U.S. Hospitals Are Asking Their Own Patients to Donate Money | Hacker News Reader

U.S. Hospitals Are Asking Their Own Patients to Donate Money

nytimes.com

97 pointspetethomas112 comments

Coming from, and only ever having lived in countries that have socialized medical care, I will never understand the general lack of goodwill towards one's fellow countrymen that your country continually rails against it. All to live with a medical industry that is, for all intents and purposes, run by corrupt insurance companies who will bleed you dry sooner than they would cover your bankruptcy inducing medical bills.

I just don't get it.

And now on top of this, having paid an arm and a leg to an insurance company that would just as soon stab me in the back as pay the medical bill my premium is supposed to cover, hospitals want donations? What the fuck is going on?

Sure the medical systems I've lived with aren't perfect, and sure they could be improved. But by and large, knowing that I can go into any medical care facility in the country and walk out fixed, without having to fight for medical care, fight for my right to be treated, fight for my right to have my medical costs taken care of. I would rather have that every day of the week, even knowing that there are others abusing this, than the alternative.

> Coming from, and only ever having lived in countries that have socialized medical care, I will never understand the general lack of goodwill towards one's fellow countrymen that your country continually rails against it.

You can probably understand in the UK how certain groups are systematically trying to gut their NHS. That seems to be the same mentality that is going in the US. Make medical care all about maximizing profit.

I can understand why those who put money and greed above people who are systematically trying to gut the NHS. I understand because to many, their God is money. Their be all and end all of life. Their alpha and their omega.

Don't confuse that with me understanding them. I am a people before everything kind of guy. In the immortal words of Princess Leia - "If money is all you love, then that's what you'll receive."

I'm vehemently opposed to the NHS being privatized. It's an institution and the crown jewel that sets Britain aside from the rest of the world. To see people supporting their attempts to privatize it and send Britain down the same path as the U.S. in my mind is the ultimate failure of the British people and it infuriates me - worse even than Brexit.

When did we become a people who believed the lies and rhetoric spewed by those on TV over our own education? When did we become a people who just blindly followed what we were told like lambs to the slaughter?

I thought we were better than that, honestly. It makes me sick.

If you could run an insurance that doesnt do any of all of this, or a hospital that didnt engage in all of this, it would exist.

Wanna guess why you cant?

Because enough people are making a lot of money from the status quo

Competition can destroy any position with oversized profits. Try again!

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

>I will never understand the general lack of goodwill towards one's fellow countrymen

Homogeneous populations are required for this. When the US was least diverse, during the 1930s-60s, the public was largely supportive of public social welfare. Despite right-wingers guffawing over European nations importing more "diversity" of late, the US is way ahead in diversifying the nation into islands of "diversity" with a rump "historic" American nation in the outlying surrounding areas. The "diverse" populations (and their "historic" allies) are inculcated with neo-Marxist propaganda that frames the people whose nation they are invading and whose largesse they are seeking to exploit as class enemies. The "historic" population has long sensed this animosity but cannot articulate it publicly and oppose it in a straightforward manner without their opponents, including the vast majority of major media, ostracizing them as dangerous lunatics. The "diverse" are deemed inherently virtuous while the "historic" inherently evil -- blood libel updated for the 21st century. What sane person who is a part of the "historic" American population would support having most of his money taken in tax to support a growing population of people who do not share his ancestry, culture, or values and who view him as inherently evil? Thus we see opposition to social welfare programs that disparately impact/benefit the "diverse" populations.

TL;DR: Most "Americans" are not "fellow countrymen" at all but distinct factions engaged in a simmering war with each other.

I fear for this happening to Europe. Immigrants put an excessive strain on the NHS, for example. One of the talking points of the Leave campaign.

Um... have you not noticed that a large portion of those providing medical care in the NHS are those same immigrants? Immigrants by and large are equal parts of the solution to problems. If you remove them all, you will quickly realise that most of the problems still remain caused by those who will continue to be ungrateful and just blame something and someone else for their problems.

