Comment by rsync | Hacker News Reader

Comment by rsync | Hacker News Reader

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"The whole reason we get insurance is to avoid those high prices."

But only for unpredictable, irregular events. Anything else is uninsurable. If someone sells you "insurance" for wellness checkups[1], regular, scheduled screenings ... or tires on your car ... you can be absolutely assured that they are taking from you as much, or more, in premiums than the cost of those services.

What you are looking for is socialized, state sponsored medical care. There is no problem in looking for that and I make no value judgement here on that.

The first step would be to stop mischaracterizing this as "insurance". It's not. It can't be.

[1] Yes, certainly wellness checkups and things like them can be enormously economically beneficial for the provider since they spend up front preventative dollars instead of emergency, acute dollars later but it still doesn't change the fact that those are not underwriteable as they are regular, on-going expenses - very much like the tires on your car.

It's rather entertaining to see the fallout of costs becoming more transparent in America's healthcare system. There is a reason why the medical field is so lucrative in the US, and it's because for decades it's been subject to extreme price obfuscation. This is great for the merchants (pharmaceuticals, doctors, hospitals, medical software providers, nurses, etc), especially for such inelastic goods such as healthcare.

Now that organizations in the US have reached a breaking point, those costs are becoming clear to the consumers and they don't like it. You're absolutely right that the term insurance is bastardized in the healthcare setting, but people will have no choice but to understand.

If people want to blame somebody, they can start with the doctors union that restricts the number of residency positions open.

Residency programs are more restricted by funding for residency spots, not by the AAMC. Funding is, very weirdly, provided by Medicare. It's all a tangled mess with lots of weird stakeholders, but saying "doctors are using rent seeking behavior to limit new entrants to the field" is a bit disingenuous.

https://economix.blogs.nytimes.com/2013/12/17/how-medicare-s...

https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html

Doesn't the AAMC regulate the number of nurse practitioners? My understanding was that increasing the pool of nurse practitioners would help alleviate the cost of treatment for basic ailments, but that number is capped by an administrative body.

I explained it to someone recently as this: "This biggest problem with the healthcare industry is that incentives are terribly misaligned and patchwork. Because most of the market is formed by accreted law rather than naturally, even incentives for a given participant (e.g. an insurance company) are usually different than what you'd expect."

From what I've read, a lot of that is due to the prices set by the RUC:

https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val...

https://www.aafp.org/news/practice-professional-issues/20120...

Good for the doctors though, at least they're smart enough to bargain in their own interest.

Nothing in these articles supports your contention. The "tangled mess" is by design. By the people who stand to profit from it.

Allow foreign doctors to work in the us with a reasonable, attainable testing period of one year, and you will find no shortage of doctors in the us within the year.

Your comment seems to overlook the fact that insurance companies negotiate better rates on many (most?) services than an individual would get going at it alone. From that perspective, I think it's reasonable to say that in our current system, insurance can allow you to essentially avoid high prices even for things that are predictable/regular.

That is because providers can't refuse healthcare to someone that needs it and can't afford it, so those costs get inflated just to be able to get a fraction of it. As rsync says, it's still not insurance, it's just the ability to be part of a group large enough to negotiate pricing, and has enough credibility for providers to trust them to be able to pay.

AFAIK that only applies to hospital emergency rooms. Your local doctor certainly can refuse service if you can't pay the bill.

Yes, of course. I meant to convey that for the providers that can't refuse, like hospitals or ambulances, sticker prices not realistic because the provider is having to gamble on which portion of the people they treat can and cannot pay, and how much, so they inflate their prices extremely high. And also to negotiate with insurers.

This is not clear, in that "concierge doctors" or cash only doctors to some, seem to have rates that are lower than what the insurance companies claim they are billed for a service. That would suggest they are lousy negotiators.

For the doctor, a great benefit of being cash only is you don't have to do billing, a non-trivial task.

I don't disagree, but I observe that if the interests of getting the lowest cost were aligned with the insurance company, and if the complexity of billing was a significant cost factor, it should be well within the capabilities of the insurance company to simplify the billing (by simplifying the requirements) in order to lower overall costs. And yet here we are :-)

I don't think this is true at all. The doctors have to justify their costs and the insurance companies have to validate that they are worth covering. Neither of those seem simple unless the insurance companies simply said, "Whatever the doctor wants to do, and whatever they charge is fine."

How do you come to that conclusion? I've seen a number of articles and cases like [1] where a company decides to charge apparently "what ever it wants" and the insurance company said "fine" and paid it. This article[2] talks about the wide range of prices for the exact same procedure within the same area. Is it your understanding that each of those different doctors justified their costs and the insurance company validated them?

[1] https://www.law360.com/articles/940691/fla-compounding-pharm...

[2] https://www.usatoday.com/story/news/politics/2016/04/27/huge...

