Healthcare is not a free market. People don't comparison shop, and couldn't even if they wanted to. Price lists are secret because providers have two prices, one for cash and one for insurance. People with health problems have stress enough dealing with insurance companies and providers, filling out endless paperwork, to deal with it even if the info was available. People in hospitals and emergency rooms CANNOT shop for alternatives since they are a captive audience.
When the social norm hardens around "don't charge what it's worth, charge what you can get" this is the result. I once asked a hospital billing agent how they could justify a $10k ER bill for 4 hours of waiting and 1 hour treatment, and they responded, "How much is your life worth?"
One place that gets it right is Germany: an inexpensive public option that gets you competent medical care almost anywhere. Bring your card, no deductibles, no paperwork, no complex calculation and a minimum of paperwork (which is a rarity in Germany). This is how it should be here.
In Germany, access to health care is becoming a major problem. I have two young kids and I’ve experienced on multiple occasions not being able to get appointments with specialists for them. Sometimes you offer to “self pay” - basically paying full cost with no insurance - and sometimes it works, other times it doesn’t.
Germany has a major doctor shortage and it can’t just attract foreign doctors like Anglo countries due to language requirements. This issue will continue to get worse as the population ages.
People act like there are no wait times in the US.
I remember a few years ago, I noticed a mole on my arm suddenly looking very irregular. I kind of panicked, thinking it was potentially skin cancer. I have decent PPO insurance, no worries, I can go call up and schedule an appointment with a dermatologist directly. I live in one of the largest metro areas in the US, tons of doctors, should be a breeze to get it checked out.
I load up the find a doctor website on my insurance company's website. There's like 30 dermatologists within an hour or so drive from me, awesome. I start calling. Not taking new patients right now. Can't be seen for 6 months, 8 months, we could get you in next year. Next year, when I might have quickly growing skin cancer?
Luckily when I finally talked to my wife about it, she reminded me she had poked my arm with a permanent marker. Some solvent, and my mole looks normal again. I still make sure to keep my dermatologist appointments, just so I don't have to deal with the new patient issues and the "we're not taking anyone new these days".
I had a different issue with extreme nystagmus come upon me. Bedridden for days, I couldn't even open my eyes without having extreme vertigo. Calling ENTs to try and get help, none would be able to see me for weeks. Luckily a friend who works with ENTs managed to get a doctor to see me but if it wasn't for that I probably would have just had to suffer at home with no answers as to what was happening.
I now know that unless I'm practically about to die, seeing a doctor that will do more than run extremely basic labs and very basic healthcare is weeks away in the US even if you have decent insurance.
I can get an MRI in a few hours for a couple hundred bucks out of pocket. I can go get blood drawn in a half hour and lab results tomorrow morning. Tons of private labs and imaging centers are looking for anyone to fill the machine or get stuck. That's not the problem. The problem is getting an M.D. to read the results and actually tell me what's wrong and a good course of action.
In both examples, just getting an MRI would have told me practically nothing. Maybe for the nystagmus, it would have told me if there was significant brain cancer. Maybe a blood test would have told me something about cancer, but there's a good chance it would have been inconclusive, I needed a biopsy (or, in hindsight, a bit of rubbing alcohol).
I've seen a case of both providers of ACA "marketplace" plans in a state each including only one of the four closest hospitals to me as "in network", with similar extremely-spotty coverage for everything else. And one excluded the massive children's hospital in the city that'd also gobbled up every pediatric care office in 50 miles, so there was, practically, only one insurer you could pick if you had kids (those two providers were the only ones offering individual insurance in that state at all, everyone else had pulled back to only doing group plans in that state; both were also companies I'd never heard of before).
This was in an actual city. Things can be even worse out in the sticks, where hospitals are much farther apart and often offer only some of the services you expect from a big-city hospital.
Lots of these plans also only cover a small geographical area, except for ER visits (which I think they have to cover). So don't get sick in a way that gets you discharged from the ER into a regular hospital bed, but still unable to get home, while traveling within your own country, if you don't want to go bankrupt.
Like it truly wouldn't have been crazy for someone on one of those plans to get some kind of travel insurance while traveling in the US. That's how fucked up our healthcare system is.
I paid out of pocket and went directly to a dermatologist in a week, where insurance wanted me to go through my doctor (my local doctor has no appointment times) first. It was skin cancer. I ended up bypassing insurance because I was scared to wait the months navigating their system would take. But also because it was supposed to be cheaper (I price shopped) than my deductible. Guess what, when you price shop, the price they tell you has no relevance to the final price.
You lived out what I had only feared. I'm sorry that happened to you, this kind of thing shouldn't happen to anyone.
> Guess what, when you price shop, the price they tell you has no relevance to the final price.
I've found they often can't realistically give any kind of useful quote. I remember getting a total cost estimate from the hospital when my second child was born, anywhere from $20k to $160k before insurance, please sign here.
Long wait times are not exclusive to public healthcare. My dermatology appointment to examine a concerning mole was scheduled 9 months out. And of course I pay for the privilege.
I'm in the US and I hav regular 6-8 month waits for non-specialists and very hit or miss luck with specialist appointments. What you describe is not solved by the us approach
When I worked in the US I had “Kaiser Permanente” which seemed to be something like an all-in-one system. You have specialists, GPs, labs and pharmacy all in one building covered by one insurance. Could something like that scale to the whole country?
Of course the approach works, we can see it work at various scales. I think what prevents it from working is that it works best when it is the only option. I don't think we could support 5 kaiser permanentes. And that feeds into insurance - there are a lot of insurance plans, and each of them would likely only support their specific kaisers
So ideally there is one insurance, with one provider that has vertical integration everywhere and then indies outside the network you can go out of pocket for, and oops I invented single payer
> When I worked in the US I had “Kaiser Permanente” which seemed to be something like an all-in-one system. You have specialists, GPs, labs and pharmacy all in one building covered by one insurance. Could something like that scale to the whole country?
We can't even scale out broadband to the entire US.
It can scale to a whole province of 5 million people.
I had Kaiser Permanente when I was in the US. Now that I'm in BC, Canada, it is very similar. I walk into any hospital in the province and every doctor and specialist in the building are part of the same system (technically they are broken up into three geographic subunits, but to the patient it basically doesn't matter). If I need some sort of treatment that hospital doesn't offer, they can immediately refer me to the correct hospital. For emergency cases the provincial ambulance service will transport you to another hospital by road or air at no cost.
There are still independent specialists and doctors outside of the hospital system, but they have access to the same records systems and the billing is so seamless that I suspect that most people don't realize it is happening since it never involves the patient outside of providing your ID.
Organizations like this have existed in some places in the US as well. I remember growing up in Houston we would go to the Kelsey-Seybold clinic. They had a lot of GPs but also a ton of specialists all under the same network and sharing the same building.
>can’t just attract foreign doctors like Anglo countries due to language requirements
That is a serious and real obstacle. German has a well-deserved reputation for being difficult to learn. I'm pretty good at learning languages but German is extremely difficult to speak properly unless you are raised in it.
Similar situation in Poland with appointments for specialists in at least 6 months and often much longer.
German public health insurances are concerned right now about their unusually high deficits. Because many millions refugees are not working they only get paid a reduced amount towards the mandatory health insurance but have the same full service. Bringing the already substituted public health insurance into insubstantial deficits and now they are increasing the rates for the working class and probably they will need additional tax money too.
Here in the USA, my wife had an infection in the root of a tooth (long story), and was trying to get in to see an oral surgeon to get proper treatment.
Even with an active infection, that could have cost her her jaw or her life if it had been left unchecked, it took months to get anyone to even make an appointment for an initial consultation. We were very fortunate that the oral surgeon we were finally able to talk to was able to fit her in for surgery within a short time after that, due to a cancellation.
People talk dismissively about the "long wait times" you get with some public healthcare systems, but always oh-so-conveniently ignore the fact that there are long wait times here too. Sometimes catastrophically so.
Almost universally, when you dig into it, the "long wait times" that exist in those systems fall into one of two categories: either they are wait times for elective procedures, where your long-term health is not at risk, or they are caused by shortages that are symptoms of unrelated problems.
Neoliberal fiscal policy to underfund public goods has slowly crept into non-American western health systems, the undercutting of the UK NHS as a leading example of a regressor. It makes everything in the system less efficient - increases calls for even less efficient privatization of healthcare. It doesn't save money for an economy except at the most superficial narrow view level of accounting.
I recently found out, after getting a big surprise bill, that you can sort of comparison shop now, at least with my insurer. They have a “Treatment cost estimator”, which I’ve found to be pretty accurate, and the price differences from one place to another are substantial.
I price shopped having skin cancer removed from my face because the total was under my high deductible. By the end the total was $2500 more than the 'price shopping' 'yes this will be the price' price even though everything went as perfect and easy as possible. This place is the number 1 clinic for doing this in the nearest city. Their waiting room was full of old guys getting skin cancers removed. And there was nothing I could do but pay the extra $2500.
AIUI, this is very difficult to do: the estimate is going to be based on a superficial (in the literal, physical sense) examination of the problem, and once they are actually in there doing what they need to do, they may very well find that there is more that needs doing than they expected.
They can't exactly pause the surgery and get you to consent to an extra few thousand dollars' worth of work.
This is another example of why healthcare really, genuinely is best left as a single-payer government-funded service. People can get the care they need to be healthy, without ever needing to worry about the uncertainty inherent in the price of such a service.
I was under the impression there were already laws in place around this signed in first Trump term?? Anyone know what I'm talking about? Now I would not be surprised that the industry flaunts it completely.
They have to provide prices for various billing codes, but you can't really make them commit to which billing codes will apply. This is for both legitimate reasons (stuff might go wrong, they might find something is different than what they thought it was just because that unavoidably happens pretty often in medicine, et c.) and for illegitimate reasons that the legitimate reasons give them cover for (medical billing departments are the organizational embodiment of smarmy, lying assholes who are constantly trying to screw everyone)
> "What's missing in health care is: It's not a traditional free market. You don't have those competitive forces"
Blaming insurers and drug companies is fashionable -- and employers is a new twist, I suppose -- but it feels like a desperate search for a facile answer. Nobody wants to hear the hard truth, which is that if you had to pay for it, you'd suddenly become a lot more picky about the health care you purchase.
You don't see the prices, so you don't care, and you can't shop around. I'm not saying there aren't a ton of other negative incentives in the system, but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.
This would be true if the people that do pay the prices had no influence on your purchasing decision, but the insurers maintain a massive hold on purchase decisions. And in reality, a ton of insured people do pay very directly for their healthcare in deductibles and denied coverage claims.
I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything.
I would love to have had healthcare in America where I was insulated fully from the costs of care. My experience was that it was rare to see a doctor where I wouldn't end p paying at least three figures despite having fantastic insurance.
Meanwhile in Canada, I can recklessly visit three doctors per day for the same issue at no out of pocket cost if I want, and it will still cost my insurer (the province of BC, in my case) less than a single doctor visit 60 miles south of here.
From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying
Many of these things you state as fact do not match my reality.
> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.
That’s basically my plan. I work for a FAANG, and have a low 2k/year max out of pocket for in-network, which is almost everything I encounter. I just book specialists when I want, and I see them as many times as I need. I can do PT 365 times per year, so as long as I don’t go more than once a day (which would be silly), I consume as much as I want. I recently chose to go to the Mayo Clinic — out of state, no referral, and everything is covered. I keep getting estimates from them of $0 since I hit my max out of pocket. The only thing I’ve been denied for is Botox for TMJ which they say is not medically proven (seems to be the opposite, but I understand why they’re wary).
I’ve never had a medication, procedure, or doctor visit denied.
You cannot consume as much and whatever type of healthcare. You have to consume from the pre-approved list of doctors that have negotiated rates with your insurer. I also do not believe for a second that if you found a doctor willing to give -for example - daily electrolyte IVs for your post workout recovery, that the insurer would touch that claim. Same thing with cosmetic or elective surgery. Will your insurer cover a facelift? Will they cover Ozempic for vanity reasons? Will they cover the full cost of all name brand drugs after your deductible is spent? And you still have to pay $2k before any of that is in effect.
Mind you, your extreme outlier reality is one that is essentially never experienced by >95% of people, and it still has constraints.
Yes, the US system works great if your are at the social peak, such as working at a FAANG. Thanks for reminding us of the level of class disparity as we struggle to pay our bills or get our children medical care.
When I was a kid, everyone no matter economic level had pretty much the same pediatric doctor group. Now the working class people around me don't really have a pediatrician, but an overworked 'nurse practitioner'.
> From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying
The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. Even your doctor has no idea -- try asking sometime! I routinely point out to my primary care doctor that the medicine/test/whatever they're recommending is expensive and low-quality, and he looks at me like I'm an alien. Statistically, I am.
