The Astonishingly High Administrative Costs of U.S. Health Care | Hacker News Reader

The Astonishingly High Administrative Costs of U.S. Health Care

nytimes.com

232 pointsdigital55166 comments

I wish I had a link for this, but I believe as Obamacare was being drafted / the economy was in dire straits in 2009, the Obama administration had to make a choice about whether to radically streamline health care, but at the cost of killing employment in (at the time) the only growing sector of the United States.

They chose to not streamline it, which is understandable, but obviously a price had to be paid at some point.

Related story, went with my wife into a small but advanced local hospital where she has a surgical consult about her sinuses. This hospital was beautiful and fully loaded with all the latest technology, big screen TVs, tablets, etc. Nonetheless, in the waiting room there were 5 office admins each with dual monitors checking people in. It’s like they didn’t get any benefit at all from the technology......

This is the problem with common economic measures. We spend 18% of GDP on health care, but that's just overhead and we should be trying to drive it to zero.

The people who are that overhead do not want it to be driven to zero.

Not per se, but they do wish their own health care weren't so @#$#@% expensive, which amounts to roughly the same thing.

Not if the “waste” represents maybe 5% of their spending but accounts for 100% of their income.

When blue collar jobs get destroyed, all I hear about is the benefits of creative destruction and the people will benefit through lower prices. When white collar jobs are threatened, everyone loses their shit.

Oddly, I hear a ton about the loss of blue collar jobs. Your rhetoric makes it look like you likely just notice and are annoyed by the people pointing out some change as inevitable.

Ultimately, this comes down to interests and money. Consider how much money is poured into saving a few well lobbied industries. Then look at how many more jobs are lost in the service/retail sector with relatively little press.

I mean, sure, we all talked about Toys R Us going under. How many jobs did that represent? Why no considerations of a bailout? Sears, etc? Tons of discussion to prop up coal, of all industries. Retail? If there has been discussion, I've missed it. (So, definitely possible.)

> annoyed by the people pointing out some change as inevitable.

I think that it's more white-collar people declaring axiomatically that all losses of blue-collar jobs are inevitable due to rising productivity (while productivity is falling), and simultaneously declaring that massive inefficiencies should be preserved to protect white-collar jobs.

If we're willing to forgo efficiency, of course all blue collar jobs could be preserved. The inevitability come from the fact that white-collar people get to choose in which areas of industry we should be efficient, and in which areas reducing inefficiencies is pointless.

I see blue collar people suggesting the opposite - for example, supporting massive inefficiencies (like repealing NAFTA) in order to protect domestic blue collar jobs.

Humans tending to empathize more readily with people like themselves is a regrettable, but not exactly exceptional or noteworthy, phenomenon.

That’s not regrettable at all when the consumer excess from trade policy hasn’t been evenly distributed across all income cohorts. There is a difference between bureaucracy and labor cost arbitrage.

Efficiency without social safety nets and other opportunities to replace existing blue collar jobs is brutal capitalism, inappropriate for a developed nation.

> Efficiency without social safety nets and other opportunities to replace existing blue collar jobs is brutal capitalism, inappropriate for a developed nation.

This position is not unanimous. I strongly disagree; "brutal capitalism" is both more efficient and more compassionate in the long run. "Social safety nets" merely transfer the burden to more people, increasing it in the process through bureaucratic overhead.

> This position is not unanimous. I strongly disagree; "brutal capitalism" is both more efficient and more compassionate in the long run. "Social safety nets" merely transfer the burden to more people, increasing it in the process through bureaucratic overhead.

The majority of Americans support social safety nets [1], so I won't be arguing that point.

Social safety nets have also been shown to reduce poverty, which reduces the burden on those paying taxes for social safety nets. [2] It would be economically irrational (and I'll go as far as to say foolish) not to support them based on that research.

[1] http://www.people-press.org/2017/10/05/2-government-regulati...

[2] https://www.theguardian.com/money/us-money-blog/2014/nov/12/...

This view is usually only shared by those who have never had to deal with all the things that come with being poor.

Social Safety nets are just that: safety nets. They are not meant to provide a living for everyone, but to cushion the fall for those who have fallen on hard times. To not let the weakest members of the tribe left out when there is no shortage of the basic commodities for existence.

We tried Brutal Capitalism before. It lead to all the evils of the Gilded age: poverty, inequality and wanton destruction of the environment by corporations gone amok.

""brutal capitalism" is both more efficient and more compassionate in the long run"

I'm not sure about that. I've watched a lot of scuffles in capitalist markets eliminate most of the competition to turn into lock-in via strong brands, control of territory, copyrights, or patents. The lock-in typically lands on a few companies that become an oligopoly of sorts. These are most noticeable in telecoms, operating systems, big chains of any kind, and so on. Once they form, they barely compete with each other. They mostly screw customers and employees over in common ways to maintain high margins. Internally, they usually form rigid hierarchies that push control more than innovation with the evidence showing they're driven by politics more than performance. If they pay a lot of advertising money, the media will also misrepresent their incompetence taking about how they're in a competitive market, struggling, or so on. Quite a few years on my resume was in one of those companies on Fortune 100 with general public none the wiser.

That doesn't even get into all the horrors of capitalism which stim from its incentives and operating environment. These companies systematically mislead people to get talent in the door, demand as much from them as possible, do as little for them as possible, do as much as possible for their controllers, discard them whenever opportune regardless of promises made, externalize as many bad things as possible, and pay bribes to lawmakers to make their evils legal. I don't have to imagine whether that was more compassionate in the long run: we're well into more messed up stuff than I can count that comes directly from financial incentives and moral apathy.

If you want to see some of that, the documentary The Corporation has a nice collection of anecdotes. I'd especially cite the examples of media suppression, taking water from Bolivians, and sweatshops. Author uploaded it in pieces on YouTube for free. I'll post first one followed by those clips.

https://www.youtube.com/watch?v=Pin8fbdGV9Y

https://www.youtube.com/watch?v=eZkDikRLQrw

https://www.youtube.com/watch?v=xw5Fon_EjGw

https://www.youtube.com/watch?v=H3m5lq9FHDo

Hell, let's add one for parents everywhere who suffer to this day due to the invention of marketing aimed at making kids nag them.

https://www.youtube.com/watch?v=Hi63rXnuWbw

I think it is more sides forming. Folks feel they are either on the side of white-collar or blue-collar. I would love to see a numbers run of the data to see if there are actual patterns.

Ultimately, I think all jobs are on the table as something that will go away someday. That day is a long way from now, though.

One of my favorite tweets from recently was in a theme of "things in your industry that are obvious, but folks out of the industry don't realize." The tweet was basically, "every piece of clothing you see was stitched together by a person." Basically, we get the impression that automation will be the big destroyer of jobs, but there is still a long way to go in that path. And, when it comes to it, white-collar jobs are probably more susceptible to automation than others. Consider, how many secretaries are there nowadays? Clerks? Data processors? I don't think these jobs have actually disappeared, but I do get the impression that they have drastically shrunken.

> Tons of discussion to prop up coal, of all industries.

I believe the argument is that domestic energy production is a matter of national security.

