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Comment by maxerickson | Hacker News Reader

Yeah, it won't. The $10,000 left after the mandatory health payments would be a cut for many social security recipients, and many of those same people are also probably getting more than $3,000 a year in health care out of Medicare.

Similar problems with Medicaid, it's worth a lot more than $3,000 to the people that are getting it (mostly because children).

This is basically taking the desire to cut entitlement programs and rephrasing it to take advantage of the attention basic income is getting these days.

I sort of expect the best thing the US can do right now to make life better and cheaper for the average citizen is to create/fund residency programs. More doctors will actually lead to lower prices. Pouring money into the demand side won't.

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> More doctors will actually lead to lower prices

It might if we had a free market for healthcare and if providers were the largest healthcare expense. But we don't, and they're not. Providers' take-home pay only amounts to about 10% of healthcare spending nationally[0].

Furthermore, the reason we don't have a competitive market is entirely due to the payer situation, not the providers. Providers (particularly hospitals, who account for a much larger chunk of spending) can't offer transparent pricing, because their cost structures are needlessly complex. I've written about this elsewhere, but in short, Medicare is not required to cover the direct costs[1] of the care that their patients receive in the reimbursements that they issue. This means that providers have to make up the difference in their contracts with private insurers, which is why they can't tell you how much a particular procedure will cost you - they really don't know, because it's not purely a function of what it costs them to treat that particular patient.

[0] http://economix.blogs.nytimes.com/2008/11/14/do-doctors-sala...

[1] I'm referring to COGS - the marginal cost per patient, which excludes markup and overhead.

I dunno, I think if there were more doctors more of them would end up working outside of hospitals.

It's certainly the case around here that doctors are moving under the hospital umbrella.

This means that providers have to make up the difference in their contracts with private insurers, which is why they can't tell you how much a particular procedure will cost you - they really don't know, because it has nothing to do with what it costs them.

Yes, this is an obnoxious tax. I don't think the hospitals are forced to keep their prices obscure though (see Massachusetts or Oklahoma), it just happens to be the best way for them to make revenue because if people could easily shop prices, they would. Another component of the problem are the many people who have a plan where they simply don't care about prices because they have a low out of pocket limit.

> It's certainly the case around here that doctors are moving under the hospital umbrella.

That's part of a trend that's a few decades old, and which has accelerated in the last 5-10 years. It's not a function of the number of physicians; physicians are selling their practices to hospitals because they can no longer sustain themselves in private practice.

> I don't think the hospitals are forced to keep their prices obscure though (see Massachusetts or Oklahoma), it just happens to be the best way for them to make revenue because if people could easily shop prices, they would.

If anything, hospitals would prefer to be able to compete this way directly. They can't, though, because there is no single 'price', even if you're talking about a discrete, routine procedure that has no risk for complications. The way medical billing works, they don't necessarily have a set price for a given service per carrier. And even if they do, that doesn't always correlate to what the patient ends up paying (which is, of course, the thing the patient actually cares about). The reason they don't have a set price - even internally - isn't because they don't want to. It's because the contracts with public and private insurers have resulted in the amount of money they need to charge for a service being a function of so many external factors that they literally can't.

Chapter 224 is a perfect example of a feel-good law that doesn't actually do anything in practice, because it fails to address the underlying complexity that's the root of the current problem with price transparency.

From what I understand, they often have no idea what services cost. This is different than not having an internal price. And there shouldn't be external factors that prevent them from measuring it.

Or are you saying that they are contractually bound to avoid tracking costs?

I don't know the answer to your question, but here's an interesting anecdote: https://news.ycombinator.com/item?id=4465845

Right, they aren't setup to bill the damn thing. It's ridiculous.

chimeracoder seems to be saying that this is because of the complexity that comes from interacting with insurance companies and the public payers. Where I don't really buy that explanation is where there is in fact a fixed capital cost associated with the machine, and a certain number of uses of the machine per year, and a pretty fixed level of complexity per use (different scans will take a different amount of time, but each type of scan will be reasonably consistent from patient to patient). So they can take a spreadsheet and put in the capital costs and the operating costs and the staffing costs and boom, they have a ballpark figure for what each scan costs. It won't be the exact number for a given scan, but it will be closer than not having any estimate at all. I don't see where complexity on the billing side prevents them from doing what I describe.

Are salaries a good measure of the income of doctors? I've read that more than half of doctors are self employed, and I suspect that their ownership stake in medical businesses produces a good portion of their incomes.

It's the other way around. As of recently, the majority of doctors are salaried (employed), not in private practice.

The numbers I cite correspond to the practice revenues, but as much as half of what doctors in private practice receive in reimbursements goes to practice expenses and insurance.

That's an interesting change. It wasn't too many years ago that my employer-provided health insurance was through a doctor-owned provider.

Not only will the voting public oppose many of these cuts, corporations (and lobbying groups representing professionals such as doctors, or AARP) will oppose them. And the latter is more ominous to me since they have the lobbying muscle in place.

>create/fund residency programs

Don't several medical lobbying groups actively coerce the government to limit the number of new doctors that can be minted, both overall and in given areas of practice? I am not optimistic about this given the lobbying groups' strong track record of protecting and furthering their self interest.

> Don't several medical lobbying groups actively coerce the government to limit the number of new doctors that can be minted, both overall and in given areas of practice?

Not really. The AMA is often blamed for limiting the number of medical school slots available, but they have nothing to do with that - it's capped by the AAMC, which has been very deliberately raising the number of medical school positions in the US for over a decade now.