You're not wrong that you can get caught in a circle of hell after you get the bill, and that insurers are an opaque barrier to purchase decisions, but that's just saying the same thing a different way -- you have no ability to shop for what should be a commodity service.
> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.
...and that's one of the few good things about our system, though I agree that the US implementation is maximally stupid. You should have to evaluate the cost and benefit of going to a (rare, expensive) specialist! While I agree that insurance companies suck, it's telling that the debate around this issue has devolved to indignation that someone should be acting to control costs by limiting the freedom to choose expensive things.
> The US has the highest cost of healthcare primarily because nobody knows what healthcare costs.
This requires explaining how places like the UK - where the cost is far more hidden than it is in the US with high-deductible plans being very common - have substantially lower costs.
Well, you're making a a series of logical fallacies (are we talking about the UK, specifically, or an unspecified constellation of "places like" they UK, so that you can avoid the false dichotomy?), but my general rebuttal would be this:
"the existence of magical unicorn places with worse price transparency than the US does not make opaque pricing good."
I'm honestly not sure what you're trying to argue. The US system is good? Price transparency is bad? UK good, US bad?
The US has better than average price transparency, as a huge proportion of us are on high-deductible plans where you directly pay the entire bill until you hit your deductible. Someone on such a plan knows their pediatrician appointment costs $300, because they have to swipe a card (or get a bill for it).
Much of the rest of the developed world doesn't ever even see a dollar amount.
Thus, the "knowing costs drops spending" theory doesn't hold up.
> Much of the rest of the developed world doesn't ever even see a dollar amount.
Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.
Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping". So if you want to call that system price transparency, then all I can do is shrug and walk away.
> Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.
I mean, go visit any Reddit thread discussing an American healthcare explanation of benefits bill. The Americans go "yup, it's expensive here"; the Europeans tend to go "I literally just paid $6 for parking for childbirth".
> Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping".
If I get a bill for $300 for a pediatrician appointment, I know what the next one is likely to cost, yes?
Again, people on high-deductible plans know very intimately how much everything is costing them.
I'm not sure why you think there is no price transparency in the US. I know exactly how much I was billed and how much my insurance paid. I generally don't ask ahead of time, because it's going to cost me $20. I get an explanation of benefits for every visit. When I was still below deductible at one appointment they gave me options and how much it would cost. What I don't really get is the option to choose. Limited providers and the network limit my options.
From your description you have extraordinary insurance. I have good insurance (according to a staff member commenting on our low deductible). It does not work how you describe. Our insurance servicer (United Healthcare) makes all the decisions. Doctor prescribed x, it gets denied. We've had denials on meds they have been covering for years. I wish we could shop around. It's just not realistic.
You're very fixated on knowing the cost beforehand.
Americans know intimately that doctors visits are going to hit them in the pocketbook. Far more than someone from a single-payer system does, where there's a good chance they will never receive a bill with a dollar amount on it.
Yet, we're the big outlier on medical costs. Knowing "this is gonna cost me, ooof" does not seem to have any impact on the costliness of the system.
My out of pocket pre-insurance costs in Portugal are so low that I sometimes forget I still need to file for reimbursement with my private insurance provider. My copays on certain plans in the US were higher than this.
There's no way the cost difference (often literally 10x+) in private healthcare with the US can be explained by anything other than "US prices are actually total bullshit".
It's not just specialists that are expensive, though. The ER is expensive. You cannot price compare during a medical crisis.
It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
This isn't cosmetic surgery comparison shopping. This is "this Doctor has experience with my rare neurological condition, has published papers on it, and has shown success in designing care plans for people like me."
> It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
Except...you absolutely should, and it isn't weird at all. If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it? [1]
Maybe you would, maybe you wouldn't, but the choice exists, and someone is making it.
[1] You can make it more complex and human, of course: most medical interventions not only cost money, but also carry serious risks. Maybe you would choose to spend an enormous amount of money, but would you also choose to take a treatment that will leave you deathly ill for the remainder of your life in exchange for 1 extra day?
> If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it?
Then be honest in society. Last time the proponents of the current system talked, they implied changing anything would result in 'death panels' that would do what you are saying. So which is it? The current system results in death panels, or prevents them? Because this is a total change from what was sold to the American public.
"Death panels" is an unfortunate name, but they exist in all systems. The current system in my country and your country has them. Any future system in either our countries will have them. It does not matter if the system is public or private.
They are simply not avoidable unless you have literally (literally literally, not figuratively literally) an unlimited budget. No country or system has unlimited resources.
> It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
But all countries do that cost-benefit analysis all the time.
Not every procedure or medication will be administered to the patient, even when those procedures and medications have been approved for use in a particular country.
Insurance companies can’t really work as things that change the expected value of the service they insure, it just doesn’t make sense. They exist to cover massive unlikely risks. I don’t blame insurance companies for being annoying services with negative expected values (that’s just inevitable).
But, whoever decided to start marketing things like low deductibles and out-of-pocket costs as a premium service, that person bears a lot of blame. They are the one that decided customers shouldn’t see most of their healthcare costs.
The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups.
Mixing in employer insurance also caused a skew, because it makes people see their employer insurance as a perk. A perk should be something you actually experience. Employers should dump money into your HSA, and subsidize a gym/healthy snacks for their campus instead (some do, of course).
> The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups.
Well, that's just silly. The whole point of insurance is to cover tail cases: Catastrophic costs with low probability. If there is no cap, why have insurance at all?
Sorry, I think I might have accidentally use a term-of-art, and misused it. I meant “no cap on how much the insurance will pay out.” But, when in the same sentence with “high deductible,” the more reasonable parse (and the one I think you read it as) is “no cap on out-of-pocket expenses.” My bad.
I had a procedure done recently. I was given a bill, I opted for a more expensive treatment, it was a ~$1500 total, my insurance wouldn't cover an extra $300, I paid it since it seemed worth the extra money. I received another bill in the mail for $300 a month later that my insurance had additionally decided not to cover. What is this world you live in where American health insurance means you don't have to comparison shop? Healthcare is a huge expense and not only are the prices high, they change after the fact at the whims of the people I'm theoretically paying to handle the negotiations.
For our kids births, it was typical to still have bills trickling in six months later from some company or another, having no idea which part they were really involved in unless we felt like spending three hours on hold to figure it out.
And always they're like YOU MUST PAY THIS IMMEDIATELY or be sent to collections even though they take their sweet fucking time getting them to you, and also make it a pain in the ass to question any of it (and some of them are serious, in two cases we had trivial-amount ones slip through the cracks of the 50+ billing and EOB and blah blah blah letters we received, and go to collections right at 30 days, not even a follow-up "hey you may have missed this, you're overdue" letter)
I wouldn't be surprised if there are a bunch of scam artists out there sending fraudulent small bills to patients with recent major procedures (guaranteed to have a mountain of confusing bills coming in for months) whose info they got from our massive privatized spy network, and having almost all of them get paid. Like, compared to some other stuff that goes on, that seems like a no-brainer of a scam to run, with likely a very high success rate (am I going to burn potentially half of a day per bill to figure out if one of these fifteen $10-$200 invoices is fraudulent? No, no I am not)
You're describing a scenario where you bought the product without knowing the price, and were shocked by the additional bill(s) you got after the fact.
At what point in your story were you able to comparison shop for a cheaper option? I know you said you chose a more expensive option, which is always your prerogative, but how many other providers did you evaluate before you made that decision?
I received a bill for the price and the price became more expensive after the fact. In my experience it's a fact of American healthcare that you always pay more than the price you are quoted. But you are usually quoted a price. I was quoted a price, I paid it, and then it increased. This is how paying for healthcare works in America.
I really wonder if there is a serious accounting scam going on here. Send a bill that ends up on the books in a prior year (so its part of the 80/20 rule) then in current year you retroactively deny it and keep it off the books.
Any sort of repair is inherently unpredictable, and healthcare especially so. Whenever I pay for something like this it's natural that the costs may prove more than what I expect. The risk that there is some irregularity with my insurance is similar, it's a risk that I take when I pay for a procedure. You can't depend that money spent on healthcare will help you in any way, it's a fact of life.
I mean, in this case I actually was able to depend on the numbers, it's just I can't depend on my insurance but then that's also a fact of insurance markets. Take away the insurance, I doubt my total cost would've been lower, even accounting for my insurance premiums and whatever my employer pays as part of that.
There's a market here, I would prefer it were more regulated, not less. A less regulated market would not help me. A less regulated market would make it easier for prices to change at random.
> Any sort of repair is inherently unpredictable, and healthcare especially so.
There are certainly acute situations that are unpredictable -- go to the ER with a gunshot wound, and nobody can tell you what it's going to cost. That's fine.
But most of the time, you're wrong. Health care moves slowly, and there's lots of time to think and plan. The costs of pretty much any procedure is pre-negotiated by the insurer and the provider, so they actually do know what it's going to cost. They just don't tell you.
There's no fundamental reason you couldn't have been quoted an accurate price in the scenario you described.
> But most of the time, you're wrong. Health care moves slowly, and there's lots of time to think and plan. The costs of pretty much any procedure is pre-negotiated by the insurer and the provider, so they actually do know what it's going to cost. They just don't tell you.
I received an itemized bill with the exact cost and what would be covered listed, then it changed after the fact. It is certainly the case that for some procedures you can't get this, but for procedures where you know the cost will be hundreds you can easily obtain such a bill. Such bills always involve guesswork though. Even absent insurance this would be true, complications happen.
> but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.
Most people in the US never see a doctor outside of emergency care because it's too expensive to do so. Price shopping doesn't do shit for the majority because the people that do get healthcare get it from their job and don't have a choice anyways which doctors they can see or not.
> most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost.
The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can.
This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year (and more like $1.5k for her parents, being tenant farmers) and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore, let alone a HCMC or Hanoi where the jobs are actually located.
Similar story for my cousin in India as well - he's attending a T5 AIIMS and is looking at 10 years of medical education (an MBBS doesn't cut it in 2025 anymore - you need an MD as well now) in order to get a $15k starting salary, but he is also lucky that his parents are both doctors. If he was not from that background he would have probably attempted the USMLE as well and leave.
Both India and Vietnam are seeing a significant medical exodus, as is the UK, South Korea, and other countries where this kind of penny pinching sentiment is rife.
HNers harp about layoffs and offshoring, but seem to only care about stagnating wages for themselves in high wage industries with no barriers to entry, relatively chill work cultures, and no risk of legal liablity.
What do you guys want? Barefoot doctors and aryuvedic treatment?
> The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can.
People already have plenty of incentive to become doctors. We just don't let them. Medical schools collude to limit the number of medical students each year (under the guise of preventing having "too many" doctors). Medical schools have ridiculous selection criteria, like picking the candidates who earned an "A" in physics instead of a "B", or who came from a rich enough family that they could perform many hours of volunteer community work (mostly because the low quotas make it otherwise impossible to select candidates without literally rolling dice).
You know what? I think tech workers aren't paid enough. There isn't enough incentive to become a tech worker. We should limit how many people can study CS each year with strict quotas. It should be illegal for a person to program a computer unless they have a CS degree from an accredited school (one in on the quota system) and have passed an exam. Practicing programming without a license (or practicing from a foreign country with a local license) should be illegal, punishable by time in jail. Finally, programmers should have access to computer tools (like encryption) which will be illegal for the rest of the population to possess, and be given the benefit of the doubt if/when they misuse them.
The difference is a SWE who merges faulty code or causes a production outage is NOT legally liable.
If a patient faces a complication or (god forbid) passes away, you as a medical practitioner are held legally liable and can lose your license and potentially even your freedom.
> This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore.
I mean, people in the US pay $250k+ tuition, median income $65k/year, work $35k/year for a while, and eventually make something like that $250k/year. A house in many US markets is $300-500k.
It's pretty much the same balance between each item, just more zeroes on the end of each number.
> It's pretty much the same balance between each item, just more zeroes on the end of each number
You cannot compare the poverty or material condition between the two.
Personal access to tap water, personal bathrooms, not having to pay a bribe to get ID, public services, school meals, public schools the actually have some sort of services, and other stuff Americans take for granted are not available to the vast majority of Vietnamese, Indians, and others in the developing world.
My SO literally had to pay a $5k bribe/speed money to get her diploma from her university otherwise she'd have to work as an unlicensed doctor for 2 years.
The rent for an illegal 1 bedroom hovel in D3 in Saigon with a tap water connection and personal bathroom goes for $250-550/mo - that's literally the monthly wage for most residents in Saigon
You really cannot compare even the worst life in the US with the life the silent majority faces in developing countries
> You really cannot compare even the worst life in the US with the life the silent majority faces in developing countries
Sure, but your example cites someone who expects to be making the median annual salary every month within a few years, right? In both places, there's a hefty up-front investment for a much-better-than-average earning employment opportunity.
> Sure, but your example cites someone who expects to be making the median annual salary every month within a few years
No.