Seems dubious. I mean, yes, we should try and maintain energy independence. I don't think we need coal for that.

Nor do I think we should necessarily just flat out drop coal. If there are avenues it makes sense to use, we should do so. However, it is a remarkably bad industry for all but the owners.

domestic energy production is a matter of national security

The #1 factor in cutting US coal consumption/production over the past decade has been cheaper natural gas from domestic fracking. The #2 factor has been the rise of US wind power, which is also domestic.

https://www.eia.gov/todayinenergy/detail.php?id=25392

That argument does not hold much water. Natural Gas is the preferred source for almost all new power plants, and the US has a LOT of it (Shale oil/gas). Not to mention the shitloads of good ol petroleum in the Permian Basin, Alaska and the Arctic.

Blue-collar jobs in manufacturing are mostly gone, unlikely to return. Blue-collar workers are encouraged to train for work in white-collar fields, like healthcare.

Before going on to also gut a large source of white-collar employment it'd be a good idea to figure out what we're going to do with the displaced white collar workers, and the blue-collar workers who have lost a potential source of employment.

Which is also weird, because they seem like a smaller voting block, increasingly so?

What if we drive it to 0, and litterally hand those people the money they would otherwise be making.

Can we re-train them to do something which is actually useful, and which benefits the rest of society? What if we spent 18% of GDP on a new space program, for example..

If you have a way of driving the cost to zero without driving the delivery of healthcare to zero, we'd all love to see the plan. Too much of it is overhead, but not all of it, nor even close to all.

Graeber in "Bullshit Jobs" quotes President Obama, but I can't find an independent source of the quote right now.

To account for that persistence, Graeber quotes President Barack Obama on the topic of privatized health care. “Everybody who supports single-payer health care says, ‘Look at all this money we would be saving from insurance and paperwork,’ ” the former President noted. “That represents one million, two million, three million jobs.”

https://www.newyorker.com/books/under-review/the-bullshit-jo...

A more optimistic formulation would be that that represents millions of people who could be doing something a bit more generally useful than mastering the intricacies of the layers and layers of bureaucracy built up around medical billing. And probably wouldn't mind having a slightly less mind-numbing job themselves.

Too bad the US is also epically bad at supporting people in career transitions.

The magnitude of the data systems migration is usually discounted as well.

Insurance companies generally have atrocious IT (it's not their core competency) and consequently inflexible IT stacks.

Elimination the layers and layers of bureaucracy also means change / rewritting all the places that's embedded in code.

... and the real kicker? Those changes have to happen on both sides of any party / counterparty transaction. While supporting a normal volume of work.

Small example? ICD-10 code support https://www.cms.gov/Medicare/Coding/ICD10/index.html

That's a capital cost though, not a marginal cost. Amortize it over the essentially infinite savings on a long enough time horizon and it's basically free.

Assuming success. Which has a pretty atrocious probability from what I saw (see above reply).

I think, though, that they would find a way to clean this all up toute de suite, if only they were given a proper incentive to do so.

For example, if there were real competition in the marketplace (say, by moving to a system where most consumers go to actually shop around and choose their own health insurance company), I expect you'd find insurance companies start to streamline their own processes, both internal and external, more-or-less immediately.

I think the issue there is risk. Specifically, what is the likelihood of success if I attempt to migrate / change / remove X system?

I can't understate the complexity and intricacies. Imagine legally defining all possible medical transactions, then writing software thats compatible with those legal agreements, then running it, changing the agreements, and adding features over 50 years. While the systems being interacted with also mutate.

And all of this being done haphazardly and uniquely because there's no one in control of the entire process (Medic-are/aid aside).

I'm hard pressed to think of a messier computing system in aggregate. I'd guess even the financial system is more rigidly defined, has fewer players, and doesn't have to map with as high fidelity to real life.

ACA provided a fair number of incentives and penalties, re: actual vs industry standard overhead. And it caused change, but there were a lot of failures.

Indeed, imagine a system where some providers are cash-only. They wouldn't even care about that ICD-10 stuff, let alone pay even the cost of entry for the proprietary coding system.

Of course, I realize, that were an insured patient to use such a provider, that would shift the insurance claims burden onto the patient (much as is often the case PPO out-of-network claims today), but this could be a point of competition for would-be insurers under your proposed system.

If a patient is cash-only, how would their electronic records be stored, if not ICD-* compatible?

Using any technology that predates ICD-*, including paper.

Current regulations may preclude using anything but a compatible EMR, but this implementatino detail is hardly fundamental to the practice of medicine.

Ironically, when I asked an old timer about the IDC field format, I was told they were that way "because that's how they were on the previous paper forms."

Point being, using proprietary data formats works up until you need to share data (e.g. labs, consults). And then the forms are the API. So either you're writting a translator or you aren't communicating with the other system.

But this is prolly a bit of a tangent. Standardized forms and coding are actually a huge benefit to efficiency.

The biggest loss in productivity (I saw) is the back-and-forth nature of the system. Provider submits claim. Insurance rejects it. Phone call is made. Claim is updated. Insurance rejects it for a different reason. Claim is updated. Claim goes through. Note: rejections are usually for technical / procedural reasons, not necessarily not wanting to pay the claim. And that process is different for each insurer.

If you really wanted to eliminate hours spent in billing, enriching the "negotiation" phase somehow would be best. But also difficult because you're essentially coding the legal contract between insurer and provider, then attempting to apply it to an actual situation. And have to play nice with the existing systems on both sides.

> when I asked an old timer about the IDC field format, I was told they were that way "because that's how they were on the previous paper forms."

That's not actually surprising, since the current insurance/billing situation easily predates the prevalence of EMRs (the recency of which those of us in the computer industry may have forgotten).

> But this is prolly a bit of a tangent. Standardized forms and coding are actually a huge benefit to efficiency.

I don't doubt standardization is a boon to efficiency by some measure. However, it doesn't necessarily translate into better medicine (which was my tangent). Less tangentially, it may not translate to cost savings, especially for a cash-only business, where it may be merely a premature optimization.

Least tangentially, there's little reason to believe that continuing with existing standards, skewed toward insurance/billing (which I admit more describes CPT than ICD), is more efficient for a cash-only provider than an alternative.

> Insurance companies generally have atrocious IT (it's not their core competency) and consequently inflexible IT stacks.

I've been working at startups in the healthcare industry for a few years now, and agree. It's not just insurance companies, either - hospitals are just as bad if not worse. It's even worse for hospitals that are affiliated with a University.

> Insurance companies generally have atrocious IT

And mandatory IT standards (e.g., those adopted under HIPAA) in the healthcare field are written almost entirely by insurance industry IT.

Everyone gripes about HIPAA, but from where I sat, it was a pretty sane standard. Admittedly I wasn't in implementation.

But it read a lot like an IETF RFC. "Covered entities shall implement network protection." "Covered entities shall not disclose PHI." Outcome-specified, implementation-agnostic. And then set penalties based on whether the breach was accidental / willful / limited / or ongoing.

> Everyone gripes about HIPAA

I am not griping about HIPAA.

The quality of stone of the specific transaction standards developed by industry groups and adopted as mandatory in regulations implementing HIPAA, OTOH, are another story.

