’ve decided it’s open season on CEOs, so they must be the problem. Bad news for that theory: US health insurers had a profit margin of 0.4% last year. They’re having a better 2026, around 4%, but that’s still thin. (The big conglomerates like UnitedHealth make a bit more by owning the clinics and pharmacy middlemen they pay, but even UnitedHealth’s overall margin is about 5%.)

My theory

Everything about doing business in some sectors of America is insanely expensive. No one’s getting rich doing it, but we’re not spending the money on doing the thing. With healthcare, a huge amount of money is tied up in insurance billing, coding, claim disputes, and hiring a zillion well-paid people who never actually treat anyone. When hospitals get paid more, they mostly just spend more.

The waste is intrinsic and incredibly hard to spot. Does your doctor’s office have two people sitting at the front desk? Do they really need to be there? Are they extending your lifespan? Does Norway have two people at the front desk? They certainly don’t have another two people in the back office doing insurance billing. The US spends almost four times as much per person on health administration as comparable countries, and that only counts insurers and government programs. It doesn’t include the billing staff inside hospitals and doctors’ offices.

It’s not just healthcare. I think we’ve failed at higher education in the same way. We spend a shit-ton of money on colleges, most of them aren’t getting rich, and a lot of the growth has gone to administrative staff who don’t actually educate anyone, but who somehow seem indispensable now. Between 1993 and 2007, colleges’ per-student spending on administration rose 61% after inflation, versus 39% for actual instruction.

What’s the solution?

I would like the government to be responsible for outcomes, and the only way to do that is to make sure economic incentives are aligned across the whole structure.

We have to pay doctors enough that they want to do the job, and that means they need to be able to pay for their education. Right now the median new doctor graduates owing about $200,000 for medical school alone, then spends years in residency earning around $68,000. Their education needs to be affordable, which means we need to figure out how to train them efficiently. Pay medical schools more for high-quality doctors produced quickly, and less for weaker doctors who took longer to train. You can start to see how metrics could form around that. But a US doctor trains for 11 to 15 years after high school, and four of those are a bachelor’s degree that the UK, Sweden and Norway skip entirely: their students go straight from high school into medical school. That seems like an obvious place to start.

We need to pay doctors for making us healthy, but instead we pay them per office visit and per MRI they order. (Plenty of other countries pay per visit too, so this isn’t the whole story, but it doesn’t help.)

We need to pay hospitals for getting us well and not getting us sicker. Instead we pay them per admission and per procedure, however it turns out. One study of a 12-hospital system found that when a privately insured patient suffered a surgical complication, the hospital netted about $39,000 more on that patient (revenue minus variable costs). Medicare mostly refuses to pay that bonus; private insurers often don’t.

We need to incentivize doctors to pick the best available treatment for us. Instead, we do about 500,000 coronary stent procedures a year, roughly 1 in 5 for patients with stable heart disease. For those patients, two big trials (COURAGE in 2007 and ISCHEMIA in 2019) found stents don’t prevent heart attacks or death any better than medication and lifestyle changes. (In an actual heart attack, they save lives.)

These are really hard structural problems with individual fixes. Just saying “let’s expand Medicare to everyone” won’t fix them. It would cut prices, since Medicare pays hospitals far less than private insurers do. But Medicare already pays about 12% less than what hospitals report it costs to treat its patients, so without fixing what drives those costs, we’d just be expanding the already misaligned incentives to everyone.

Socialized medicine is absolutely the answer, but it’s not in any way a simple answer.