This is someone who spent $50k in debt just to end up earning the same salary ($700-800/mo) if she worked in a factory sowing clothes (which give free dormitory housing vs paying $200-400/mo in rent like non factory workers do), working in the unregulated vice industry in Singapore, UAE, of Korea, or doing nails under the table while overstaying their B2 visa in East San Jose - like a number of my SO's peers who didn't make it into a degree program that leads to you becoming a doctor, dentist, bureaucrat, or engineer.
Spending 8-10 years of education just to end up earning a similar amount as a factory worker makes people who devoted so much time and effort angry, and why you see a significant exodus of medical professionals in developing countries to developed countries, becuase they are not remunerated enough.
Remunerating people less only exacerbates brain drains.
And note how this is specifically medical professionals - other white collar roles pay less and are much more competitive or difficult to land a job in VN
Saying the median American has a life comparable to the median Vietnamese is TRULY out of touch.
"her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years"
A $6k a year tuition is double the median household salary for most Vietnamese. And unlike in developed counties, student loans are essentially non-existent for the majority of the population. To get a loan, it means going to a tattooed snaggle tooth guy wearing a flower shirt who exchanges gold and foreign exchange, and getting a double digit monthly loan. Best case, you are lucky and have land you can mortgage or family abroad you can beg for remittances. Additionally, tuition is paid up-front - not monthly payment plans. Additionally, the universities didn't provide half of the materials needed like scalpels or gauze - that came out of pocket at US prices.
Additionally, for someone from the bottom half of society, like my SO's family, social security and public services are non-existent, so they are dependent on their children sending them $150-200/mo while their kids are paying $250/mo in rent and $100-150/mo in incidentals on best case a $700-800/mo salary.
If you are a woman from the bottom half of society, like my SO and her peers - it is almost impossible to afford 8-10 years of no cash flow. If you are an 18 year old woman in the Central Highlands or the Mekong Delta, immediately working in a factory with a subsidized dormitory and food means you can immediately start sending cash to family to help them out. Alternatively, earning $15k-$20k working in the "unregulated vice industry" in Singapore, South Korea, the UAE, and others starts looking extremely lucrative (usually referred to work there by that snaggle tooth guy I mentioned). Best case, you get an arranged marriage with someone in the diaspora in the US or become a "Viet Bu" in Malaysia or Singapore.
My SO was literally the only person from her social class at her medical school (Vietnam's equivalent of Harvard Med) - everyone else were the children of doctors, bureaucrats, diaspora Vietnamese, businessmen, MPS officers, and other crème-a-la-creme of Viet society.
For people in my SO's case who somehow even make it to medical school, they all try to leave to practice in Japan (which my SO did), Taiwan, South Korea, or the US as soon as possible becuase it is the only way they can even recoup the cost. And this is exacerbating the medical health crisis in much of Vietnam, because a rural government doctor in a village like my SO's (if they are lucky enough to even get a doctor) would earn a $100-200/mo government salary that is almost always late.
Like, there are massive issues in the US, but to even compare the that to those faced by the bottom half of a developing country is legitimately out of touch and actually insulting as it trivializes the pains billions of people face across developing countries.
Small(ish) OT, but after years and years of leaning in favor of a private healthcare system I have completely reversed my opinion.
I will spare you the ethical and moral reasons, and give you a practical one.
Private healthcare, being a business, cannot afford the investments of public one. Instead it operates following the Pareto principle where 20% of services and treatments cover 90%+ of patient needs.
Now this works with much joy over most of your life, but there are just too many edge cases over a life time where this will screw you.
E.g. A close friend of mine gave birth in a private clinic. The most luxurious one with almost a dozen people following her.
All of this: pointless. Her child had complications minutes after birth, and no single private hospital in our country has a pediatric intensive care unit, or, to label it more correctly a pediatric _reanimation_ unit.
The only private hospitals that do? University ones, as they operate on slightly different financial basis and incentives.
This goes beyond this example I have. It doesn't matter if you're in a country with good private healthcare (e.g. Switzerland) or a crap one, public healthcare is accepted to be a money loser for the greater good and will cover more services. Always.
Mind you, I'm not saying that a single public hospital will offer everything and private is bad, just stating that there's many situations where it's easier to find the service offered in public rather than private health care.
In Switzerland *no single hospital* has a proper PICU. There's one in Luzern and St. Gallen but they are under equipped for all the emergency situations. They are essentially sub-intensive, and if your child has such a complication, good luck.
The only ones that do are all university hospitals and they only do so because they operate on a very different financial non-profit model.
And I'm talking about Switzerland.
PICU isn't just an example of service and treatments where even very very rich countries with quality healthcare are relatively uncovered compared to much poorer countries with public health care.
It's not even the happiest one, because PICU is still "relatively" common, so I don't want to focus on it.
Other examples of treatments that are relatively common in public health care are organ transplants, ICU for infective diseases, post trauma (stroke-like) rehabilitation are just some of the examples of treatments you're gonna find in many public hospitals in a country but extremely rarely in neighboring countries with excellent private healthcare.
My controversial belief is that the barrier to become a doctor is way too high. I think barriers need to be reduced.. I mean think about it - I learned software pretty much by being put into it and forced to learn.
I understand medicine is slightly different but my hunch is that any sufficiently smart person can do well enough as a doctor after 1-2 years of theory.
This might anger a lot of people because there’s a trend where we elevate medicine and doctors to a godly level.
Thankfully with the internet and AI, knowledge is not gatekept as much now.
I wish we allow more people to become doctors and intelligent people to become doctors. The type of people who choose to become doctors are not problem solvers, at least from my experience.
Of course my argument doesn’t work exactly for surgeons but I think we should not artificially reduce their numbers.
In New York, the moderate Democrats, like their governor and health commissioner, have for years been proposing to join the Interstate Medical Licensure Compact for doctors and the Nurse Licensure Compact for nurses from other states.
The far left Democrats have consistently blocked such proposals, usually without so much as a hearing.
Forget other countries, they won’t even let health professionals from the United States practice. I believe this is true of several large state Democratic parties.
Well, I happen agree with this allegedly controversial opinion, but the fact that we invent legal fictions like "nurse practitioners" and "physicians assistants" I think sort of proves the point that it is controversial in the wider public consciousness.
We create these roles and gradually give them more and more autonomy precisely because we can't agree to produce (or import) more MDs. MDs actually see the writing on the wall, too. Their lobbying organizations are strenuously opposed to expanding NP and PA roles.
Strange because this was not mentioned in the article. Doctor wages contribute way more than silly insurance companies whose margins are lower single digits.
There should be a good career ladder for nurses to become actual doctors if they perform well on the job. No need to gatekeep now that we have AI and internet.
Look at the buckets: Things like Dental Services, Home Health Care, Nursing Care Facilities... This tells you about healthcare spending at the macro level, but doesn't explain why a particular doctor visit cost so much (I don't use any "nursing care facilities" or "dental services" when I visit the doctor for a sprained ankle, for example).
When you go to the doctor for a sprained ankle, where does that money go? By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan). Where does the other 85% go? Certainly some it is the cost of running a clinic (staff, rent, equipment, etc), but what about the rest?
Then look at doctor's income. Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more. Where do you think that money comes from?
> By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan).
I'm aware of two huge exceptions that are large enough to make this basically not-true.
1) This doesn't apply when they're administering a self-funded plan, like most plans provided by large companies. This represents a giant chunk of US health insurance.
2) This doesn't apply to new plans (I believe in the first two years of operation). I admit I've not looked into it, but I'd be shocked if this isn't being gamed such that a fairly high proportion of plans that aren't excluded by #1, are always "new" and so not subject to those limits.
"According to Reinhardt, “doctors’ net take-home pay (that is income minus expenses) amounts to only about 10% of overall health care spending."
It's also a big incentive for the insurer to increase prices. If they want more revenues, and more profits, they have to get overall spending to go up.
> Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more.
> Again, that's most frequently called becoming a nurse practitioner.
Personally, I would always rather see a physician due to how much more training/experience they have. A physician who's out of residency will have gotten at least 3 years of on the job training (after medical school). A nurse practitioner may have just gotten their BSN and then gone straight into an NP program without ever working a single day as a nurse.
But yes, you're right, this person is absolutely describing NPs.
> Personally, I would always rather see a physician due to how much more training/experience they have.
There's a very good chance, if you're seeing a NP, that the NP has a lot more experience with that sort of condition than the docs. After all, the practice is sending those sorts of issues to the NP. My dad's a radiologist, but they haven't assessed a minor break in decades, because they're very subspecialized.
If it's unusual or complex, the NP is probably the first to say "we'll need to make an appt with Dr. So and So".
Another thing the US could do would be to offer a fast and easy path for foreign medical doctors to immigrate and start practicing medicine with minimal barriers.
Unfortunately, right now, it is difficult for doctors to do so much as move to and start practicing in a different state. But if you want medical costs to actually come down and to ensure availability, you need to multiply the number of doctors available to treat people.
It doesn't matter what the insurance company margins are.
It matters how much they add to the cost.
Typically, "margins" means the profit they make over and above expenses. For insurance companies, the salaries of all the people they employ, and the rent/mortgage/upkeep on their buildings & grounds, would all be classified as expenses that would not generally be included in their margins.
But in a single-payer system, none of that cost would even exist. We have to pay for all of that through our premiums, and we get nothing out of it.
1. In the United States, insurance companies are legally mandated to pay out at least 85% of premiums as medical expenses. It's called the Medical Loss Ratio if you care to Google it. That stipulation is part of the ACA / "Obamacare". If they spend less than 85%, they are legally required to issue refunds. The 15% that insurance companies get to keep has to cover both administrative costs and their profit.
2. Single-payer systems still have administrative costs. The administrative cost of running England's NHS is not zero. But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.
3. Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.
> In the United States, insurance companies are legally mandated to pay out at least 85% of premiums as medical expenses.
Which means, of course, that their main option to increase profit is to increase overall spending on healthcare. Reducing cost is directly against their interests.
"According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue. Insurance industry-funded studies exclude private plans’ marketing costs and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower."
> Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.
I mean, that's a start.
If you chart the US against the rest of the OECD, we're doing something bafflingly expensive versus everyone else. It is certain to be multi-factorial, but our insurance setup absolutely plays a role. https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
> But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.
This is only true if you assume that health insurance companies have no influence on the cost of care. That is, however, patently false.
How many risk dying because of costs? You won’t reduce quality that much if you have a smart person looking at your medical problems. But decreasing the costs may outweigh the benefits.
I can’t prove this but my intuition says that you don’t need this high of a barrier.
And I think you're vastly underestimating the silliness of the requirements to get into medical school.
Medical schools care whether you got an A or B in your undergrad physics-for-life-sciences lab (I know this because I had to deal with annoying grade-grubbing pre-meds as a TA for that class). I would feel 100% comfortable with being treated by a physician who "only" earned a B in my undergraduate physics.
Medical schools also care about how many hours of volunteer community service you do. So, I guess all the applicants who had to work a job through undergrad can just go fuck themselves.
You might start by asking why medical schools care about such silly things. It's such a strange metric! The answer is that medical school collude to limit the number of doctors (so that we don't have "too many"!). Since the quota is so low, they have an enormous ratio of qualified applicants to seats. , So, they need objective criteria to pick some people over others. A or B in undergrad physics (or number of hours of community service) is an objective, quantitative way to cull the herd of overqualified applicants.
Personally, I always thought a better solution would be to have med school applicants roll a die. While I would be 100% comfortable being treated by someone who earn a "B" in my physics class, I'm not sure I want an unlucky surgeon operating on me.
So one problem with a nurse -> MD career track is that they are just fundamentally different roles. It's not (just) number of years of schooling, but what they study. Nurses don't do diagnoses or prescriptions, and don't receive much if any formal training in those areas. So I'm doubtful you can make up that difference with just on the job training (though doctors who were once nurses might be better doctors).
That said, I think that a RN -> NP career track with some kind of "executive NP" program (analogous to "executive MBA"), followed by supervision under an MD and eventually graduating to full autonomy, is an interesting idea.
> Increase nurses, allow them to get promoted to doctors.
I think this sentence shows that you don't really understand the difference between the two jobs. Nurses and physicians have wildly different training/education. There are things about the body that any first year medical student could tell you, that nurses never learn even after decades of experience (because they don't need to).
You didn’t read my post. I literally wrote training doesn’t matter. An intelligent nurse without a formal medical background but with enough experience can outperform a doctor. Maybe you can give the nurse a year or two of formal medicine theory as a certification that allows them to become a doctor.
I had eye surgery three weeks ago. Prior to my eye surgery, I emailed and called my health insurance to get a total out of pocket cost, none could be given. The only thing I heard over and over is your deductible is X.
I spoke to to the eye surgeon's billing department and the same happened. How the F* can it be like this? To top it off, I just got a bill for $300 after paying $1300.