"A more optimistic formulation would be that that represents millions of people who could be doing something a bit more generally useful than mastering the intricacies of the layers and layers of bureaucracy built up around medical billing. And probably wouldn't mind having a slightly less mind-numbing job themselves."

The same could be said of coal miners. And miners probably didn't take on school loans to learn their profession.

It's easy to handwave retraining millions of workers, but it's not that simple, and the jobs have to exist.

The source appears to be this 2006 article in The Nation:

https://www.thenation.com/article/mr-obama-goes-washington/

It's interesting that Obama's argument for protecting health insurance administration jobs precedes both his presidential campaign and the Great Recession. The whole article is a telling foreshadowing that future-President Obama was not going to be as progressive as progressives hoped (or as conservatives feared). It's also a painful reminder that propping up low-value or even negative-value activities to "preserve jobs" is a bipartisan sport.

Obama and Hillary competed on their healthcare plans. Obama's plan was more favorable to existing interests. His argument was that Hillary's plan was too aggressive and would never make it through Congress, whereas a vote for him and his plan ensured successful passage of a reform package. From the article,

  "If I think we can achieve those same goals within the
  existing institutions, then I am going to try to do that,
  because I think it's going to be easier to do and less
  disruptive and less costly and less painful...."

  ...

  Obama is telling the truth--he's not opposed to structural
  changes at all. However, he appears to be interested in
  fighting only for those changes that fit within the existing
  boundaries of what's considered mainstream in Washington....

It was funny because Hillary spent years working behind the scenes with insurers and providers and had their [tepid] buy-in. It's not like her plan was particularly radical, and really Obama just tweaked her framework. But Obama moved right to out-flank Hillary, capturing more centrist votes in both the primary and the general. Despite GOP rants to the contrary, Obama spent most of administration to the right of mainstream Democrats. His policies were typically crafted to at least be tolerable to conservatives, but his sensibilities were wasted in the spiteful partisan political culture. It wasn't until his last 1 or 2 years in office that the Democratic leadership convinced him to start pushing policies demanded by the Democratic base (e.g. Dreamers, etc).

"It's also a painful reminder that propping up low-value or even negative-value activities to "preserve jobs" is a bipartisan sport."

They have positive value to the people in those jobs, and losing those jobs is high negative value to them and their communities.

Propping up useless jobs is only unacceptable to some when it is blue-collar jobs in red states(eg steel and coal).

Isn't Obama just arguing for a version of the broken windows fallacy?

If many people currently rely on breaking and repairing windows for their livelihood, a “stop breaking windows” type law has real negative consequences, unfortunately.

Only in the extremely short term and only for those who are participating in the racket. It would be a great net gain for society.

The US is a democracy. The people in the racket vote. Its why democracies are oil tankers that can only change course slowly.

Obama wasn't arguing for anything, he was just explaining the politics of why single payer would be difficult to get through Congress. (For better or worse, Obama was famously disconnected from writing "Obamacare" and left it to Congress.) As an explanation of the politics, Obama's quote—"That represents one million, two million, three million jobs"—is exactly right. Sen. Lieberman (Ind, Connecticut) killed the public option, allegedly because of the importance of the insurance industry to Connecticut.

I was watching the Expanse tv show and they were talking about how half the population was on Basic Assistance.

I am not sure if it will ever happen, especially not in America were work is sacred. But paying people not to have jobs seems like a good deal. Keeps them from fucking up and maybe they can do something productive for society like growing wine or teaching children in Bangladesh to read.

And think of all the doctors who would be pissed off to become de facto slaves of the state. Of course they could get paid by catering to the rich who would pay them out of pocket...

How do you eliminate wasteful jobs without backlash? Stop hiring and let attrition take care of the problem?

In 2009, they'd have to look to increase employment elsewhere.

That's still painful, because you have an entire pipeline of people feeding those useless jobs. Yes, the ones with the useless jobs get to stay, but the many people who were planning their lives around getting a useless job(with their useless skills) now need to find something to do.

Let me be clear: I don't support keep useless jobs around simply because it would be painful to the employee to lose their job.

Isn't another benefit that this will foster greater entreupenurship and thus create 'job creators'?

Right now, if you are employed and have insurance, you are really just subsidizing these jobs - middle-class welfare.

Based on my experience (working around insurance IT during ACA implementation), the best solution is setting performance goals, then rebating some of the savings to the party for exceeding them. With the rebates tailing off after a number of years.

This allows the party cutting costs the flexibility to reallocate now-redundant people directly to problem areas, without having to procure additional funding. The rebates cover the cost of retraining (maybe mandate this for for-profit parties).

Why wouldn't the party simply fire the "redundancies" and pocket the money?

Not-for-profit insurances entities (e.g. Blue Cross Blue Shield) legally can't pocket (in any beneficial way) the savings.

Aside from that, there's a huge amount of undocumented knowledge in the field. Given its stability, people can still work 20-30 years for the same company.

Given there are always areas who need more people, I can't believe you'd rather have someone who knows nothing than the person with 20-30 years of experience (salary aside, admittedly).

I would dispute that. My experience in the hospital side of same field has been that within the framework of the existing healthcare system it's hard to reduce costs without worsening health outcomes. The costs we can cut most easily are staff, services and supplies. Cutting services reduces revenue, nullifying incentives. Trying to deliver the same services with reduced staff and supplies impacts quality.

The jobs that can be cut without reducing quality are the administrative nonsense like dickering back and forth with the insurance company, but those jobs also can't be cut without reducing revenue. It would take a change to the way we pay for healthcare to significantly reduce costs, and/or getting the cost of pharmaceuticals under control. There's a lot of fat in pharma too but that's another conversation.

I believe you. Providers are ultimately the profit center, and insurance operations the cost center.

I would argue that it simply isn't the responsibility of the state to ensure that there is a continuing market for a given set of skills.

Sure, it's a problem when industries and job classes disappear - but keeping them around doesn't solve the problem, it only defers it. In many (most? all?) cases it even makes it worse.

People about to lose their job and therefore their home, health insurance for their family, children's college fund, etc. need a solution, not a theory of why that solution isn't some particular institution's responsibility. If not government, then who?

> In 2009, they'd have to look to increase employment elsewhere

A goverment-mandated major healthcare streamlining would reduce health administration and support (financing, management, IT, billing, coding, legal support, etc., etc., etc.) in the long term, but in the short term it would create lots of jobs—and mostly in the same general space—in a a surge that (with the most likely kind of implementation timeline) would ramp up over a couple years of implementation planning, stay steady for a few years of main implementation, and then taper off to the new, lower equilibrium as new systems and processes moved from implementation to routine operation.

Probably no better time for that than an economic downturn where employment was soft, if the government is deficit funding to subsidize the implementation costs. It's basically a short-term jobs program with long term dividends for the whole economy.

I really how you've framed this. In a sense, it's much like other investments in infrastructure (except digital, rather than a highway or rail line): lots of jobs during construction, and then once it's done it's a public good. Perfect for during a downturn.

I work in automation, and what's happened when a location introduces our tech is not an immediate loss of jobs, but rather the existing employees move to higher productivity roles. Any job losses eventually come via attrition and non-replacement.