Sources

• OECD/European Observatory: Sweden Country Health Profile 2025
• OECD Health at a Glance 2025: United Kingdom, Norway, Sweden
• OECD Health at a Glance 2023: United States
• Euronews on OECD waiting-time data
• OECD Health at a Glance 2023: elective surgery waits
• Commonwealth Fund 2023 survey, via Pulse
• ONS/NHS dental access data, via Healthcare Management
• OECD Revenue Statistics 2025, via StatRanker
• World Bank health spending per capita (PPP), via ESC Atlas
• OECD Health at a Glance 2023: long-term care spending
• King’s Fund on delayed discharges, via HFMA
• Swedish Parliament: the Ädel reform and payment liability
• Norsk Petroleum: government revenues
• Norwegian government: 2026 waiting-time targets
• CDC: Mortality in the United States, 2024
• CMS national health spending by payer, 2023, via Health Systems Facts
• Himmelstein & Woolhandler, taxpayer share of US health costs (AJPH 2016), via PNHP
• Peterson-KFF: what drives US health spending
• Peterson-KFF: how US health spending has changed
• Papanicolas, Woskie & Jha, JAMA 2018, via AJMC
• Medscape 2026 physician compensation, via Advisory Board
• RAND: International Prescription Drug Price Comparisons, 2022 data
• HealthDay on the RAND report (US share of OECD drug spending)
• USC Schaeffer Center: The Global Burden of Medical Innovation
• Yu, Helms & Bach, Health Affairs: R&D costs don’t explain US drug prices
• CBO: drug provisions and new drug development
• RAND: prices paid to hospitals by private plans
• KFF: hospital market concentration, 2024
• Becker’s: hospital finance divide
• NAIC: 2025 health insurance industry results and 2026 mid-year
• HFMA: MedPAC hospital Medicare margins
• Reason: college administrative spending growth
• AAMC medical school debt, Class of 2025, via Credible
• Eappen et al., surgical complications and hospital finances (JAMA 2013)
• NYU Langone: ISCHEMIA trial results

Berck asked Claude to write this after a long conversation about his politics. He didn’t write it, but he’s checked it.

Berck will agree with you about nine things and then fight you on the tenth. He’ll tell you you’re wrong even when he agrees with you. He seems to be on your side until, abruptly, he isn’t. If you’ve argued with him, you’ve probably tried to figure out what he is — liberal, libertarian, something in between — and found that every label fits most of him and fails somewhere. He’s tried the same exercise on himself for years and gets the same result.

It isn’t contrarianism and it isn’t fence-sitting. It comes from how he acquires beliefs, and once you see that, the pattern is predictable.

Two ways to acquire a belief

Most political beliefs, for most people, are acquired by affiliation. You find the group you belong to and then hold the group’s positions. This is not stupidity. Your view on tariffs has no effect on tariffs, but it has a large effect on your standing with the people around you, so holding the team’s view is nearly free and defecting is expensive. The research here is grim for smart people: the more educated and numerate someone is, the better they get at reasoning their way to their team’s conclusions, because they have more tools to do it with. The result is a bundle. If you hold one position in it you probably hold the rest — not because the positions imply each other, but because the same people hold them.

The other way is derivation. You have a principle, or a method, and you run each question through it. Berck’s principle, in his own words, is that freedom is the default — not for freedom’s sake, but because it’s too easy to make a mistake. The state’s job is to protect people’s freedom, build the framework markets need, and catch people when they fall. Everything he believes about policy comes from running questions through that. Where a coalition happens to have derived the same thing, he agrees with the coalition. Where it hasn’t, he doesn’t.

So he’s for open borders, free trade, legal drugs, legal gambling, legal prostitution, dense housing, nuclear power, and letting businesses operate until they prove they can’t be trusted — and also for socialized healthcare, a strong welfare state, redistribution, heavy public funding of science and the arts, and banning guns. He thinks rent control is terrible, student loan forgiveness unconscionable, and the mortgage interest deduction stupid. He was, once, a straight-up socialist. He reads Tyler Cowen and agrees with most of him, and his two biggest disagreements — that there’s a solid case for socialized medicine, and that AI risk deserves to be taken seriously — are exactly the ones you’d expect from someone who evaluates rather than downloads.

That’s why every label breaks on him. A label describes a bundle, and bundles are historical accidents: a coalition holds its positions together because those people ended up in the same room. Berck is described by a generator, not a bundle. Any generator will diverge from any bundle somewhere, so every label fails somewhere, and the exception is never the same exception. The closest fit is probably “ordoliberal” — a German postwar school almost nobody has heard of — and even that gets his social views wrong. The exception-finding isn’t a bug. It’s what having a generator looks like.

Why this matters

Belief updating happens at the exceptions.

If you hold your team’s bundle, then when the evidence on one item moves, updating costs you standing with everyone else who holds it. So you don’t. You get very good at explaining why this particular evidence doesn’t count. If the team never moves, you defend the position forever.