> Employers themselves are at the mercy of entities that have even more market power: Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care in the United States.
I guess it would be a crazy idea to include the people charging for the service as a reason for the rising costs or the fact that they expect high income after paying a $1M to be educated and also have to contend with rising malpractice insurance and fraudulent lawsuits.
I think that irritation should be focused on the middle people. Between the doctor, the insurance company and the patient. There are a lot of people sticking their fingers in the pie driving up the cost. We've all heard about the $25 Band-Aid.
One major issue with centrally planned healthcare is that the value of health is variable to the individual. Particularly beyond the line between technically dead and technically still alive.
A poor, uninterested, or other valued[1] person would only sacrifice $N to improve their health beyond "still alive". A rich person, or highly interested, or other valued[2] person would sacrifice potentially many multiples of $N.
Take Bryan Johnson[3] for example is willing to spend on many improvements to his life. For example, in Canada he'd be basically unable to do what he wants to do with his own money.
As one such person I am happy to pay more for more. What I really think is needed here is improvements in contracts and transparency. For example, there should be a contractually binding price agreement (of which the prices themselves are publicly available to all including competitors) for any non-emergency non-urgent procedure. (If time is of the essence then we need to prioritize that, naturally)
As an example of being willing to pay more, my insurance isn't willing to pay for the exploratory labs, and software platform, that function health built and provides for $499 a year. I'm willing to pay it, it has benefitted me over the standard annual physical, and to me it was worth $499. It also likely will save my insurance $1000s maybe $10000s over my life time too. (We discovered something concerning...)
[1] - (eg a father who prioritizes spending on their kids)
[2] - (eg a father who prioritizes being there for their kids later in their life)
[3] - https://youtu.be/pfSFnFWb8X4
Almost no one gets "health insurance" through their employers. Most employees get health benefits.
In the US, a majority of large employers don't buy insurance in the strict actuarial sense. They self-fund health benefits under ERISA, paying claims directly and hiring insurers only as administrators (ASOs). The plan may contract with an insurer (e.g. UnitedHealthcare, Aetna, Cigna) to process claims and run the network, but for most employees at large firms, the insurer is not actually insuring anything. Self-funded ERISA plans are regulated by the US Department of Labor, not state insurance commissioners.
Zero discussion of the 3:1 premium limit in the ACA. The ACA mandates that you can only charge older people 3x the premium you charge younger people. Older people account for an extremely outsized portion of healthcare services received. This means that no matter how little healthcare you need as a healthy young person, you have to pay 33% of the estimated cost of care for someone who is end-of-life and possibly consuming hundreds of thousands of dollars (or more) worth of medical care.
Older male got some Tadalafil from the doctor and not covered by insurance. Cost 530$. Told them i will not be using insurance and did an RX code and the prescription was 11$.
The system is beyond silly in pricing.
Another prescription had a 10$ copay since it was just a generic drug. Again I requested please don’t run through insurance and the rx price was 4$.
I did a deep dive into understanding how prescription pricing works in the US, long story short it is insanely way too complex and for profit private health care insurance is not good for the health of the population.
I live in the US. A family member close to me is unable to make appointments any closer than 6 months to receive lifesaving care. This is despite getting the most premium insurance they could find.
They (easily) found someone who will see them out of pocket. It's not a supply issue in this country, it's an incentives issue.
The framing of this article I find quite disappointing from NPR. Sure employers are not about to just hand out free money are going to try to spend as little as possible but to put your employer in the same space as the others or even the government is a... wild interpretation of the problem.
I was half expecting there to be something in here about the average that employers were spending going down to justify the headline but that was nowhere to be found.
> "It's kind of hidden, because [premium deductions are] coming out of your paycheck and if you're not paying close attention, it may not be obvious,
I have to ask, who the hell is not looking at the amount that is coming out of their paycheck when it comes to open enrollment? Sure you may just accept it since what is your choice, but I think the systems I use generally show how much it is going to change.
Am I just becoming more sensitive to clickbait that outright lies or are headlines getting worse? Nothing in this article justifies any blame to your employer.
Blame everyone but the government, eh? To be expected considering the source. But we won't solve anything without looking at the root of the problem. Unfortunately, it seems to me like that dooms us to not solve anything.
I think we can assume that no matter what your political persuasion, in some sense the government is ultimately at fault, either for overregulating or for allowing for the existence of privatized healthcare. As such, it needn't be said, and we can focus the conversation on the proximal rather than ultimate cause.
1. Move the deductions from the employer to the individual. That unlinks health care from your employer. It will also inject market forces and discipline to our health care system, since the person paying for the care is now in charge of the insurance.
2. Repeal the ACA mandates and enact interstate laws which permits low-deductible, low mandate policies along with reintroducing catastrophic insurance. The current status quo forces young people to pay for old people and those less responsible with their health. What we have now is prepaid medical care, not insureance. This also removes the insurance monopolies states and companies have created together.
We have the worst of all possible systems at present.
The chances of any elected politician doing this are exactly zero. We're going in the opposite direction and it's only a matter of time. There are very few places left on the internet that would even entertain discussion of this. This site is no longer one of them.
Really? I thought most of the excess cost of healthcare in the US is due to the artificially restricted supply of doctors, causing them to have extremely high salaries compared to similarly demanding work in the US, or to the same work in other countries (although US salaries are super high in general). But the article kind of handwaves and vaguely blames big business or whatever.
Every area of California is controlled by various healthcare monopolies. In Sacramento, it's Sutter Health. In San Diego, it's Perlman. In Bay Area, you have Kaiser. We have no choice or free market. You either pay them or you don't have access to decent reliable health care. I am honestly starting to think about just not having health care and going to Mexico/Canada when I need something--and we make well into the top 10% for wages. I don't know how others can pay for healthcare and all the premiums. I just paid like $300 for a minor skin care treatment at a dermatologist that I had to wait weeks for an appointment with. It's a clear racket. Oh and despite all this, none of the local speech therapists are in-network so we have to submit individual claims and they don't pay the full amount. It's a scam.
I buy Gary Stevenson’s diagnosis that the root cause of the rising cost of everything is increasing inequality and industry capture by the wealthy.
There are two sides to this. The first is, hospitals are owned by investors, and have to increase profits. The typical playbook of trying to acquire at least a local monopoly to price-fix is in play everywhere.
The other side is: to achieve high profit margins chase wealthy customers and cater to their preferences. Headhunt star staff with increased salaries. Build shiny new hospitals and prioritize private rooms (HIPAA provided a great excuse here). To woo investors turn administrator into a CEO position with commensurate pay.
None of this incentivizes providing quality health care to non-wealthy people at a fair price. It incentivizes trying to get rid of lower income patients as quickly as possible to make room for high income or well insured patients who can be billed more.
Same as housing, this issue is everywhere in the western world. We can try to tackle it by itself (transparent pricing would probably help a great deal), but the root issue is bigger: the rich are getting what they want on both sides of the equation. They don’t want affordable healthcare.
> Traditional Medicare has significantly lower administrative costs than private insurance with 1.1 percent of spending in 2024 going towards administration compared to between roughly 12-18 percent for private insurers in previous years. Coincidentally, the bloated administrative spending of American health care is one of the factors contributing to why the United States spends around twice as much per person compared to other developed nations even though we have worse health outcomes.
I'm sure it would be if I could get open source surgery online from dabbling amateurs. Unfortunately for most people they have to go the hospital and don't exactly have a plethora of options there.
We see that already with LASIK and other cosmetic procedures. They are not cheap, but often an order of magnitude lower than medically necessary insurance-covered work.
We have two unavoidable necessities in life — food and healthcare (and housing, but i’ll leave that out because it’s an odd fit in this analogy).
The food system is basically a free market (with some weak safety regulations). The apparent end-state of this free market that America has arrived at is tragic. Sure, people like me are free to select healthy, nutritious food at reasonable prices, but at a population level, 70% are overweight and 30% are obese, with all the risk and disease that comes with that.
This is where free markets (in necessary goods) tend to end up. Perfect for ensuring the concentration of capital, disastrous for the average consumer (and never mind the “externalities“…)
> Blame insurers, drug companies — and your employer
> That's because employers will be paying a lot more
> Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care
> more people are going to the doctor or other providers. But that surge in demand has also led to a surge in prices.
> Last year, the average U.S. employer spent more than $19,000 per employee to provide family coverage while the employee kicked in $6,000,
Why should health care ever get cheaper? Americans treat our bodies like garbage bins for sugar and fat. Old people spend 100ks just to die in a hospital 3 months later. The narrative is always that some rich dude did it to you though?
Perhaps a solution is to reward people to a greater extent for those who improve their health. Quit smoking, premiums come down. Lose weight, premiums come down. The insurance companies should be working with the doctors and the patients to identify ways they can improve their health to bring down the premium. A healthier person I would assume is a less pecuniary risk to the health insurance company
> Americans treat our bodies like garbage bins for sugar and fat.
Even this isn't so simple. Foods in America are engineered explicitly to increase consumption, often (but not exclusively) by increasing fat, sugar, and salt. A good example of this is bread, as most breads sold in the US would be classified as cake in other countries due to the added sugar.
The only way to avoid this is to make your own food by scratch, which simply isn't viable for a large population living paycheck to paycheck.
After the rise in popularity of Ozempic, packaged food companies started trying to figure out how to engineer food that would overcome even Ozempic's craving suppressions. It's truly ruthless what they are doing to us. https://www.foxnews.com/food-drink/medical-experts-warn-big-...
Healthcare is not a free market. People don't comparison shop, and couldn't even if they wanted to. Price lists are secret because providers have two prices, one for cash and one for insurance. People with health problems have stress enough dealing with insurance companies and providers, filling out endless paperwork, to deal with it even if the info was available. People in hospitals and emergency rooms CANNOT shop for alternatives since they are a captive audience.
When the social norm hardens around "don't charge what it's worth, charge what you can get" this is the result. I once asked a hospital billing agent how they could justify a $10k ER bill for 4 hours of waiting and 1 hour treatment, and they responded, "How much is your life worth?"
One place that gets it right is Germany: an inexpensive public option that gets you competent medical care almost anywhere. Bring your card, no deductibles, no paperwork, no complex calculation and a minimum of paperwork (which is a rarity in Germany). This is how it should be here.
In Germany, access to health care is becoming a major problem. I have two young kids and I’ve experienced on multiple occasions not being able to get appointments with specialists for them. Sometimes you offer to “self pay” - basically paying full cost with no insurance - and sometimes it works, other times it doesn’t.
Germany has a major doctor shortage and it can’t just attract foreign doctors like Anglo countries due to language requirements. This issue will continue to get worse as the population ages.
I basically entirely gave up trying to see an ophthalmologist in the US. Wait times 6+ months out.
It's not better here. Just seeing my GP takes weeks, and he's overwhelmed.
People act like there are no wait times in the US.
I remember a few years ago, I noticed a mole on my arm suddenly looking very irregular. I kind of panicked, thinking it was potentially skin cancer. I have decent PPO insurance, no worries, I can go call up and schedule an appointment with a dermatologist directly. I live in one of the largest metro areas in the US, tons of doctors, should be a breeze to get it checked out.
I load up the find a doctor website on my insurance company's website. There's like 30 dermatologists within an hour or so drive from me, awesome. I start calling. Not taking new patients right now. Can't be seen for 6 months, 8 months, we could get you in next year. Next year, when I might have quickly growing skin cancer?
Luckily when I finally talked to my wife about it, she reminded me she had poked my arm with a permanent marker. Some solvent, and my mole looks normal again. I still make sure to keep my dermatologist appointments, just so I don't have to deal with the new patient issues and the "we're not taking anyone new these days".
I had a different issue with extreme nystagmus come upon me. Bedridden for days, I couldn't even open my eyes without having extreme vertigo. Calling ENTs to try and get help, none would be able to see me for weeks. Luckily a friend who works with ENTs managed to get a doctor to see me but if it wasn't for that I probably would have just had to suffer at home with no answers as to what was happening.
I now know that unless I'm practically about to die, seeing a doctor that will do more than run extremely basic labs and very basic healthcare is weeks away in the US even if you have decent insurance.
I think it must be very regional in the US. I have never experienced any wait times beyond a couple weeks once for an MRI.
I can get an MRI in a few hours for a couple hundred bucks out of pocket. I can go get blood drawn in a half hour and lab results tomorrow morning. Tons of private labs and imaging centers are looking for anyone to fill the machine or get stuck. That's not the problem. The problem is getting an M.D. to read the results and actually tell me what's wrong and a good course of action.
In both examples, just getting an MRI would have told me practically nothing. Maybe for the nystagmus, it would have told me if there was significant brain cancer. Maybe a blood test would have told me something about cancer, but there's a good chance it would have been inconclusive, I needed a biopsy (or, in hindsight, a bit of rubbing alcohol).