But even if that cap were lifted altogether, the number of practicing physicians would be completely unaffected, because we already have more MDs than we have residency slots available. Increasing residency programs would require funding, and currently Medicare is the source of funds for residency programs. Hospitals would typically make a loss on residency programs otherwise; contrary to what some people believe, they're actually quite expensive to operate.

>...Hospitals would typically make a loss on residency programs otherwise; contrary to what some people believe, they're actually quite expensive to operate.

How does that work? Residents make very little money and do a lot of work. How are they not a profit center for hospitals?

> Residents make very little money and do a lot of work. How are they not a profit center for hospitals?

Residents start their first year knowing literally nothing about practicing medicine. Medical school teaches the foundation, but you learn the practice during residency. In addition, the ratio of attending physicians to residents is capped by law (i believe it's 3:1).

Would a startup want to hire three fresh-out-of-high-school interns for every full-time employee? I can't think of any company that does this. At some point they'd get up to speed, yes, but in the short term they'd be a huge drag.

>Residents start their first year knowing literally nothing about practicing medicine.

If this is true, it really indicates that how we train medical practitioners needs to be reformed. (If true, maybe there should be different programs for people wanting to become medical researchers vs those who treat patients.)

>In addition, the ratio of attending physicians to residents is capped by law (i believe it's 3:1).

Are hospitals actually at that 3:1 ratio? The AAMC seems to be saying the limiting factor right now is the limits on medicare subsidies for residents: https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html

>...Would a startup want to hire three fresh-out-of-high-school interns for every full-time employee?

Probably closer would be companies hiring engineering students straight out of college. Those college projects the students did generally aren’t anything like the work they will be doing. Companies don’t hire at a 3 to 1 ratio, but they do hire them and they pay them more than residents get paid and don’t get subsidies from the government to do so.

I was originally replying to your comment: >...Hospitals would typically make a loss on residency programs otherwise; contrary to what some people believe, they're actually quite expensive to operate.

Thinking about it, I guess if hospitals don’t bill patients for work done by residents, then they would obviously need to paid by the government (or someone else) but I don’t know if that is how it works.

If the public at large tells those lobbies to go screw, Congress will listen.

So start talking about how we need more doctors in the US.

> The $10,000 left after the mandatory health payments would be a cut for many social security recipients

The easy way to do this is to give people a one-time election between social security and the basic income, so that nobody can object that they're not better off. Anybody who isn't at or close to retirement will choose the basic income because it begins paying immediately, the lifetime payments are higher and they wouldn't have to pay social security tax anymore. Then in 20 years or so there would be no one left on social security and it could be discontinued.

> Similar problems with Medicaid, it's worth a lot more than $3,000 to the people that are getting it (mostly because children).

It seems like your argument is that we can't do it because there are a relatively small number of people who would be better off under the existing system. But by that logic we could never change anything, even if the net benefits are very large, as long as there is anyone who is better off under the status quo.

> It seems like your argument is that we can't do it because there are a relatively small number of people who would be better off under the existing system. But by that logic we could never change anything, even if the net benefits are very large, as long as there is anyone who is better off under the status quo.

I think this is an incredibly unfair and callous assessment of what's going on with catastrophic health care coverage. It's not about "the relatively small number of people who would be better off under the existing system." It's about the relatively small number people who are alive under the existing system who would be dead under the proposed one.

That's actually an incredibly short-sighted risk calculation that intentionally weighs some unknowns as higher value than others.

For example, I can make the same kind of argument in the opposite direction: if UBI creates a disincentive within inner cities for fewer kids to become drug dealers, which creates less opportunities for violence, leading to significantly less deaths in the inner city, I think that you are making "an incredibly unfair and callous assessment" as well.

Saying that any plan that transfers risk from the current state to a different state that is potentially net better for all is to miss the point that we've already chosen a system that disadvantages SOMEONE... and to change it will probably disadvantage someone different.

We do not live in some Vulcan dystopia. The idea of essentially telling people, who are currently alive, "Yes, we can keep you alive, but by letting you die, there is some probability (which we don't really know and are just guessing at) that we can use the saved money to prevent 1.2 deaths" strikes me as the plot of a horror science fiction movie.

I am all for UBI, but like another poster said I don't think it works without universal health care if you get rid of all the other current transfer payments. It seems the author of the article agrees, but I don't see how the 3K for insurance makes the numbers add up.

> The idea of essentially telling people, who are currently alive, "Yes, we can keep you alive, but by letting you die, there is some probability (which we don't really know and are just guessing at) that we can use the saved money to prevent 1.2 deaths" strikes me as the plot of a horror science fiction movie.

People hate having to make that choice. Hate it. But that doesn't make it go away. We could make cars safer in well-known obvious ways, but they would be more expensive and use more fuel. Many, many, many lives would be saved if we immediately stopped burning coal, but electricity would be more expensive, and then maybe some people would freeze to death because they can't afford heat, or because they became unemployed and lost medical coverage. And in some cases we may even be getting it wrong, but that doesn't get you out of having to make a hard decision.

The UBI proposal in the article (one I find pretty weak, and I'm a huge proponent of UBI) is that you're getting $10k plus healthcare. So there's that.

But.

There is no part of the proposal that covers making sure coverage is equal in value to Medicare - in a private market I'm betting benefits start getting cut post-haste. UBI without universal healthcare is a nightmare, and is all but privatizing Medicare. Surprise!

Also, since children under 18 don't get UBI, they would have to be covered by their parents' $3k/annual buy. But again, privatized "universal" healthcare? No thanks.

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