Foster competition?

If a company can capture a greater share of the market by offering the same service with a lower premium, isn't that what they'll do?

I don't know why that effect is not present now, but it could have much to do with the way most people get insurance through a group policy provided by their employer (and therefore get no chance to shop around).

> I don't know why that effect is not present now

Inelastic demand. Whether you have a debilitating/life-threatening illness, or are worried whether the lump in your throat is heartburn or the cancer that'll end your life, your incentive to engage with competing market presences is massively diminished for several reasons (urgency, many people have a desire for their life-or-death decisions not to be commoditized, etc.).

That explains why people don't shop around for health care. But it doesn't explain why they won't shop around for health insurance.

Insurance companies have cleverly handed off administration of their crappy system to the facilities that do the work. Their systems often betray a lack of understanding of what is being done and it’s time consuming to work through. A quick search suggests that 15% of US healthcare costs are due to this - $350 billion. Pretty sure that this isn’t news to anyone.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283267/

I hope this is part of how Amazon / JPM / Berkshire goes after health care, by becoming a TPA and reducing these admin costs through an API layer:

https://blog.jacob.vi/amazon-as-a-tpa-or-how-amazon-solved-i...

Probably won't happen though.

This may be being handled off to us. I just got appts for both a nutritionists and a sleep specialist, and the clinics explicitly asked ME to find out if it is covered, mumbling something about the particular insurer (blue shield of AL) requiring it

This is why I'm really a big fan of HMOs (of which I'm a member). Wasteful spending hurts both the medical provider and the insurer because they're the same entity. I realize an HMO may not be for everyone, but whenever the idea of universal health care comes up Kaiser Permantee is a really good model to look at. I ran the numbers the last time a healthcare reform proposal came up in California, and it would have been cheaper for the state to just give a "Kaiser Permantee for all" scheme than to expand Medicaid/Medical for everyone.

Kaiser Permanente (excluding their Medicare Advantage, Medi-Cal managed care, etc., plans) covers employed or financially independent individuals and their dependents, who have a different health profile than the whole population. They also charge higher it of pocket costs for some services than would be acceptable for coverage that was expected to have utility to the medically indigent. So, yeah, it'd be cheaper to buy everyone a KP individual plan with prices set based on the cost of insuring the people that can afford KP individual plans. But it wouldn't make a whole lot of sense as a universal approach.

Most HMOs are not as good as KP. They aren't run as a profit center like most of US healthcare.

> Most HMOs are not as good as KP.

There are several (but still not most, I would agree) that are if you also have a good medical group. KP is the medical group as well as the insurer, so it (aside from any benefit from synergies and absence of interparty conflict) provides a more consistent experience on that end.

This is seriously obnoxious. The last few times someone in my family has been to see the doctor, something hasn't been covered for some inexplicable reason. It always turns out that according to the insurance company there is some disallowed code and the insurance company won't say what the right one is. The doctors office always acts annoyed that you're bothering them with petty details like a $2000 charge. It's infuriating.

Where I worked, the insurance companies that had payer agreements with the provider (clinic) had a contract that specifically called out which codes they would pay, and how much they would pay for it. Codes submitted to insurance for payment on claims that were NOT in the contract were denied, and then the ball rests in the providers court to deal with it.

> Obamacare was being drafted / the economy was in dire straits in 2009, the Obama administration had to make a choice about whether to radically streamline health care, but at the cost of killing employment in (at the time) the only growing sector of the United States.

The basic outline of healthcare reform that all the leading candidates in the Democratic side had signed on to well before the first of the 2008 privates had gained broad consensus among party elites well before that. It was not a reaction to conditions in 2009, unless there was a whole lot of parallel construction to cover up the Democratic Party’s access to a reliable crystal ball (an idea that the 2016 election would cast serious doubt on even if it was otherwise plausible.)

"the economy was in dire straits in 2009"

I'm a foreigner but to me Obamacare appears to be an effort to ensure that everyone in the US can have reasonably priced access to healthcare. That seems a laudable aim. In the UK we have the National Health Service which has a similar aim.

The NHS was formed in 1948. The UK economy at the time could also be described as being in dire straits but perhaps with a little more emphasis.

Did you know Obamacare fined you $695 or 2.5% of your household's income (whichever is greater) if you went for more than 2 months without health insurance? That doesn't seem very laudable.

You're exempt if the lowest-priced coverage available to you would cost more than 8.13% of your household income.

You're exempt if you were uninsured for no more than two consecutive months during the year.

You're exempt if you're a U.S. citizen living abroad.

You're exempt if you're incarcerated.

You're exempt if you can demonstrate that you experienced a hardship during the year.

Etc

I'm not exempt. What laudable goal could there be for such a fine?

It's dealing with the free-rider problem. The system would work best with as many people participating as possible, and you don't want people waiting until they get sick to get insurance, since under the ACA they would receive coverage for conditions that arose prior to being insured.

If it's been more than 2 months and you get sick you can't just automatically sign up and be covered. You have to wait until January 1rst of the next year for your coverage to start.

I think had they chosen a radical path... it wouldn't have gotten the votes.

At my wife's practice they employ two people full time just to do insurance authorizations.

edit: actually one of those people does verification (checking to see what insurance patients have, what is covered, and estimate what they will owe) and the other person just does authorization (getting the insurance company to approve the procedure)

I use my GP as the example. It's a fun tale.

When he was in a partnership with 4 other doctors, he started with a paper system. They had two receptionists, and three clerk/billers. I used to help him out with some tech stuff.

They implemented an EMR prior to the Medicare mandate, with an ROI driven by dropping 2.5 FTE. They ended up dropping the clerks and hiring IT expertise at a cost 50% higher than the clerks.

Medicare mandate came, and the EMR didn't meet requirements and had to be replaced. They joined a larger physician group, and paid for 0.2 IT FTE. But they had to hire two PAs and a NP to drive revenue and now have 6 clerical people. (+1 from paper)

Now they were acqui-hired by a sprawling medical network. Their cost center became a dumping ground for redundant hospital staff and they have 10 non-medical people (+5 from paper-based, independent practice). Now they run two EMRs and are transitioning to a third. They lost the ability to collect money at the counter, and now bill for every co-pay and lab. (My wife received a paper bill for $0.78 for a pregnancy test via postal mail)

In short, between bad policy, government encouragement of cartel behavior, and general stupid big company bullshit my doctor went from a progressive medical practice with talented doctors and medical staff to a bloated sales funnel for unnecessary specialist care over the course of about 15 years.

Granted America’s love for ACA is sound. Poor people shouldn’t have to forgo medical procedures because they are poor and die.

But the execution is a giant shit show. Trump abandoned it but I highly doubt anything will replace it.

If Trump doesn’t cause another financial disaster, there are chances the next President can make some headway to get US a sane healthcare system.

It’s so ripe for disruption. Amazon’s insane valuation I bet is also based on the fact that they are going after Healthcare. If they can bring Amazon level service and convinience we may turn the tables.

Personal preference but even though I don’t support making Bezos accumulate so much wealth, Amazon prime service is unbeatable. It’s just so darn convenient. I don’t see any close alternative.