It's going to be different by region, but also by health insurance plan, by provider, and by income bracket.
I've seen a case of both providers of ACA "marketplace" plans in a state each including only one of the four closest hospitals to me as "in network", with similar extremely-spotty coverage for everything else. And one excluded the massive children's hospital in the city that'd also gobbled up every pediatric care office in 50 miles, so there was, practically, only one insurer you could pick if you had kids (those two providers were the only ones offering individual insurance in that state at all, everyone else had pulled back to only doing group plans in that state; both were also companies I'd never heard of before).
This was in an actual city. Things can be even worse out in the sticks, where hospitals are much farther apart and often offer only some of the services you expect from a big-city hospital.
Lots of these plans also only cover a small geographical area, except for ER visits (which I think they have to cover). So don't get sick in a way that gets you discharged from the ER into a regular hospital bed, but still unable to get home, while traveling within your own country, if you don't want to go bankrupt.
Like it truly wouldn't have been crazy for someone on one of those plans to get some kind of travel insurance while traveling in the US. That's how fucked up our healthcare system is.
I paid out of pocket and went directly to a dermatologist in a week, where insurance wanted me to go through my doctor (my local doctor has no appointment times) first. It was skin cancer. I ended up bypassing insurance because I was scared to wait the months navigating their system would take. But also because it was supposed to be cheaper (I price shopped) than my deductible. Guess what, when you price shop, the price they tell you has no relevance to the final price.
You lived out what I had only feared. I'm sorry that happened to you, this kind of thing shouldn't happen to anyone.
> Guess what, when you price shop, the price they tell you has no relevance to the final price.
I've found they often can't realistically give any kind of useful quote. I remember getting a total cost estimate from the hospital when my second child was born, anywhere from $20k to $160k before insurance, please sign here.
Long wait times are not exclusive to public healthcare. My dermatology appointment to examine a concerning mole was scheduled 9 months out. And of course I pay for the privilege.
I'm in the US and I hav regular 6-8 month waits for non-specialists and very hit or miss luck with specialist appointments. What you describe is not solved by the us approach
When I worked in the US I had “Kaiser Permanente” which seemed to be something like an all-in-one system. You have specialists, GPs, labs and pharmacy all in one building covered by one insurance. Could something like that scale to the whole country?
I think the answer is a "yes, and"
Of course the approach works, we can see it work at various scales. I think what prevents it from working is that it works best when it is the only option. I don't think we could support 5 kaiser permanentes. And that feeds into insurance - there are a lot of insurance plans, and each of them would likely only support their specific kaisers
So ideally there is one insurance, with one provider that has vertical integration everywhere and then indies outside the network you can go out of pocket for, and oops I invented single payer
> When I worked in the US I had “Kaiser Permanente” which seemed to be something like an all-in-one system. You have specialists, GPs, labs and pharmacy all in one building covered by one insurance. Could something like that scale to the whole country?
We can't even scale out broadband to the entire US.
It can scale to a whole province of 5 million people.
I had Kaiser Permanente when I was in the US. Now that I'm in BC, Canada, it is very similar. I walk into any hospital in the province and every doctor and specialist in the building are part of the same system (technically they are broken up into three geographic subunits, but to the patient it basically doesn't matter). If I need some sort of treatment that hospital doesn't offer, they can immediately refer me to the correct hospital. For emergency cases the provincial ambulance service will transport you to another hospital by road or air at no cost.
There are still independent specialists and doctors outside of the hospital system, but they have access to the same records systems and the billing is so seamless that I suspect that most people don't realize it is happening since it never involves the patient outside of providing your ID.
Organizations like this have existed in some places in the US as well. I remember growing up in Houston we would go to the Kelsey-Seybold clinic. They had a lot of GPs but also a ton of specialists all under the same network and sharing the same building.
>can’t just attract foreign doctors like Anglo countries due to language requirements
That is a serious and real obstacle. German has a well-deserved reputation for being difficult to learn. I'm pretty good at learning languages but German is extremely difficult to speak properly unless you are raised in it.
Similar situation in Poland with appointments for specialists in at least 6 months and often much longer.
German public health insurances are concerned right now about their unusually high deficits. Because many millions refugees are not working they only get paid a reduced amount towards the mandatory health insurance but have the same full service. Bringing the already substituted public health insurance into insubstantial deficits and now they are increasing the rates for the working class and probably they will need additional tax money too.
Here in the USA, my wife had an infection in the root of a tooth (long story), and was trying to get in to see an oral surgeon to get proper treatment.
Even with an active infection, that could have cost her her jaw or her life if it had been left unchecked, it took months to get anyone to even make an appointment for an initial consultation. We were very fortunate that the oral surgeon we were finally able to talk to was able to fit her in for surgery within a short time after that, due to a cancellation.
People talk dismissively about the "long wait times" you get with some public healthcare systems, but always oh-so-conveniently ignore the fact that there are long wait times here too. Sometimes catastrophically so.
Almost universally, when you dig into it, the "long wait times" that exist in those systems fall into one of two categories: either they are wait times for elective procedures, where your long-term health is not at risk, or they are caused by shortages that are symptoms of unrelated problems.
Same here. Our doctor went "concierge" and we had to wait nine (9) months for a doctor (GP) willing to take new patients.
The worst case scenario you're describing for Germany is just the common case for the entire US though.
Neoliberal fiscal policy to underfund public goods has slowly crept into non-American western health systems, the undercutting of the UK NHS as a leading example of a regressor. It makes everything in the system less efficient - increases calls for even less efficient privatization of healthcare. It doesn't save money for an economy except at the most superficial narrow view level of accounting.
I recently found out, after getting a big surprise bill, that you can sort of comparison shop now, at least with my insurer. They have a “Treatment cost estimator”, which I’ve found to be pretty accurate, and the price differences from one place to another are substantial.
I price shopped having skin cancer removed from my face because the total was under my high deductible. By the end the total was $2500 more than the 'price shopping' 'yes this will be the price' price even though everything went as perfect and easy as possible. This place is the number 1 clinic for doing this in the nearest city. Their waiting room was full of old guys getting skin cancers removed. And there was nothing I could do but pay the extra $2500.
Perhaps this is a place the government could help? -- to make estimates contractually binding.
that would just increase prices to cover wider range of possible outcomes that can't necessarily be predicted going in
AIUI, this is very difficult to do: the estimate is going to be based on a superficial (in the literal, physical sense) examination of the problem, and once they are actually in there doing what they need to do, they may very well find that there is more that needs doing than they expected.
They can't exactly pause the surgery and get you to consent to an extra few thousand dollars' worth of work.
This is another example of why healthcare really, genuinely is best left as a single-payer government-funded service. People can get the care they need to be healthy, without ever needing to worry about the uncertainty inherent in the price of such a service.
I was under the impression there were already laws in place around this signed in first Trump term?? Anyone know what I'm talking about? Now I would not be surprised that the industry flaunts it completely.
They have to provide prices for various billing codes, but you can't really make them commit to which billing codes will apply. This is for both legitimate reasons (stuff might go wrong, they might find something is different than what they thought it was just because that unavoidably happens pretty often in medicine, et c.) and for illegitimate reasons that the legitimate reasons give them cover for (medical billing departments are the organizational embodiment of smarmy, lying assholes who are constantly trying to screw everyone)
I think its the last part. For most cases you are planning ahead to come get some particular thing done, yet still get fucked around.
They buried the lede:
> "What's missing in health care is: It's not a traditional free market. You don't have those competitive forces"
Blaming insurers and drug companies is fashionable -- and employers is a new twist, I suppose -- but it feels like a desperate search for a facile answer. Nobody wants to hear the hard truth, which is that if you had to pay for it, you'd suddenly become a lot more picky about the health care you purchase.
You don't see the prices, so you don't care, and you can't shop around. I'm not saying there aren't a ton of other negative incentives in the system, but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.
This would be true if the people that do pay the prices had no influence on your purchasing decision, but the insurers maintain a massive hold on purchase decisions. And in reality, a ton of insured people do pay very directly for their healthcare in deductibles and denied coverage claims.
I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything.
I would love to have had healthcare in America where I was insulated fully from the costs of care. My experience was that it was rare to see a doctor where I wouldn't end p paying at least three figures despite having fantastic insurance.
Meanwhile in Canada, I can recklessly visit three doctors per day for the same issue at no out of pocket cost if I want, and it will still cost my insurer (the province of BC, in my case) less than a single doctor visit 60 miles south of here.
From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying
Many of these things you state as fact do not match my reality.
> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.
That’s basically my plan. I work for a FAANG, and have a low 2k/year max out of pocket for in-network, which is almost everything I encounter. I just book specialists when I want, and I see them as many times as I need. I can do PT 365 times per year, so as long as I don’t go more than once a day (which would be silly), I consume as much as I want. I recently chose to go to the Mayo Clinic — out of state, no referral, and everything is covered. I keep getting estimates from them of $0 since I hit my max out of pocket. The only thing I’ve been denied for is Botox for TMJ which they say is not medically proven (seems to be the opposite, but I understand why they’re wary).
I’ve never had a medication, procedure, or doctor visit denied.
"in-network" is the key phrase here.
You cannot consume as much and whatever type of healthcare. You have to consume from the pre-approved list of doctors that have negotiated rates with your insurer. I also do not believe for a second that if you found a doctor willing to give -for example - daily electrolyte IVs for your post workout recovery, that the insurer would touch that claim. Same thing with cosmetic or elective surgery. Will your insurer cover a facelift? Will they cover Ozempic for vanity reasons? Will they cover the full cost of all name brand drugs after your deductible is spent? And you still have to pay $2k before any of that is in effect.
Mind you, your extreme outlier reality is one that is essentially never experienced by >95% of people, and it still has constraints.
Yes, the US system works great if your are at the social peak, such as working at a FAANG. Thanks for reminding us of the level of class disparity as we struggle to pay our bills or get our children medical care.
When I was a kid, everyone no matter economic level had pretty much the same pediatric doctor group. Now the working class people around me don't really have a pediatrician, but an overworked 'nurse practitioner'.
> From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying
The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. Even your doctor has no idea -- try asking sometime! I routinely point out to my primary care doctor that the medicine/test/whatever they're recommending is expensive and low-quality, and he looks at me like I'm an alien. Statistically, I am.
You're not wrong that you can get caught in a circle of hell after you get the bill, and that insurers are an opaque barrier to purchase decisions, but that's just saying the same thing a different way -- you have no ability to shop for what should be a commodity service.
> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.
...and that's one of the few good things about our system, though I agree that the US implementation is maximally stupid. You should have to evaluate the cost and benefit of going to a (rare, expensive) specialist! While I agree that insurance companies suck, it's telling that the debate around this issue has devolved to indignation that someone should be acting to control costs by limiting the freedom to choose expensive things.
> The US has the highest cost of healthcare primarily because nobody knows what healthcare costs.
This requires explaining how places like the UK - where the cost is far more hidden than it is in the US with high-deductible plans being very common - have substantially lower costs.
Well, you're making a a series of logical fallacies (are we talking about the UK, specifically, or an unspecified constellation of "places like" they UK, so that you can avoid the false dichotomy?), but my general rebuttal would be this:
"the existence of magical unicorn places with worse price transparency than the US does not make opaque pricing good."
I'm honestly not sure what you're trying to argue. The US system is good? Price transparency is bad? UK good, US bad?
The US has better than average price transparency, as a huge proportion of us are on high-deductible plans where you directly pay the entire bill until you hit your deductible. Someone on such a plan knows their pediatrician appointment costs $300, because they have to swipe a card (or get a bill for it).
Much of the rest of the developed world doesn't ever even see a dollar amount.
Thus, the "knowing costs drops spending" theory doesn't hold up.
> Much of the rest of the developed world doesn't ever even see a dollar amount.
Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.
Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping". So if you want to call that system price transparency, then all I can do is shrug and walk away.
> Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.
I mean, go visit any Reddit thread discussing an American healthcare explanation of benefits bill. The Americans go "yup, it's expensive here"; the Europeans tend to go "I literally just paid $6 for parking for childbirth".
> Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping".
If I get a bill for $300 for a pediatrician appointment, I know what the next one is likely to cost, yes?
Again, people on high-deductible plans know very intimately how much everything is costing them.
> If I get a bill for $300 for a pediatrician appointment, I know what the next one is likely to cost, yes?
No. The next one could be more, it could be less. There could be other fees. You have no idea, because there is no price transparency.
You obviously know this is true, or you wouldn't have used the words "likely to cost". You're just arguing to argue.
I'm not sure why you think there is no price transparency in the US. I know exactly how much I was billed and how much my insurance paid. I generally don't ask ahead of time, because it's going to cost me $20. I get an explanation of benefits for every visit. When I was still below deductible at one appointment they gave me options and how much it would cost. What I don't really get is the option to choose. Limited providers and the network limit my options. From your description you have extraordinary insurance. I have good insurance (according to a staff member commenting on our low deductible). It does not work how you describe. Our insurance servicer (United Healthcare) makes all the decisions. Doctor prescribed x, it gets denied. We've had denials on meds they have been covering for years. I wish we could shop around. It's just not realistic.