Alright, I'm the creator of this user account and the one that made it public, and I'm going to claim it back now. Maybe I'm a dumb kid, but I think if any country can maintain a highly diverse population without internal "simmering war", it's the US. The greed of hospitals is not somehow explained by xenophobia. Generations of people born in perverse power structures, doing their best to strengthen and reinforce them, seems much more suitable of an explanation. Genetics will mix and people will evolve. Deal with it.

Yeah, a whole lot of us do not get it either.

I am committed to change. This system has gutted me twice now. I didn't even get sick, though at one point I basically traded a house for someone I loved.

We are long past need for reform.

Hold up. We already have to pay through the nose for medical care, so where is all this money going that these hospitals need to ask for more? Is non-profit a different class that is somehow left out of the con that is the US healthcare system?

Administration bloat. I really wish costs were more transparent so we could reason about what drives cost. Doesn't seem sustainable that Hospitals are businesses, but that's the capitalistic way of solving things.

>Administration bloat. I really wish costs were more transparent so we could reason about what drives cost.

The second sentence seems to contradict the first. What about the insurance providers?

That's what is typically said about hospitals and other institutions (like universities). But I don't really know, because the cost of medical care in this country is obscured beyond belief. Check out the horror multitude of horror stories people have in figuring out the costs they incurred at hospitals.

It's both administration bloat, and doctor salaries.

Doctors in the US get saddled with mountains of student debt, and then make mountains of money, once they pay it off.

Don't forget they also have to pay malpractice insurance and, you know, have a highly specialized job which requires a whole lot of training.

Specialized training, the supply of which is artificially constrained by the AMA/RUC.

Is it? Genuine question, I don't know anything about that.

https://thescotandscotland.wordpress.com/2015/08/19/american...

Yes, similar regulatory capture happens in most accredited professions, like lawyers (bar exam), accountants (CPA) and finance professionals (CFA). It benefits the people who have already achieved the certification to make it harder for others to achieve (limit supply to increase their pricing power).

The AMA also actively lobbies against proposals to give nurse practitioners more patient access. [1]

[1] https://www.ama-assn.org/press-center/ama-statements/ama-sta...

Are the CPA or CFA harder to achieve than in the past?

Very hard to quantify this. CFA pass rates have trended down since the 60s, for all three tests [1]. However, it could just be that more people are taking it or less-prepared people are taking it. Also worth noting that things like derivatives, alternatives, and international standards (GIPS, FRA) weren't on the exam in the 60s.

I'm having a harder time finding pass rates for the CPA before 2006. They seem to have gone up a little in that 12 year window 2006-2017 [2]. The tax code has also gotten larger and more complex over the past 50 years, so that is worth noting.

[1] https://analystprep.com/blog/cfa-historical-pass-rates/

[2] https://en.wikipedia.org/wiki/Uniform_Certified_Public_Accou...

The supply of doctors is not constrained by the AMA. The actual constraint is funding for residency slots at teaching hospitals. Every year there are students who graduate from medical school with an MD but fail to get matched to a residency and thus can't practice medicine.

Most residency funding comes from the federal government. Complain to your Congresspeople, not the AMA.

As if hospital systems with millions of dollars of net income couldn't fund a few slots.

Complain to everybody.

Just look at their cars in the parking lot. Doctors are doing very well.

Or look at the suicide rates, and reconsider.

I don't think the suicide rate would change if their salary was lower. It probably has more todo with stress often caused by profit-maximizing.

Maybe not, but you sure as hell would get fewer doctors.

Aren't a lot of these hospitals where "admin bloat" is an issue, actually non-profit? That doesn't strike me as very capitalistic. Capitalistic enterprises have residual claimants, who hold formal equity in the business and thus face a crystal-clear incentive to minimize costs and maximize perceived quality-of-service. Non-profits don't.

You expect megacorporations to not be bloated?

non profit does not mean low salaries. They pay themselves enough to just run a little red ink so they can cry to the state.

Define "capitalism" [0]: an economic system characterized by private or corporate ownership of capital goods, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market.

Define "free market" [1]: an economic market or system in which prices are based on competition among private businesses and not controlled by a government. (Note: the first definition is a bit vague, so I used the second entry.)

Hospitals aren't competing in a free market. They don't suck because of capitalism, they suck because of government intervention. Right now our medical system is basically the worst of both worlds--it's not affordable nor universal.