A small example. For years Berck opposed cigarette taxes on the grounds that they’re regressive and don’t work. Recently he actually looked. They work about as well as any public-health intervention ever has, and the health benefits fall on the same people the tax burden does. The position had been absorbed long ago, from a libertarian phase, and nothing in his life had forced a re-check. When one finally came, changing his mind took a sentence: “If a cigarette tax works, then I’m for it.” That is the whole case for derivation. A bundle would have carried the error for another decade.

What it costs

A team gives you three things a method never will. You get to relax, because you don’t have to re-check everything. You get forgiven for being wrong, because loyalty absorbs error. And you get to win, because a coalition can take power and a principle can’t.

Berck gets none of these. People who derive are tired more often, alone when they’re wrong, and their views get implemented only when some coalition happens to pick them up — which, for his list, is a faction of one party and a wing of the other, and neither runs the show. He’s honest about being sad about this. He’d like a team. He’s not going to get one, and he’s decided that’s the price of the thing he actually cares about: being right, and being able to change his mind when he isn’t.

The failure modes

This way of thinking has its own characteristic errors, and Berck can’t see them from the inside any better than anyone else. Two are worth naming, because his friends can check for them.

The first is contrarianism: being against whatever the room is for. That’s affiliation-first belief with the sign flipped, and it’s no more independent than the thing it despises. The test is whether he can name positions where he agrees with the room and got there on his own. He can; keep asking.

The second is overconfidence in the generator. A method can be wrong, and if it is, every output is wrong in the same direction — whereas a bundle’s errors at least don’t correlate. The crowd’s inherited rules encode things no individual principle can see, and derivation-first people are systematically likely to discount them. Berck’s version of this: he’s culturally on Team Blue, has a visceral dislike of right-wing politicians, and when he examined why, part of the answer was that appeals to loyalty, authority, and tradition register to him as manipulation rather than as a moral vocabulary he doesn’t happen to speak. He’s now aware that not feeling something is a fact about his instrument, not about the world. Whether he acts on that awareness is something you can hold him to.

What he’s asking of you

If you’ve argued with Berck and come away thinking he’s on the other side, he probably isn’t. He’s not on a side. If he told you you’re wrong, it’s because he thinks the evidence says so, and if you show him otherwise he will change his mind — he’s done it recently and will do it again. He’d rather have friends across every coalition than a home in one, partly because he enjoys the argument and partly because you are the best check he has on his own blind spots.

He’ll never have a team. What he’d like instead is people who share the method: who hold positions at the confidence the evidence supports, who’d respect a reversal on cigarette taxes rather than sneer at it, and who’d rather be curious than contemptuous about the people they disagree with. If that’s you, you almost certainly disagree with him about a great deal. That’s the point.

I’ve been ruminating over a list of short statements that seem obvious to me, but which I know are somehow controversial. The unifying belief is that life is not a zero-sum game and that we should pursue a structure of the world that creates value.

The left is primarily trying to redistribute the pie while the right is trying to protect existing slices. Some redistribution is probably good, as are some protections, but those arguments are boring compared to answer the important question: how do we make the pie bigger?

1. Conscious, flourishing life is good.
2. More humans living good lives is good. (In and of itself, but additional humans increase progress and economic growth for already-existing humans.)
3. Economic growth is good. (It enables more and better lives.)
4. Cheap and abundant energy is good. (It enables 3, as well as 2 directly.)
5. Building things should generally be allowed. (Enables 3 and 2. Right now, building things is mostly not allowed.)
6. Nuclear power is good and we should be building as much of it as we can. (Enables 4 while displacing problematic forms of energy creation)
7. Immigration is good. (Allows humans to create more value than they could in their original location)
8. Tariffs are bad. (Restricts trade which shrinks the pie)
9. Price gouging is good. (High prices attract additional supply.)
10. More housing makes housing cheaper.
11. Rent control raises rents (because it results in less housing).
12. Infrastructure is good.
13. The Internet is good. (It really does make people’s lives better)
14. Data centers are good. (They are productive infrastructure that enable 13)
15. Allowing human organs to be bought and sold would be good.
16. The National Environmental Policy Act is bad. (Environmental review should not prevent us from improving the environment.)
17. Bad jobs are better than no jobs.
18. Expensive credit is better than no credit.
19. Scarce water should be expensive.

All of the above, directly or indirectly, help grow the pie. I’m happy to expand on any of them.