You're very fixated on knowing the cost beforehand.
Americans know intimately that doctors visits are going to hit them in the pocketbook. Far more than someone from a single-payer system does, where there's a good chance they will never receive a bill with a dollar amount on it.
Yet, we're the big outlier on medical costs. Knowing "this is gonna cost me, ooof" does not seem to have any impact on the costliness of the system.
My out of pocket pre-insurance costs in Portugal are so low that I sometimes forget I still need to file for reimbursement with my private insurance provider. My copays on certain plans in the US were higher than this.
There's no way the cost difference (often literally 10x+) in private healthcare with the US can be explained by anything other than "US prices are actually total bullshit".
It's not just specialists that are expensive, though. The ER is expensive. You cannot price compare during a medical crisis.
It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
This isn't cosmetic surgery comparison shopping. This is "this Doctor has experience with my rare neurological condition, has published papers on it, and has shown success in designing care plans for people like me."
> It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
Except...you absolutely should, and it isn't weird at all. If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it? [1]
Maybe you would, maybe you wouldn't, but the choice exists, and someone is making it.
[1] You can make it more complex and human, of course: most medical interventions not only cost money, but also carry serious risks. Maybe you would choose to spend an enormous amount of money, but would you also choose to take a treatment that will leave you deathly ill for the remainder of your life in exchange for 1 extra day?
> If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it?
This isn't theoretical. People do exactly this. https://www.newsweek.com/doctor-sold-fake-miracle-cures-near...
Then be honest in society. Last time the proponents of the current system talked, they implied changing anything would result in 'death panels' that would do what you are saying. So which is it? The current system results in death panels, or prevents them? Because this is a total change from what was sold to the American public.
"Death panels" is an unfortunate name, but they exist in all systems. The current system in my country and your country has them. Any future system in either our countries will have them. It does not matter if the system is public or private.
They are simply not avoidable unless you have literally (literally literally, not figuratively literally) an unlimited budget. No country or system has unlimited resources.
> It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.
But all countries do that cost-benefit analysis all the time.
Not every procedure or medication will be administered to the patient, even when those procedures and medications have been approved for use in a particular country.
Insurance companies can’t really work as things that change the expected value of the service they insure, it just doesn’t make sense. They exist to cover massive unlikely risks. I don’t blame insurance companies for being annoying services with negative expected values (that’s just inevitable).
But, whoever decided to start marketing things like low deductibles and out-of-pocket costs as a premium service, that person bears a lot of blame. They are the one that decided customers shouldn’t see most of their healthcare costs.
The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups.
Mixing in employer insurance also caused a skew, because it makes people see their employer insurance as a perk. A perk should be something you actually experience. Employers should dump money into your HSA, and subsidize a gym/healthy snacks for their campus instead (some do, of course).
> The ideal that actually lets customers see pricing info is: a health savings account, a high-deductible insurance with no cap, and then as a cost savings measure the insurance company can incentivize yearly check-ups.
Well, that's just silly. The whole point of insurance is to cover tail cases: Catastrophic costs with low probability. If there is no cap, why have insurance at all?
Sorry, I think I might have accidentally use a term-of-art, and misused it. I meant “no cap on how much the insurance will pay out.” But, when in the same sentence with “high deductible,” the more reasonable parse (and the one I think you read it as) is “no cap on out-of-pocket expenses.” My bad.
I had a procedure done recently. I was given a bill, I opted for a more expensive treatment, it was a ~$1500 total, my insurance wouldn't cover an extra $300, I paid it since it seemed worth the extra money. I received another bill in the mail for $300 a month later that my insurance had additionally decided not to cover. What is this world you live in where American health insurance means you don't have to comparison shop? Healthcare is a huge expense and not only are the prices high, they change after the fact at the whims of the people I'm theoretically paying to handle the negotiations.
For our kids births, it was typical to still have bills trickling in six months later from some company or another, having no idea which part they were really involved in unless we felt like spending three hours on hold to figure it out.
And always they're like YOU MUST PAY THIS IMMEDIATELY or be sent to collections even though they take their sweet fucking time getting them to you, and also make it a pain in the ass to question any of it (and some of them are serious, in two cases we had trivial-amount ones slip through the cracks of the 50+ billing and EOB and blah blah blah letters we received, and go to collections right at 30 days, not even a follow-up "hey you may have missed this, you're overdue" letter)
I wouldn't be surprised if there are a bunch of scam artists out there sending fraudulent small bills to patients with recent major procedures (guaranteed to have a mountain of confusing bills coming in for months) whose info they got from our massive privatized spy network, and having almost all of them get paid. Like, compared to some other stuff that goes on, that seems like a no-brainer of a scam to run, with likely a very high success rate (am I going to burn potentially half of a day per bill to figure out if one of these fifteen $10-$200 invoices is fraudulent? No, no I am not)
You're describing a scenario where you bought the product without knowing the price, and were shocked by the additional bill(s) you got after the fact.
At what point in your story were you able to comparison shop for a cheaper option? I know you said you chose a more expensive option, which is always your prerogative, but how many other providers did you evaluate before you made that decision?
I received a bill for the price and the price became more expensive after the fact. In my experience it's a fact of American healthcare that you always pay more than the price you are quoted. But you are usually quoted a price. I was quoted a price, I paid it, and then it increased. This is how paying for healthcare works in America.
I really wonder if there is a serious accounting scam going on here. Send a bill that ends up on the books in a prior year (so its part of the 80/20 rule) then in current year you retroactively deny it and keep it off the books.
OK. So...you were presented a number, but you can't depend on the number, and therefore my question stands: how do you shop for a cheaper option?
Any sort of repair is inherently unpredictable, and healthcare especially so. Whenever I pay for something like this it's natural that the costs may prove more than what I expect. The risk that there is some irregularity with my insurance is similar, it's a risk that I take when I pay for a procedure. You can't depend that money spent on healthcare will help you in any way, it's a fact of life.
I mean, in this case I actually was able to depend on the numbers, it's just I can't depend on my insurance but then that's also a fact of insurance markets. Take away the insurance, I doubt my total cost would've been lower, even accounting for my insurance premiums and whatever my employer pays as part of that.
There's a market here, I would prefer it were more regulated, not less. A less regulated market would not help me. A less regulated market would make it easier for prices to change at random.
> Any sort of repair is inherently unpredictable, and healthcare especially so.
There are certainly acute situations that are unpredictable -- go to the ER with a gunshot wound, and nobody can tell you what it's going to cost. That's fine.
But most of the time, you're wrong. Health care moves slowly, and there's lots of time to think and plan. The costs of pretty much any procedure is pre-negotiated by the insurer and the provider, so they actually do know what it's going to cost. They just don't tell you.
There's no fundamental reason you couldn't have been quoted an accurate price in the scenario you described.
> But most of the time, you're wrong. Health care moves slowly, and there's lots of time to think and plan. The costs of pretty much any procedure is pre-negotiated by the insurer and the provider, so they actually do know what it's going to cost. They just don't tell you.
I received an itemized bill with the exact cost and what would be covered listed, then it changed after the fact. It is certainly the case that for some procedures you can't get this, but for procedures where you know the cost will be hundreds you can easily obtain such a bill. Such bills always involve guesswork though. Even absent insurance this would be true, complications happen.
He explicitly said he did know the price. The price changed.
He said he was presented a price. That price was not correct, so...it wasn't the price.
> but the big one is that most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost, to the point that most people don't even know what the cost is.
Most people in the US never see a doctor outside of emergency care because it's too expensive to do so. Price shopping doesn't do shit for the majority because the people that do get healthcare get it from their job and don't have a choice anyways which doctors they can see or not.
> most people (in the US, anyway) view doctors as a magical priesthood that is worth any cost.
The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can.
This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year (and more like $1.5k for her parents, being tenant farmers) and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore, let alone a HCMC or Hanoi where the jobs are actually located.
Similar story for my cousin in India as well - he's attending a T5 AIIMS and is looking at 10 years of medical education (an MBBS doesn't cut it in 2025 anymore - you need an MD as well now) in order to get a $15k starting salary, but he is also lucky that his parents are both doctors. If he was not from that background he would have probably attempted the USMLE as well and leave.
Both India and Vietnam are seeing a significant medical exodus, as is the UK, South Korea, and other countries where this kind of penny pinching sentiment is rife.
HNers harp about layoffs and offshoring, but seem to only care about stagnating wages for themselves in high wage industries with no barriers to entry, relatively chill work cultures, and no risk of legal liablity.
What do you guys want? Barefoot doctors and aryuvedic treatment?
> The alternative is, if you don't incentivize someone financially to spend a decade studying medicine, they won't or they will immigrate to somewhere where they can.
People already have plenty of incentive to become doctors. We just don't let them. Medical schools collude to limit the number of medical students each year (under the guise of preventing having "too many" doctors). Medical schools have ridiculous selection criteria, like picking the candidates who earned an "A" in physics instead of a "B", or who came from a rich enough family that they could perform many hours of volunteer community work (mostly because the low quotas make it otherwise impossible to select candidates without literally rolling dice).
You know what? I think tech workers aren't paid enough. There isn't enough incentive to become a tech worker. We should limit how many people can study CS each year with strict quotas. It should be illegal for a person to program a computer unless they have a CS degree from an accredited school (one in on the quota system) and have passed an exam. Practicing programming without a license (or practicing from a foreign country with a local license) should be illegal, punishable by time in jail. Finally, programmers should have access to computer tools (like encryption) which will be illegal for the rest of the population to possess, and be given the benefit of the doubt if/when they misuse them.
Do you see how ridiculous this sounds?
The difference is a SWE who merges faulty code or causes a production outage is NOT legally liable.
If a patient faces a complication or (god forbid) passes away, you as a medical practitioner are held legally liable and can lose your license and potentially even your freedom.
> This is what my SO did when leaving Vietnam - her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years. Unsurprisingly, she chose to leave just like the rest of her peers, because you can't even buy a house in a tier 4 city in Vietnam without spending $100k anymore.
I mean, people in the US pay $250k+ tuition, median income $65k/year, work $35k/year for a while, and eventually make something like that $250k/year. A house in many US markets is $300-500k.
It's pretty much the same balance between each item, just more zeroes on the end of each number.
> It's pretty much the same balance between each item, just more zeroes on the end of each number
You cannot compare the poverty or material condition between the two.
Personal access to tap water, personal bathrooms, not having to pay a bribe to get ID, public services, school meals, public schools the actually have some sort of services, and other stuff Americans take for granted are not available to the vast majority of Vietnamese, Indians, and others in the developing world.
My SO literally had to pay a $5k bribe/speed money to get her diploma from her university otherwise she'd have to work as an unlicensed doctor for 2 years.
The rent for an illegal 1 bedroom hovel in D3 in Saigon with a tap water connection and personal bathroom goes for $250-550/mo - that's literally the monthly wage for most residents in Saigon
You really cannot compare even the worst life in the US with the life the silent majority faces in developing countries
> You really cannot compare even the worst life in the US with the life the silent majority faces in developing countries
Sure, but your example cites someone who expects to be making the median annual salary every month within a few years, right? In both places, there's a hefty up-front investment for a much-better-than-average earning employment opportunity.
> Sure, but your example cites someone who expects to be making the median annual salary every month within a few years
No.
This is someone who spent $50k in debt just to end up earning the same salary ($700-800/mo) if she worked in a factory sowing clothes (which give free dormitory housing vs paying $200-400/mo in rent like non factory workers do), working in the unregulated vice industry in Singapore, UAE, of Korea, or doing nails under the table while overstaying their B2 visa in East San Jose - like a number of my SO's peers who didn't make it into a degree program that leads to you becoming a doctor, dentist, bureaucrat, or engineer.
Spending 8-10 years of education just to end up earning a similar amount as a factory worker makes people who devoted so much time and effort angry, and why you see a significant exodus of medical professionals in developing countries to developed countries, becuase they are not remunerated enough.
Remunerating people less only exacerbates brain drains.
And note how this is specifically medical professionals - other white collar roles pay less and are much more competitive or difficult to land a job in VN
Saying the median American has a life comparable to the median Vietnamese is TRULY out of touch.
"her med school tuition was around $6k/yr in a country where median household incomes are $2-3k per year and she'd end up working for $700-800/mo working 70 hour weeks and best case $2k/mo in 5-7 years"
I'm still not seeing the bad investment here.
> investment
To make an investment you need capital.