What's interesting is I heard that if you pay cash, up front the doctor's office will charge you less. So I had this appointment (forgot for what) and they gave an estimate with my insurance. I asked...if I wanted to pay for all of it right now, how much would it cost...and she said it would be the same.

Of course I said ok, fine...run it through insurance. That year I wasn't going to meet deductible so I had no incentive to go through insurance.

My wife needed an MRI last year. The hospital quoted us $4000 as self-pay, but would knock it down to $2000 if we paid cash up front. This was late December, so we picked up insurance through the marketplace and she had the MRI done in January, billed to insurance at $250.

This still boggles my mind... I understand the insurance provider negotiates bulk rates, but we were paying up front, in cash, and were still quoted 8x the insurance price.

I've had a doctors office tell me that it was literally impossible for them to estimate, let alone quote me, a price for how much my visit would cost.

(My finger was infected. I needed a week of antibiotics. That was it.)

Yup. Same experience here... had to have an emergency appendectomy and my biggest worry wasn't the operation itself but its cost. I persisted in asking the doctors for an estimate, but they wouldn't budge. Neither would the clerical staff... which made 0 sense to me. Its not the first operation they have done, I just wanted rough figures (i.e. 5k? 50k? 500k?) but they wouldn't give me that either.

Final billing: 55k in total, but because of insurance I paid about 5k. Which still left me wondering... what did people without insurance do? How could they possibly pay that much money, if they couldn't even get insurance?

They go broke. The exact number is disputed [0], but health costs are a major cause of bankruptcy in the USA (as opposed to most other developed countries where this uncertainty about costs doesn't exist).

I discovered an interesting fact the other day about the US's massive % of GDP spent on health; they spend about the same % of public monies on health that other developed countries do, the extra % is private spending! [1]

Anecdata: I am in Australia and have private health insurance (notably: otherwise I'd be paying an extra tax levy and be worse of in $ terms), but all that has meant is that I can go to a private hospital instead of a public one for elective surgery. For ~$2k a year. A few years back I broke both my collarbone and my ankle on separate occasions. The ankle repair was entirely free. The collarbone was setting too slowly (opportunity cost: I needed to get back to work ASAP... normally they just put your arm in a sling and let it stitch naturally), so I opted to have a surgical repair, which was about $2k all up for the out-of-pockets.

[0]: https://www.thebalance.com/medical-bankruptcy-statistics-415... [1]: https://www.healthsystemtracker.org/chart-collection/health-...

go broke as you mention, and often go without care.

Sometimes being dumped from a hospital in the middle of the night drugged at some random location.

Often times a small problem gets put off and becomes a much larger problem.

It becomes a burden on family and friends, sometimes leads to amputations and other surgeries such that otherwise could of been avoided with better care.

This a huge problem for a lot of people, especially if you add in the dental care that is needed and not obtained around the country.

ymmv

My mum was on holiday in the US and had to go to hospital in NYC. For 2 days in hospital - no operations and only a few xrays - the bill was around $30,000. I had a look at the bill and over $10,000 of this was for drugs. If she had been given what they said she would have been dead. Basically the hospital just made up a number and fudged expenses. We asked friends about it and they said the way the system works is that they give you a bill then you negotiate - usually you pay around 30% of the first amount - pretty similar to the way bazaars work around the world. Luckily she had travel insurance so just gave it all to them to sort out.

You can also get out on a payment plan that lasts for like 20 years. Then after a few years the hospital writes off the debt and says you don't have to pay - assuming you haven't declared bankruptcy yet.

We had a baby. Bill is north of 25k. We paid about 3k out of pocket, rest was covered by insurance.

Even then it’s a pretty crazy amount for what is supposed to be a routine delivery. No epidural was administered.

I can see why young people aren’t having babies. You work like a dog to pay rent and barely make it. Having a kid puts those finances in jeopardy.

I'm just glad no other industry operates this way.

"oh need new tires? We can't tell you how much it costs till we actually install your tires"

Last time I visited a doctor without insurance I had the same experience. I visited a PA for half an hour and had a vial of blood drawn and apparently the mathematics required to determine the cost of that was so complicated it required several days of calculation.

> What's interesting is I heard that if you pay cash, up front the doctor's office will charge you less.

I was a member of a "health cost sharing ministry" for about a year, while working for a startup that didn't offer insurance.

The idea was that I paid a monthly membership fee to the ministry, and in exchange they would cover my healthcare costs - minus a set amount, for which I was responsible directly. If I made the effort to negotiate a discount with the provider, that discount counted toward the part I was responsible for.

By inquiring about a cash discount and being able to provide a reasonable assurance that the bill would actually get paid in a timely manner, I never once paid out of pocket for a doctor's visit during that time.

I’m not following.

If the doctor appointment costs $100, the ministry pays $90. If OP negotiates the price to $90,OP pays nothing. Ministry still pays $90.

In Oregon it’s illegal to bill different amounts to different payers. So you have to be billed what they would be bill insurance for.

They can give you a processing discount but it is negligible and only applies to services rendered at that time.

Also they have to pay the insurance handling clerk whether you pay cash or not. The marginal savings are small.

For how many doctors?

Ideally we'd be in a situation where your wife had time to do much of that stuff herself, so that she was cutting prices to attract patient load instead of paying 2 people to help increase the time available to serve patient load.

I usually link to this chart whenever this topic comes up.

Growth of Physicians & Administrators 1970-2009 http://gomerblog.com/2015/12/healthcare-costs/

TL;DR: Our overhead is ridiculous.

Any one who has worked inside the beast knows single payer is the correct next step, followed by replacing fee-for-service (treating disease) with capitation (incentivizing wellness).

Not a big mystery. Just look around at what other jurisdictions are doing, copy what works.

Single payer will never be implemented in the US without massive political and social change. It is ideologically opposed here in at least three ways:

1. Healthcare is a luxury that must be earned. Giving it away to people who don’t deserve it is categorically bad.

2. Jobs are important. Universal healthcare would mean fewer people working in the various health industry bureaucracies, which is categorically bad.

3. Business is important. Universal healthcare would kill or cripple health insurance business which is categorically bad.

If I believed that, I wouldn't get out of bed every day. A large part of choosing action (activism, startups, remodeling, etc) is suspending disbelief.

I have friends working on single payer. I just attended a policy planning event last night. To your point, the outlook is pretty bleak.

I give money. I've also decided to also give time and labor.

Meanwhile, I've come up with a Plan B, a way to hack the current system to expand affordable coverage. Early feedback from my policy and industry friends has been very positive (which is a novel experience for me).

That entire site seems clearly satire.. not sure if you were being serious or what?

Ugh. Content farm. I just grabbed the first hit. My bad.

https://duckduckgo.com/?q=growth+of+physicians+and+administr...

Maybe this instance is more reputable?

https://fee.org/articles/the-chart-that-could-undo-the-us-he...

For future, I'll try to find the original cite.

I'm gonna be super chagrinned, embarrassed if I've been forwarding "fake news".

Good eye. Thank you.