Each doctor offers hundreds of services/procedures. Each one has a different price. The insurance company needs a certain number of doctors in the network to be competitive and they can't really have hard cutoffs for every single item. It's not that surprising that there are outliers.

Additionally, lots of doctors often bill incorrectly on purpose so that a particular services/procedure gets covered, so I am not sure we should keep "justified" and "validated" in these discussions.

Most doctors in my area will charge less in cash for people who don't have insurance vs. what they charge insurance companies for the same services.

I worked in health care and saw so much money wasted. The ACA was suppose to bring the same risk factors to everyone, so you got the same premiums based on age, gender and smoking status. Big companies got big breaks for employees and the rich paid less.

This might have worked if everyone was required to buy from the market place and there were no employer plans. Obama's famous "You can keep your existing health coverage" was a terrible, terrible decision.

I watched the Medicare/Medicate group for my company and they might have complained about not getting enough money, but I really think they did. Things had fixed prices and there'd be plenty of money if BlueCross didn't spend money on advertising, useless wellness programs and shitty IBM technology.

Everyone should just get Meidcare/Medicade. The government won't control healthcare, it will just get contracted out to providers. They'll have to cut costs and not waste so much money (they waste A LOT!)

Capitalism + Health care is a failed experiment. Socialized health care does work, in every high income country that's not the United States. Australia fought against the Abbot government when they wanted to introduce copays. That's right, Australians don't have doctor co-pays (they kinda do now, but wavers are in place and the plan was effectively defeated).

The fact that the US government requires us to buy private health insurance at insane rates is absolutely insane and the Supreme Court should have struck it down. You are not a car. Your body shouldn't have a fee for existing.

It shouldn't have a fee for existing so long as you're cool with me not paying a fee for when your body breaks down.

You can also negotiate on your own. I've occasionally had medical bills that for whatever reason were not covered. I call the provider and if I owe $1,000 I'll say I can pay $500 today to settle it. That's more than they will get selling the debt to a collector so they will take it.

You generally can't negotiate in advance though, because most providers seem unable or unwilling to tell you what anything is going to cost.

Not sure I get you. "But only for unpredictable, irregular events." But if I went into the Doctor's office without insurance, could they turn me away? The bill would be too high?

We looked into ACA... but we thought that the process of switching over from AETNA to COBRA would be painless (weeks at most). So we just went through with it. We did not know it would end up like it has.

The operations for insurance is a daunting, slippery rope. Can you not lay some fault onto insurance and its operations?

What would you characterize this as? People slipping up? That's how the "system has always worked"? People forgetting to process paperwork needed so people can get to their appointments?

I think the parent is objecting to the use of the word "insurance". By definition, insurance is a form of risk management, to protect yourself against unexpected cost or loss. You can't be "insured" for regular wellness checkups and screenings; that word just doesn't make sense there, as those are expected, regular costs. Coverage for that is more like a "health plan", which is, in reality, what we have, despite the industry's insistence on calling it insurance.

(But yes, admittedly, this is just pedantry.)

Ah, I understand - thank you.

I believe OP is talking more generally about insurance (not just health). Insurance covers you for unusual unexpected large-cost events at the cost of regular, predictable payments. They are useful in capping your risk exposure.

But if the events are rather certain, then the insurer can only act as a payment plan on the events. The risk is 100%, so at least 100% is priced into your premium (profits, a overhead, etc take it over 100).

Except even the 100% risk is spread over the group. So if I have some known condition that will definitely incur $10,000 in medical expenses this year, it's still possible that my premiums total less than that, but everyone's premium is a bit higher than it would otherwise be, to cover my extra costs.

Even covered wellness care probably comes out a bit less than it would otherwise cost, because not everyone uses it even though it's covered. Some people, like me, just don't go to the doctor.

This is why the poster called it a socialized system. You are literally spreading the costs to the society of individuals in the plan. That is not insurance.

Now, it is common for "socialized" to be a scary word. So that people try and name it other things. But you aren't spreading the risk here. You are only spreading the costs.

Well, I'd also argue that you are spreading the benefits. Which is a good thing to me. Point being, though, it is not insurance.

"Except even the 100% risk is spread over the group. So if I have some known condition that will definitely incur $10,000 in medical expenses this year, it's still possible that my premiums total less than that, but everyone's premium is a bit higher than it would otherwise be, to cover my extra costs."

This is why I used wellness checks and tire changes as examples - they are regular and universal.

I'd say that healthcare is just one of the fields where bureaucratic incompetence is horrifying. There are many others, like the legal system confusing two people with the same name in the same town.

The takeaway is that one shouldn't predicate success on lawyers creating a Borges-fidelity 1:1 mapping of the real world into law.

This isn't quite correct for American health care. It is absolutely cheaper to pay insurance premiums than to pay directly for medical bills. The insurance company takes in more premiums than benefits that they pay out but the price that insurance companies negotiate for a procedure is dramatically lower than what you would be able to get if paying directly.

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