A $6k a year tuition is double the median household salary for most Vietnamese. And unlike in developed counties, student loans are essentially non-existent for the majority of the population. To get a loan, it means going to a tattooed snaggle tooth guy wearing a flower shirt who exchanges gold and foreign exchange, and getting a double digit monthly loan. Best case, you are lucky and have land you can mortgage or family abroad you can beg for remittances. Additionally, tuition is paid up-front - not monthly payment plans. Additionally, the universities didn't provide half of the materials needed like scalpels or gauze - that came out of pocket at US prices.
Additionally, for someone from the bottom half of society, like my SO's family, social security and public services are non-existent, so they are dependent on their children sending them $150-200/mo while their kids are paying $250/mo in rent and $100-150/mo in incidentals on best case a $700-800/mo salary.
If you are a woman from the bottom half of society, like my SO and her peers - it is almost impossible to afford 8-10 years of no cash flow. If you are an 18 year old woman in the Central Highlands or the Mekong Delta, immediately working in a factory with a subsidized dormitory and food means you can immediately start sending cash to family to help them out. Alternatively, earning $15k-$20k working in the "unregulated vice industry" in Singapore, South Korea, the UAE, and others starts looking extremely lucrative (usually referred to work there by that snaggle tooth guy I mentioned). Best case, you get an arranged marriage with someone in the diaspora in the US or become a "Viet Bu" in Malaysia or Singapore.
My SO was literally the only person from her social class at her medical school (Vietnam's equivalent of Harvard Med) - everyone else were the children of doctors, bureaucrats, diaspora Vietnamese, businessmen, MPS officers, and other crème-a-la-creme of Viet society.
For people in my SO's case who somehow even make it to medical school, they all try to leave to practice in Japan (which my SO did), Taiwan, South Korea, or the US as soon as possible becuase it is the only way they can even recoup the cost. And this is exacerbating the medical health crisis in much of Vietnam, because a rural government doctor in a village like my SO's (if they are lucky enough to even get a doctor) would earn a $100-200/mo government salary that is almost always late.
Like, there are massive issues in the US, but to even compare the that to those faced by the bottom half of a developing country is legitimately out of touch and actually insulting as it trivializes the pains billions of people face across developing countries.
Small(ish) OT, but after years and years of leaning in favor of a private healthcare system I have completely reversed my opinion.
I will spare you the ethical and moral reasons, and give you a practical one.
Private healthcare, being a business, cannot afford the investments of public one. Instead it operates following the Pareto principle where 20% of services and treatments cover 90%+ of patient needs.
Now this works with much joy over most of your life, but there are just too many edge cases over a life time where this will screw you.
E.g. A close friend of mine gave birth in a private clinic. The most luxurious one with almost a dozen people following her.
All of this: pointless. Her child had complications minutes after birth, and no single private hospital in our country has a pediatric intensive care unit, or, to label it more correctly a pediatric _reanimation_ unit.
The only private hospitals that do? University ones, as they operate on slightly different financial basis and incentives.
This goes beyond this example I have. It doesn't matter if you're in a country with good private healthcare (e.g. Switzerland) or a crap one, public healthcare is accepted to be a money loser for the greater good and will cover more services. Always.
Mind you, I'm not saying that a single public hospital will offer everything and private is bad, just stating that there's many situations where it's easier to find the service offered in public rather than private health care.
You say that only "big, public" hospitals can afford the NICU. But don't you just mean "big"? It's just a question of how often it is used, right?
In Switzerland *no single hospital* has a proper PICU. There's one in Luzern and St. Gallen but they are under equipped for all the emergency situations. They are essentially sub-intensive, and if your child has such a complication, good luck.
The only ones that do are all university hospitals and they only do so because they operate on a very different financial non-profit model.
And I'm talking about Switzerland.
PICU isn't just an example of service and treatments where even very very rich countries with quality healthcare are relatively uncovered compared to much poorer countries with public health care.
It's not even the happiest one, because PICU is still "relatively" common, so I don't want to focus on it.
Other examples of treatments that are relatively common in public health care are organ transplants, ICU for infective diseases, post trauma (stroke-like) rehabilitation are just some of the examples of treatments you're gonna find in many public hospitals in a country but extremely rarely in neighboring countries with excellent private healthcare.
My controversial belief is that the barrier to become a doctor is way too high. I think barriers need to be reduced.. I mean think about it - I learned software pretty much by being put into it and forced to learn.
I understand medicine is slightly different but my hunch is that any sufficiently smart person can do well enough as a doctor after 1-2 years of theory.
This might anger a lot of people because there’s a trend where we elevate medicine and doctors to a godly level.
Thankfully with the internet and AI, knowledge is not gatekept as much now.
I wish we allow more people to become doctors and intelligent people to become doctors. The type of people who choose to become doctors are not problem solvers, at least from my experience.
Of course my argument doesn’t work exactly for surgeons but I think we should not artificially reduce their numbers.
In New York, the moderate Democrats, like their governor and health commissioner, have for years been proposing to join the Interstate Medical Licensure Compact for doctors and the Nurse Licensure Compact for nurses from other states.
The far left Democrats have consistently blocked such proposals, usually without so much as a hearing.
Forget other countries, they won’t even let health professionals from the United States practice. I believe this is true of several large state Democratic parties.
It's not that controversial - it's why you're quite likely to see a nurse practitioner for more routine issues.
Well, I happen agree with this allegedly controversial opinion, but the fact that we invent legal fictions like "nurse practitioners" and "physicians assistants" I think sort of proves the point that it is controversial in the wider public consciousness.
We create these roles and gradually give them more and more autonomy precisely because we can't agree to produce (or import) more MDs. MDs actually see the writing on the wall, too. Their lobbying organizations are strenuously opposed to expanding NP and PA roles.
Strange because this was not mentioned in the article. Doctor wages contribute way more than silly insurance companies whose margins are lower single digits.
There should be a good career ladder for nurses to become actual doctors if they perform well on the job. No need to gatekeep now that we have AI and internet.
> Doctor wages contribute way more than silly insurance companies whose margins are lower single digits.
The numbers don't back this up. https://www.cms.gov/files/document/nations-health-dollar-whe...
> There should be a good career ladder for nurses to become actual doctors if they perform well on the job.
Again, that's most frequently called becoming a nurse practitioner.
Those graphs don't really refute the point.
Look at the buckets: Things like Dental Services, Home Health Care, Nursing Care Facilities... This tells you about healthcare spending at the macro level, but doesn't explain why a particular doctor visit cost so much (I don't use any "nursing care facilities" or "dental services" when I visit the doctor for a sprained ankle, for example).
When you go to the doctor for a sprained ankle, where does that money go? By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan). Where does the other 85% go? Certainly some it is the cost of running a clinic (staff, rent, equipment, etc), but what about the rest?
Then look at doctor's income. Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more. Where do you think that money comes from?
> By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan).
I'm aware of two huge exceptions that are large enough to make this basically not-true.
1) This doesn't apply when they're administering a self-funded plan, like most plans provided by large companies. This represents a giant chunk of US health insurance.
2) This doesn't apply to new plans (I believe in the first two years of operation). I admit I've not looked into it, but I'd be shocked if this isn't being gamed such that a fairly high proportion of plans that aren't excluded by #1, are always "new" and so not subject to those limits.
> By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan).
That's quite a bit to a middleman.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6179628/
"According to Reinhardt, “doctors’ net take-home pay (that is income minus expenses) amounts to only about 10% of overall health care spending."
It's also a big incentive for the insurer to increase prices. If they want more revenues, and more profits, they have to get overall spending to go up.
> Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more.
Good. They should.
> Again, that's most frequently called becoming a nurse practitioner.
Personally, I would always rather see a physician due to how much more training/experience they have. A physician who's out of residency will have gotten at least 3 years of on the job training (after medical school). A nurse practitioner may have just gotten their BSN and then gone straight into an NP program without ever working a single day as a nurse.
But yes, you're right, this person is absolutely describing NPs.
> Personally, I would always rather see a physician due to how much more training/experience they have.
There's a very good chance, if you're seeing a NP, that the NP has a lot more experience with that sort of condition than the docs. After all, the practice is sending those sorts of issues to the NP. My dad's a radiologist, but they haven't assessed a minor break in decades, because they're very subspecialized.
If it's unusual or complex, the NP is probably the first to say "we'll need to make an appt with Dr. So and So".
Wrong. This is just the money government spends which goes to insurance which is used to pay doctors. Don’t use these figures.
Go on, give us the right figures, then.
The first chart includes "private healthcare insurance" as an input, so I'm pretty sure you're wrong.
The $4.9 trillion detailed in this chart is "the official [estimate] of total health care spending in the United States". https://www.cms.gov/data-research/statistics-trends-and-repo...
Another thing the US could do would be to offer a fast and easy path for foreign medical doctors to immigrate and start practicing medicine with minimal barriers.
Unfortunately, right now, it is difficult for doctors to do so much as move to and start practicing in a different state. But if you want medical costs to actually come down and to ensure availability, you need to multiply the number of doctors available to treat people.
It doesn't matter what the insurance company margins are.
It matters how much they add to the cost.
Typically, "margins" means the profit they make over and above expenses. For insurance companies, the salaries of all the people they employ, and the rent/mortgage/upkeep on their buildings & grounds, would all be classified as expenses that would not generally be included in their margins.
But in a single-payer system, none of that cost would even exist. We have to pay for all of that through our premiums, and we get nothing out of it.
1. In the United States, insurance companies are legally mandated to pay out at least 85% of premiums as medical expenses. It's called the Medical Loss Ratio if you care to Google it. That stipulation is part of the ACA / "Obamacare". If they spend less than 85%, they are legally required to issue refunds. The 15% that insurance companies get to keep has to cover both administrative costs and their profit.
2. Single-payer systems still have administrative costs. The administrative cost of running England's NHS is not zero. But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.
3. Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.
> In the United States, insurance companies are legally mandated to pay out at least 85% of premiums as medical expenses.
Which means, of course, that their main option to increase profit is to increase overall spending on healthcare. Reducing cost is directly against their interests.
UnitedHealthcare buys up physician practices, and pays theirs higher rates. That's part of the 85% bucket, but they're profiting off it. https://www.statnews.com/2024/11/25/unitedhealth-higher-paym...
> Single-payer systems still have administrative costs.
https://www.healthaffairs.org/do/10.1377/forefront.20110920....
"According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue. Insurance industry-funded studies exclude private plans’ marketing costs and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower."
> Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.
I mean, that's a start.
If you chart the US against the rest of the OECD, we're doing something bafflingly expensive versus everyone else. It is certain to be multi-factorial, but our insurance setup absolutely plays a role. https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
> But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.
This is only true if you assume that health insurance companies have no influence on the cost of care. That is, however, patently false.
> I learned software pretty much by being put into it and forced to learn.
And how many people are at risk of dying if you screw up at your job? My guess is exactly 0.
How many risk dying because of costs? You won’t reduce quality that much if you have a smart person looking at your medical problems. But decreasing the costs may outweigh the benefits.
I can’t prove this but my intuition says that you don’t need this high of a barrier.
> You won’t reduce quality that much if you have a smart person looking at your medical problems.
I think you're vastly underestimating the complexity of the human body and the amount of education necessary to do a good job as a physician.
And I think you're vastly underestimating the silliness of the requirements to get into medical school.
Medical schools care whether you got an A or B in your undergrad physics-for-life-sciences lab (I know this because I had to deal with annoying grade-grubbing pre-meds as a TA for that class). I would feel 100% comfortable with being treated by a physician who "only" earned a B in my undergraduate physics.
Medical schools also care about how many hours of volunteer community service you do. So, I guess all the applicants who had to work a job through undergrad can just go fuck themselves.
You might start by asking why medical schools care about such silly things. It's such a strange metric! The answer is that medical school collude to limit the number of doctors (so that we don't have "too many"!). Since the quota is so low, they have an enormous ratio of qualified applicants to seats. , So, they need objective criteria to pick some people over others. A or B in undergrad physics (or number of hours of community service) is an objective, quantitative way to cull the herd of overqualified applicants.
Personally, I always thought a better solution would be to have med school applicants roll a die. While I would be 100% comfortable being treated by someone who earn a "B" in my physics class, I'm not sure I want an unlucky surgeon operating on me.
So nursing?
Increase nurses, allow them to get promoted to doctors. Reduce barrier for both nurses and doctors.
I don’t think having to study for 10-15 years to become an MD reflects in the marginal benefits. A couple of years is probably all you need.
So one problem with a nurse -> MD career track is that they are just fundamentally different roles. It's not (just) number of years of schooling, but what they study. Nurses don't do diagnoses or prescriptions, and don't receive much if any formal training in those areas. So I'm doubtful you can make up that difference with just on the job training (though doctors who were once nurses might be better doctors).
That said, I think that a RN -> NP career track with some kind of "executive NP" program (analogous to "executive MBA"), followed by supervision under an MD and eventually graduating to full autonomy, is an interesting idea.