As worded, it sounds like emulating the Switzerland or Germany model is the best solution. They offer decent patient choice but don't pay significantly higher for that choice than single-system countries. USA citizens on average prefer choice, and would probably agree to pay a little more to get choice.

I think the biggest driver of healthcare costs is the middle-men. All of the people who pad the bill, add fees, etc. The doctors who step into the O.R. for a minute and charge a fee[0]. They all add to feeding at the trough, so to speak..

[0]. https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-sur...

I wonder with more frequency every day if there will ever truly be a solution to the problem of rising health care costs in the US. I see a lot of posts here suggesting that privatization should be removed, and any jobs lost that are related to the current industry will be unfortunate byproducts of getting rid of a broken system; a necessary evil that will ultimately make way for a health care system that is both cheaper and available to all.

It's tempting and easy to adopt that line of thinking given where, I would suspect most of us here, are at in our lives from a career and financial perspective. As a software developer, it's easy for me to switch jobs and make a good wage. I can weather most unforeseen costs. In the decade plus that I spent working blue collar jobs for a very low wage, I would've been screwed if I'd lost my job.

This speaks to a much larger problem that is consuming the US every day. I don't have any answers, but I can empathize with those who fear their livelihoods being taken away, even if saving those jobs has a net negative effect on the economy and job market. There isn't a day that goes by, especially in today's political climate, where I'm not thankful for having the opportunity to put myself in a better position. I'm the outlier, though. Most people can never bring themselves up out of poverty.

...any jobs lost that are related to the current industry will be unfortunate byproducts of getting rid of a broken system

I'm tempted to argue that an equal number of jobs are lost every day to the opportunity cost of people not taking business risks due to the added risk of losing their healthcare, myself included. My optimistic vision is that the economic growth resulting from removing this burden will absorb the displaced workers, plus create even more jobs on top of that.

We forget. This isn’t going to happen overnight. Sure people will lose jobs, but not millions overnight.

Imagine how many humans are spending their lives doing busy work. We can free them up to do better things.

Imagine how many good doctors have to join a medical factory where they churn out patients and slap big bills. Going solo doesn’t make sense.

Just the way cloud made it so Indie hackers can build great products with a small team, Healthcare needs this “cloud” like system which takes care of all the unnecessary bullshit related to insurance and payments so they can focus on the core of providing great service and making people healthier.

Going one step further, just eliminate insurance, and the entire billing system becomes unnecessary.

My mom had an experience in a country with national health care. She got injured while hiking, and got treated at the clinic in the first town she reached. Whey they were done, she asked how to pay. They said: "You don't pay for health care." Well, what about foreigners? It turned out they simply didn't have any way of figuring out a price or taking her money. Those mechanisms didn't exist. It was probably cheaper for them to dish out free care to a few foreigners, than to manage a complete billing and collection infrastructure.

The problem with this logic is that things like insurance companies are making decisions that bankrupt and even kill people every day, for their own profit. That’s the reality of privatized healthcare.

I empathize with the people who would lose their livehoods as well, but not above people who are broke or dying, right now, because of how terrible the American healthcare system is.

> That’s the reality of privatized healthcare.

What makes you say this a problem with "privatized healthcare" rather than a systemic problem with how it works in the U.S.?

If we had a similarly broken system for say, acquiring groceries, no one would even question firing everyone involved to replace it with something different for the greater good.

Trust me, if somebody was getting rich off of selling groceries and they had managed to convince the people who hadn't starved yet that things were fine and anybody who couldn't afford groceries was a freeloader, nothing would change.

Administrative = bureaucratic.

Government-run healthcare has the same problems associated with heavily regulated sectors like our current healthcare system, but to a much larger degree because of lack of incentives to improve performance.

The way to decrease cost is decrease regulation and get rid of all the unnecessary paper pushers we have right now.

Back in Health Care Policy class I dug through these numbers and the opposite was true: bureaucratic overhead was much larger in the US system. The US system also wound up being twice as expensive overall.

Has that changed or are you just repeating a talking point you heard somewhere?

Markets serve the person with bargaining power. If doctors and drug companies have all the bargaining power -- and in the most important health care situations, they do -- why do you think a free-er market will give you a better deal?

The US system is a combination of heavily regulated private industry and government-run healthcare.

The US is ridiculously more expensive than other countries precisely because of regulations and government-run bureaucracy (and defensive medicine, and poorly run bidding for drugs and equipment, and fraud).

Government-run healthcare actually puts all the bargaining power in themselves, but they don't try to cut costs because that's not an incentive in government. Actually with government, the more you spend in one year, the more you get budgeted the next year. The worst way to run a government agency, in the eyes of bureaucrats is to run leaner than budget because your budget will be cut the next year.

Doctors have very close to no bargaining power.

The US healthcare industry is more expensive simply because it is run for profit.

There are plenty of other developed nations with regulation that manage to grant healthcare to all their citizens without the cluster-fuck the US makes out of the situation.

Do these other countries ration their healthcare in any fashion?

In other words, do they deny services in the name of cost savings? The United States rations health care, albeit covertly, but other countries ostensibly do it.

Will Americans be ok with being denied services just to save money?

> Markets serve the person with bargaining power. If doctors and drug companies have all the bargaining power -- and in the most important health care situations, they do -- why do you think a free-er market will give you a better deal?

Contrary to popular opinion, doctors have close to zero bargaining power in the US. That's why private practices have been rapidly shutting their doors over the last 10-15 years - they've been losing money, so they've had to sell their practices to large provider networks. But even those hospital networks don't have much bargaining power, which is why many of those have been going out of business and either shutting their doors or consolidating in the last 5-10 years.

Anecdotal, but I worked for a specialty EMR and consolidation was the big trend at the time (~2010). Lots of one-offs and small chains getting acquired and folded into larger networks. Many of these smaller providers were either not or barely profitable and we saw plenty of others go under.

Long term strategy for the EMR was focusing on the hospital networks because the trend seemed clear at the time.

My point: the consumers are powerless. Whether doctors are individually powerful or only powerful as a member of an organization is entirely tangential, except in that the consumer is even less powerful in the second case.

EDIT: I now have two people providing evidence that actually reinforces my core point in order to argue with me about a synechdoche. I don't know whether to laugh or cry.

> My point: the consumers are powerless.

Yes, but that's a far cry from saying the doctors are powerful. They're not. They're powerless too.

> Whether doctors are individually powerful or only powerful as a member of an organization is entirely tangential.

Doctors are neither powerful as individuals nor as members of any organization. Despite common misconception, they have almost as little power as patients do.

s/Doctors/Health Care Providers then. The more you insist on precision, the less accessible this debate becomes. I hope you have a good reason.

The salaries say that doctors are more powerful than patients -- but we both agree that they are powerless compared to the organizations that employ them. What of it?

> s/Doctors/Health Care Providers then. The more you insist on precision, the less accessible this debate becomes. I hope you have a good reason.

Yes, because there's a big difference between doctors and provider networks, and as I've already explained above, neither has the level of power that people generally believe they do.

> The salaries say that doctors are more powerful than patients

I have no idea what this is even supposed to mean. You're not comparing like quantities.

> we both agree that they are powerless compared to the organizations that employ them.

No, we don't, because I've already said that the hospital networks (which employ the majority of doctors these days) don't really have much power either.

”If doctors and drug companies have all the bargaining power -- and in the most important health care situations, they do”

Not everywhere. It’s miles away from what people in the USA think they want, but governments can intervene on behalf of patients. https://www.government.nl/topics/medicines/keeping-medicines...:

”The Ministry of Health, Welfare and Sport and the Healthcare Institute of the Netherlands decide what drugs fall under the standard health insurance package […] The Netherlands and Belgium are going to jointly negotiate lower drug prices with pharmaceutical companies. Together, the two countries represent a larger group of patients. This will make it easier for them to negotiate lower prices with drug companies. They will especially try to negotiate lower prices for expensive medicines, including orphan drugs which are used to treat rare diseases.“

>If doctors and drug companies have all the bargaining power -- and in the most important health care situations, they do -- why do you think a free-er market will give you a better deal?

Much of that bargaining power has been given to them by the government which denies your human right to medicine without their blessing.

Patent laws, forcing you to go to a doctor to get medicine, and the arbitrary prohibition of unprofitable/unpatentable medicines like cannabis all contribute to their bargaining power.

Ideally you would be able to get a cash based health insurance policy where they would have a doctor diagnose you quickly/cheaply and then give you the cash to pay the doctor yourself. This way you could fly to different countries for cheaper care. That's what I would do anyways.

Healthcare tends towards natural monopolies. Without competitive pressures, what incentives are there for them to slim?

The health care and pharma industry is in serious need of some whistle-blowers.

"Your desire to live is my opportunity" - some health care administrator.

Never ascribe to malice, what can be explained by apathy.

If you're so apathetic as to be actively harmful that's still malicious.

Also, as they are actively looking to increase profits, I can't possibly see how this is "apathetic".

Quit making excuses for garbage people.

You know what's easy? Blaming people.

"How could they be so evil / greedy / stupid / mean / etc? Don't worry. We'll fire them and bring in new people. Everything fixed."

You know what's harder but more productive? Admitting there are systemic, structural issues. And having enough compassion for people trying to do their jobs.

Because suddenly there's no easy scapegoat. And the only response is to actually change the system.

The issue with the US health system isn't some malevolent Oz pulling strings behind the scenes, but that none of the legally defined and empowered players have their interests fully aligned with the patient.

Worse: Some of the players have their interests exactly the opposite of other players. In particular, the doctors want to get paid, and the insurance company makes money partly by finding ways to not pay doctors. So the insurance companies pay people to find ways to not pay doctors, and the doctors pay people to find ways to get the insurance companies to pay. (Almost?) all of those people, on both sides, are a net lost to society as a whole.

And that's partly my point.

Does the doctor want to kill you? No, he or she wants to heal you and be paid well.

Does the claims analyst at the insurance company want customers to die? No, he or she wants to pay as little as possible while keeping you healthy.

And yet when both of these players are placed in the system we've constructed, the strictly dominating, logical strategies for both are sociopathic. And so they adjust their behavior in that direction.

I'm hopeful that pushing outcome-driven analytics onto the medical field will drive a lot of productive change. The whole reason we abstracted care choices from payment is that we couldn't answer the question, "How much is this procedure / test / consult worth to you?"

And without that, we're waving our hands in the air as to whether or not it makes sense to skip an MRI scan.

Bad assumption:

"Indiana cardiologists sued for alleged unnecessary surgeries" (October 28, 2014)

MUNSTER, Ind. (WLS) -- Dozens of people are joining a lawsuit filed against three Northwest Indiana cardiologists as well as Munster Community Hospital for allegedly performing unnecessary procedures.

After two patients announced legal action six months ago, dozens more have come forward accusing three Indiana doctors of medical malpractice and, in some cases, wrongful death. Lawyers say their investigation has revealed that 75 percent of heart procedures were performed unnecessarily....

http://abc7chicago.com/health/indiana-cardiologists-sued-for...

https://scholar.google.com/scholar?q=unnecessary%20surgery&b...

(550,000 results)

https://duckduckgo.com/?q="unnecessary+surgery"+fraud

The example does not disprove the point. Somewhere around 50M surgeries / year. Some of those are going to be bad.

If you want to talk about defensive medicine and financial and legal malincentives that pressure doctors into anti-patient choices, I'm all ears. Freakonomics had a great mini-series on that.

But pointing to horrific botched or fraudulent surgeries and acting outraged? Meh. I accepted some humans were immoral a long time ago. If it's most surgeons or many surgeons, or they aren't getting sued and/or charged with malpractice, then it's an issue. Otherwise, I leave it to the local nightly news.

The extreme cases both refute your blanket allegations of fundamental goodwill and strongly suggest there might be a substantially larger set of less-nefarrious and malevolent, but still corrupt practices: Insurance and workers comp fraud, overprescriptions, unnecessary labs and imaging, pharma kickbacks, the opioids crisis and Perdue pharma specifically, device and equipment practices, and far, farr, far more.

The fundamental problem is that in the US, most providers are paid to render services, drugs, and equipment, but not for making or keeping patients and populations healthy.

Payors (insurance companies and administrators) are similaly incentivised on profits, not outcomes.

There are three possibilities.

1) Extreme cases are pervasive

2) Extreme cases occur but are rare

3) Extreme cases never happen

Aside from the absurdity of abusing statistically-defined adjectives, I'll assume you know what I mean.

The health care industry is BIG. Things happen a lot, even if they're only 0.01% of the time.

I haven't seen any proof that indicate (1) is true, previous shock post included. And if it's not, it's not the most important problem to focus on. In contrast to, say, the incentives you note.

The perverse incentives are what create the extreme cases. It's plainly obvious that the US healthcare system as a whole is an extreme case when compared to the rest of the world.

> No, he or she wants to heal you and be paid well.

That first part isn't guaranteed in a for-profit system.

Suggesting there aren't malicious forces actively pushing for their bottom line over say, structural changes that would improve healthcare for everyone is really really dumb.

Sometimes there really are just evil greedy people being bad.

Are there greedy people out there? Of course. Do I spend time focusing on them? Not a minute. That's what the justice system is for, and it's not terrible at punishing people who break the law.

Th difference is in outcome.

If you focus on people, you get to feel righteous, targeted anger, and nothing ever changes.

If you focus on the system, you're left viscerally unsatisfied ("The US healthcare system is dysfunctional? I can't yell at that..."), but might effect real change.

often, the malicious force actively pushing for increasing profits is systemic itself - the responsibility of public company executives to maximise shareholder value.

also, most of the time I think "evil greedy people" is just people who are far enough abstracted away from the impact of their deeds that they have no connection to the impact. If you're looking at departmental budgets all day, you probably don't see the patient who gets refused treatment.

Arendt's book introduced the expression and concept "the banality of evil".[6] Her thesis is that Eichmann was not a fanatic or sociopath, but an extremely average person who relied on cliché defenses rather than thinking for himself and was motivated by professional promotion rather than ideology. Banality, in this sense, is not that Eichmann's actions were ordinary, or that there is a potential Eichmann in all of us, but that his actions were motivated by a sort of stupidity which was wholly unexceptional.

https://en.wikipedia.org/wiki/Eichmann_in_Jerusalem#The_bana...

http://i.imgur.com/ddU50.jpg

"We prefer your extinction to the loss of our job!"