> Increase nurses, allow them to get promoted to doctors.
I think this sentence shows that you don't really understand the difference between the two jobs. Nurses and physicians have wildly different training/education. There are things about the body that any first year medical student could tell you, that nurses never learn even after decades of experience (because they don't need to).
You didn’t read my post. I literally wrote training doesn’t matter. An intelligent nurse without a formal medical background but with enough experience can outperform a doctor. Maybe you can give the nurse a year or two of formal medicine theory as a certification that allows them to become a doctor.
What would you define as "a formal medical background?" Schooling? The schooling that nurses and physicians receive is very different.
> Increase nurses, allow them to get promoted to doctors.
We already do this.
https://en.wikipedia.org/wiki/Nurse_practitioner
I had eye surgery three weeks ago. Prior to my eye surgery, I emailed and called my health insurance to get a total out of pocket cost, none could be given. The only thing I heard over and over is your deductible is X.
I spoke to to the eye surgeon's billing department and the same happened. How the F* can it be like this? To top it off, I just got a bill for $300 after paying $1300.
The system is completely broken.
> Employers themselves are at the mercy of entities that have even more market power: Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care in the United States.
Yeah, nice headline!
Yeah the head line was clickbaity
Just absolutely idiotic and selfish on the editor’s part. They are miseducating a casual audience and building a false understanding for the masses.
People who only read headlines are misinformed, who could have guessed
[dead]
I guess it would be a crazy idea to include the people charging for the service as a reason for the rising costs or the fact that they expect high income after paying a $1M to be educated and also have to contend with rising malpractice insurance and fraudulent lawsuits.
I think that irritation should be focused on the middle people. Between the doctor, the insurance company and the patient. There are a lot of people sticking their fingers in the pie driving up the cost. We've all heard about the $25 Band-Aid.
One major issue with centrally planned healthcare is that the value of health is variable to the individual. Particularly beyond the line between technically dead and technically still alive.
A poor, uninterested, or other valued[1] person would only sacrifice $N to improve their health beyond "still alive". A rich person, or highly interested, or other valued[2] person would sacrifice potentially many multiples of $N.
Take Bryan Johnson[3] for example is willing to spend on many improvements to his life. For example, in Canada he'd be basically unable to do what he wants to do with his own money.
As one such person I am happy to pay more for more. What I really think is needed here is improvements in contracts and transparency. For example, there should be a contractually binding price agreement (of which the prices themselves are publicly available to all including competitors) for any non-emergency non-urgent procedure. (If time is of the essence then we need to prioritize that, naturally)
As an example of being willing to pay more, my insurance isn't willing to pay for the exploratory labs, and software platform, that function health built and provides for $499 a year. I'm willing to pay it, it has benefitted me over the standard annual physical, and to me it was worth $499. It also likely will save my insurance $1000s maybe $10000s over my life time too. (We discovered something concerning...)
[1] - (eg a father who prioritizes spending on their kids) [2] - (eg a father who prioritizes being there for their kids later in their life) [3] - https://youtu.be/pfSFnFWb8X4
Wherever there are high operating margins for an industry, that's a good indication something anticompetitive is happening.
Occasionally, you get situation like Nvidia which has huge margins because their competitors don't know how to make a decent product.
Almost no one gets "health insurance" through their employers. Most employees get health benefits.
In the US, a majority of large employers don't buy insurance in the strict actuarial sense. They self-fund health benefits under ERISA, paying claims directly and hiring insurers only as administrators (ASOs). The plan may contract with an insurer (e.g. UnitedHealthcare, Aetna, Cigna) to process claims and run the network, but for most employees at large firms, the insurer is not actually insuring anything. Self-funded ERISA plans are regulated by the US Department of Labor, not state insurance commissioners.
Pretty sure Baumol has like 80% of the blame here.
Not for drugs or insurers though.
Zero discussion of the 3:1 premium limit in the ACA. The ACA mandates that you can only charge older people 3x the premium you charge younger people. Older people account for an extremely outsized portion of healthcare services received. This means that no matter how little healthcare you need as a healthy young person, you have to pay 33% of the estimated cost of care for someone who is end-of-life and possibly consuming hundreds of thousands of dollars (or more) worth of medical care.
Older male got some Tadalafil from the doctor and not covered by insurance. Cost 530$. Told them i will not be using insurance and did an RX code and the prescription was 11$.
The system is beyond silly in pricing.
Another prescription had a 10$ copay since it was just a generic drug. Again I requested please don’t run through insurance and the rx price was 4$.
I did a deep dive into understanding how prescription pricing works in the US, long story short it is insanely way too complex and for profit private health care insurance is not good for the health of the population.
What about health care providers? They're the ones that are often sending out the bills for service(s) rendered:
* https://archive.is/https://www.noahpinion.blog/p/insurance-c...
"Why are we paying the people who do the actual work? Shouldn't we save more for the middlemen?"
I live in the US. A family member close to me is unable to make appointments any closer than 6 months to receive lifesaving care. This is despite getting the most premium insurance they could find.
They (easily) found someone who will see them out of pocket. It's not a supply issue in this country, it's an incentives issue.
The framing of this article I find quite disappointing from NPR. Sure employers are not about to just hand out free money are going to try to spend as little as possible but to put your employer in the same space as the others or even the government is a... wild interpretation of the problem.
I was half expecting there to be something in here about the average that employers were spending going down to justify the headline but that was nowhere to be found.
> "It's kind of hidden, because [premium deductions are] coming out of your paycheck and if you're not paying close attention, it may not be obvious,
I have to ask, who the hell is not looking at the amount that is coming out of their paycheck when it comes to open enrollment? Sure you may just accept it since what is your choice, but I think the systems I use generally show how much it is going to change.
Am I just becoming more sensitive to clickbait that outright lies or are headlines getting worse? Nothing in this article justifies any blame to your employer.
Blame everyone but the government, eh? To be expected considering the source. But we won't solve anything without looking at the root of the problem. Unfortunately, it seems to me like that dooms us to not solve anything.
> Blame everyone but the government
I think we can assume that no matter what your political persuasion, in some sense the government is ultimately at fault, either for overregulating or for allowing for the existence of privatized healthcare. As such, it needn't be said, and we can focus the conversation on the proximal rather than ultimate cause.
Blame government but what is your solution?
1. Move the deductions from the employer to the individual. That unlinks health care from your employer. It will also inject market forces and discipline to our health care system, since the person paying for the care is now in charge of the insurance.
2. Repeal the ACA mandates and enact interstate laws which permits low-deductible, low mandate policies along with reintroducing catastrophic insurance. The current status quo forces young people to pay for old people and those less responsible with their health. What we have now is prepaid medical care, not insureance. This also removes the insurance monopolies states and companies have created together.
We have the worst of all possible systems at present.
The chances of any elected politician doing this are exactly zero. We're going in the opposite direction and it's only a matter of time. There are very few places left on the internet that would even entertain discussion of this. This site is no longer one of them.
Really? I thought most of the excess cost of healthcare in the US is due to the artificially restricted supply of doctors, causing them to have extremely high salaries compared to similarly demanding work in the US, or to the same work in other countries (although US salaries are super high in general). But the article kind of handwaves and vaguely blames big business or whatever.
[dupe]
Multiple discussions this week:
Health Insurance Costs for Businesses to Rise by Most in 15 Years
https://news.ycombinator.com/item?id=45212976
Americans face biggest increase in health insurance costs in 15 years
https://news.ycombinator.com/item?id=45157389
Every area of California is controlled by various healthcare monopolies. In Sacramento, it's Sutter Health. In San Diego, it's Perlman. In Bay Area, you have Kaiser. We have no choice or free market. You either pay them or you don't have access to decent reliable health care. I am honestly starting to think about just not having health care and going to Mexico/Canada when I need something--and we make well into the top 10% for wages. I don't know how others can pay for healthcare and all the premiums. I just paid like $300 for a minor skin care treatment at a dermatologist that I had to wait weeks for an appointment with. It's a clear racket. Oh and despite all this, none of the local speech therapists are in-network so we have to submit individual claims and they don't pay the full amount. It's a scam.
ah the shweet land of liberty, the american dreamers
I buy Gary Stevenson’s diagnosis that the root cause of the rising cost of everything is increasing inequality and industry capture by the wealthy.
There are two sides to this. The first is, hospitals are owned by investors, and have to increase profits. The typical playbook of trying to acquire at least a local monopoly to price-fix is in play everywhere.
The other side is: to achieve high profit margins chase wealthy customers and cater to their preferences. Headhunt star staff with increased salaries. Build shiny new hospitals and prioritize private rooms (HIPAA provided a great excuse here). To woo investors turn administrator into a CEO position with commensurate pay.
None of this incentivizes providing quality health care to non-wealthy people at a fair price. It incentivizes trying to get rid of lower income patients as quickly as possible to make room for high income or well insured patients who can be billed more.
Same as housing, this issue is everywhere in the western world. We can try to tackle it by itself (transparent pricing would probably help a great deal), but the root issue is bigger: the rich are getting what they want on both sides of the equation. They don’t want affordable healthcare.
You can't be surprised when industries that are shackled to the government through payment and/or regulations end up inefficient.
Saddens me to think about, but imagine if American healthcare and innovation was nearly as "free market" as smart phones, LLMs, etc.
Except the rest of the developed world has more shackling, half the costs, and similar outcomes.
https://commons.wikimedia.org/wiki/File:OECD_health_expendit...
> Saddens me to think about, but imagine if American healthcare and innovation was nearly as "free market" as smart phones, LLMs, etc.
That sounds horrid.
That's because the monopsony of universal health care fixes the prices. We're kinda caught in the middle in the US.
The assertion was that the high-regulation approach is inefficient, though.
Cheaper, universally accessible, and same outcomes seems more efficient, yes?
I'd say we have an easy way to compare this: look only at Medicare and Medicaid spend vs. the other countries.
Medicare is restricted to the elderly and the disabled; Medicaid is limited to very low-income folks. That would be a problematic comparison.
That said: https://cepr.net/publications/can-we-just-admit-were-wasting...
> Traditional Medicare has significantly lower administrative costs than private insurance with 1.1 percent of spending in 2024 going towards administration compared to between roughly 12-18 percent for private insurers in previous years. Coincidentally, the bloated administrative spending of American health care is one of the factors contributing to why the United States spends around twice as much per person compared to other developed nations even though we have worse health outcomes.
I'm sure it would be if I could get open source surgery online from dabbling amateurs. Unfortunately for most people they have to go the hospital and don't exactly have a plethora of options there.
We see that already with LASIK and other cosmetic procedures. They are not cheap, but often an order of magnitude lower than medically necessary insurance-covered work.
We have two unavoidable necessities in life — food and healthcare (and housing, but i’ll leave that out because it’s an odd fit in this analogy).
The food system is basically a free market (with some weak safety regulations). The apparent end-state of this free market that America has arrived at is tragic. Sure, people like me are free to select healthy, nutritious food at reasonable prices, but at a population level, 70% are overweight and 30% are obese, with all the risk and disease that comes with that.
This is where free markets (in necessary goods) tend to end up. Perfect for ensuring the concentration of capital, disastrous for the average consumer (and never mind the “externalities“…)
> Blame insurers, drug companies — and your employer
> That's because employers will be paying a lot more
> Drug companies, pharmacy benefit managers, hospitals and others have collectively driven up the costs of accessing medical care
> more people are going to the doctor or other providers. But that surge in demand has also led to a surge in prices.
> Last year, the average U.S. employer spent more than $19,000 per employee to provide family coverage while the employee kicked in $6,000,
Why should health care ever get cheaper? Americans treat our bodies like garbage bins for sugar and fat. Old people spend 100ks just to die in a hospital 3 months later. The narrative is always that some rich dude did it to you though?
Both can be true though, most people don't care about their health until it's too late, but the health care system isn't sane either.
Perhaps a solution is to reward people to a greater extent for those who improve their health. Quit smoking, premiums come down. Lose weight, premiums come down. The insurance companies should be working with the doctors and the patients to identify ways they can improve their health to bring down the premium. A healthier person I would assume is a less pecuniary risk to the health insurance company
But they don't seem to do that.
> Americans treat our bodies like garbage bins for sugar and fat.
Even this isn't so simple. Foods in America are engineered explicitly to increase consumption, often (but not exclusively) by increasing fat, sugar, and salt. A good example of this is bread, as most breads sold in the US would be classified as cake in other countries due to the added sugar.
The only way to avoid this is to make your own food by scratch, which simply isn't viable for a large population living paycheck to paycheck.
After the rise in popularity of Ozempic, packaged food companies started trying to figure out how to engineer food that would overcome even Ozempic's craving suppressions. It's truly ruthless what they are doing to us. https://www.foxnews.com/food-drink/medical-experts-warn-big-...
Obesity and diet aren’t the primary drivers of expense in the American health care system. The market structure is.