"Too far-fetched?" "Not enough, really."

That is an awesome comic.

If you ever want to know why something sucks, just look at who is bribing politicians:

https://www.opensecrets.org/lobby/top.php?indexType=s

So here is the process it takes to get medicine that is legal in china.

>Schedule appointment, talk to 1 person

>Wait in the lobby, talk to 1 person and fill out government HIPPA + clinic paperwork

>Go to back room, talk to nurse. Fill out paperwork

>Wait

>Talk to Physicians Assistant or Physician, get perscription

>Pay office 120 dollars

>forward perscription to pharmacy 1-2 people involved

>Go to pharmacy

>Talk to person at register

>Pay

Remember that in China, you just go to the store to buy 4$ amoxicillin. And despite the Physicians in the United States screaming about superbugs, China and Mexico both havent made superbugs despite not having massive regulations.

This is a self made problem from corruption. The Medical profession milks the consumer because the consumer has no other option.

Antibiotic resistant e.coli with mcr1 found in China.

https://www.scientificamerican.com/article/superbug-resistan...

You're being downvoted probably because of the superbug statement...but my wife had surgery to remove a breast lump. It cost $3k and with all these appointments it happened over the course of 2 months. The cost does not include all these other scans and crap before.

My cousin went to China (family visit). Lump was discovered here...surgery in China. Got seen in one day, surgery the next. $800.

When my wife discovered a new lump...just doing follow up scans was $900. $500 for imaging center, $200 for the doctor at the imaging center...and $200 for her annual physical (they billed it as a problem visit and not an annual because she brought up the fact she has a lump, rather than the doctor finding it, even though breast cancer detection is part of annual!...still fighting, but I'll probably drop it because it's so stressful and time consuming)

So that’s why I can’t be seen for a physical and problem at the same time. What a load of shit.

Yeah...its all about the money. I have mild allergies in the spring that don't really bother me... Last year I did my appointment for my annual in the spring. Doctor goes, you have allergies. If I write you a prescription I gotta charge you as a problem visit. I recommend you try over the counter Claritan and if it doesn't help, come back.

Now this doctor didn't own the practice, it's a decent size local franchise. Maybe that's their policy. But atleast the doctor told me up front. For my wife...we didn't know till we got the bill. Funny thing is the doctor signed paperwork that my wife did an annual (i get $$ from work if we do annuals)

Of all the healthcare systems to negatively compare the US system to, I don't really think China is a good pick. Comparing the times that I've had to use medical care in China to my general experience in the US, I would opt for the latter every time. For a simple outpatient visit, I showed up to a well-regarded hospital, where I was greeted with a 2-hour wait, an overwhelmed front desk staff, and a session with a doctor that felt too rushed.

For recurring mild headaches, the doctor prescribed medicine that a doctor in the US would have recommended only for migraines. I tossed that RX script in the trash as soon as I left the office. This was my first personal brush with the flip side of the easy access to drugs in China: the phenomenon of overprescription (https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.... & https://blogs.wsj.com/chinarealtime/2015/04/02/chinas-health...).

If you've spent time in China (and it sounds like you may have), you've probably been exposed to the level of health supplement and "pharmaceutical" product marketing in China. It's prevalent on TV, on WeChat, and in newspapers. Supplements like "Nao Bai Jin", which is effectively just melatonin, get pushed on the public without government intervention. "Doctors" regularly appear on elaborate infomercials to promote supplements that claim to do everything from removing heavy metals from you blood to improving kidney function. All of these are available without a prescription.

---

This is not to mention that if you're too poor to afford private health insurance in China (i.e. the vast majority of the population), you're stuck with the bare bones basic health insurance the government provides.

For all the hysteria around Obamacare "death panels", it is actually the case in China that patients with terminal conditions are routinely sent home, since hospitals are so overcrowded (particularly in larger cities) and bed spaces are so limited. If the cost of drugs for a treatable disease or condition is too high, public insurance can refuse to pay for it outright.

If it's political corruption you're worried about, keep in mind that the Chinese FDA is only getting a much-needed reorganization as an independent agency this year, and has seen scandals like this: https://foreignpolicy.com/2014/08/13/a-whistleblower-goes-pu.... This is not to mention that still fresh in many people's memories are the massive coverup of SARS in 2003, and a coverup of avian flu in 2013 (https://www.theguardian.com/world/2013/apr/03/china-reports-...).

I'm no fan of administrative bloat, and it's somewhat ironic that access to drugs in China is in many ways more "free market" than in the US, but I don't think medical/pharma "corruption" is any less prevalent in China.

Your choice of amoxicilin is a very bad example.

Antibiotics aren't tightly controlled enough. We need international treaties that prevent this kind of over the counter sale and countries required to track statistics of the prescription of antibiotics. The utter disregard of the commons that is the effectiveness of antibiotics makes me despair.

The reason that health care costs rise in almost all countries is that we are doing something wrong. The question is what? Can it be that doctors who do not try to find the root causes of diseases have no solutions ? Can it be that doctors who prescribe drugs to suppress symtoms cause problems in the long run ?

Cancer is a disease with high costs where a lot can be gained. Watch a documentary about Dr Burzynski who has a cure for various types of cancer: https://www.youtube.com/watch?v=rBUGVkmmwbk The documentary shows how officials and the National Cancer Institute work against him and hence continue the high cost.

On websites like https://drhyman.com and https://www.chriskresser.com you can find doctors who explain a lot about root causes of diseases and how to cure oneself. If all would read these sites the costs for health would drop more than 50%.

Chris Kresser -- despite his many virtues -- is not a doctor. Moreover, he has never published any research indicating his findings or results are statistically significant. While his advice is often good, there is no reason to believe that it offers 'cures' to diseases hitherto considered uncurable. If anything, the fact that you think he's a doctor with magic cures suggests the need for ever more regulation, and thus bureaucracy.

> If anything, the fact that you think he's a doctor with magic cures suggests the need for ever more regulation, and thus bureaucracy.

Why? Why should the state assume the burden of protecting someone from themselves?

I might see it differently if knowledgeable, well-researched care were difficult to find... but it's not. If someone decides they want to go to a homeopath to treat their terminal illness, why should we stop them?

The government shouldn't protect people from themselves. It should however prevent people who are not doctors from falsely advertising they are.

Because working out if someone is a competent doctor is hard and expecting every single person in society to work it out for themselves, regardless of their level of free time, education, or access to information, is a massive burden.

To rephrase this. As wasteful as it may seem to "protect people from themselves" there is a good reason to believe not having some of those protections is actually more expensive.

Consider the costs of seatbelt enforcement. They are real and exist. More, for most people and most rides, the seatbelt truly did nothing for you. To the point that if you got a ticket, it almost certainly cost you more than you are projected to save from having a seatbelt in the short term.

However, for society at large, we tremendously benefit by having everyone use seatbelts. From less time lost on the job, to fewer ER trips from lower collision wrecks.

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