If hospitals and doctors were operating in a free market then it would lead to lower prices and an increase in quality. You can see some evidence of this in medical areas which aren't typically covered by insurance and are less heavily regulated, with laser eye surgery probably being one of the best examples.

You've managed to identify that the problem is government intervention, yet you appear to hint at trying to solve the problem with even more government intervention? Historically that hasn't gone over very well. Have you seriously considered alternatives? I believe a medical system cannot provide more than two of the following three guarantees: affordability, quality, and universality. This will probably be an unpopular opinion, but I think dropping universality is the best choice. You can still maintain a social safety net to catch people that fall through the cracks, and I posit that it would be cheaper and superior to our current system.

[0] https://www.merriam-webster.com/dictionary/capitalism

[1] https://www.merriam-webster.com/dictionary/free%20market

I honestly believe that the ongoing battle between hospitals and insurance companies are a big contributor to the problem. After that, I think short-sited management is a big issue as well as the ever increasing executive compensation.

> We already have to pay through the nose for medical care, so where is all this money going that these hospitals need to ask for more?

Private insurance companies. EDIT: Out of network specialists. Pharmaceutical companies.

Wouldn't paying for insurance be separate from a bill from the hospital? If I'm paying for medical care then that money isn't going to the insurance company.

You require care. Insurance company agrees to pay X. They pay X to hospital. This has no relation to the actual cost of the care you received. Hospital, you, and the uninsured split what health insurance doesn't pay for. That remainder has to come from somewhere.

Sorry are you saying the rates that are negotiated by insurance companies are too low to cover the actual costs of the hospital? That still doesn't explain where the money is going and why healthcare is so expensive. Why would the hospitals' costs be so high?

Please don't be sorry! I have done a lot of research into this, as I've been overly exposed to exorbitant healthcare costs, insurance appeals processes, and medical debt negotiation and settlement. This caused me to dig deep to find out why. My email is in my profile, I am happy to discuss at length and even hop on a phone call.

https://www.forbes.com/sites/robertpearl/2017/11/07/hospital...

> Three factors contributed to the need for layoffs: (1) reduced reimbursements from payers, including the Massachusetts government, which limits annual growth in healthcare spending to 3.6%, a number that will drop to 3.1% next year, (2) high capital costs, both for new buildings and for the hospital’s electronic health record (EHR) system, and (3) high labor expenses among its largely unionized workforce.

> That, along with higher labor and drug costs, explained the Cleveland Clinic’s economic headwinds, according to outgoing CEO Dr. Toby Cosgrove. And though he did not specifically reference Medicare, years of flat reimbursement levels have resulted in the program paying only 90% of hospital costs for the “older,” “sicker” and “more expensive” patients.

> The challenges confronting these hospital giants mirror the difficulties nearly all community hospitals face. Relatively flat Medicare payments are constraining revenues. The payer mix is shifting to lower-priced patients, including those on Medicaid. Many once-profitable services are moving to outpatient venues, including physician-owned “surgicenters” and diagnostic facilities. And as one of the most unionized industries, hospitals continue to increase wages while drug companies continue raising prices – at three times the rate of healthcare inflation.

> With pressure mounting, hospital administrators find themselves wedged deeper between a rock and a hard place. They know doctors, nurses, and staff will fight the changes required to boost efficiency, especially those that involve increasing productivity or lowering headcount. But at the same time, their bargaining power is diminishing as health-plan consolidation continues. The four largest insurance companies now own 83% of the national market.

Possible solutions:

* Government sponsorship through HHS of electronic medical records management. Have USDS and 18F to spearhead the project (cc matt_cutts), leveraging their experience revamping technology service delivery within the VA. This removes Epic's profit out of the equation.

* Government management of insurance. Medicare participants are fairly satisfied with it, and it can be just as efficient as Social Security. Cover everyone with Medicare, increase Medicare payroll deductions accordingly, and leave private insurance for additional fanciness some may desire (private rooms instead of shared rooms in hospitals, for example). This removes most of the profit from private medical insurance.

* Make it illegal to advertise drugs to consumers (this is only legal in the US and New Zealand). You immediately eliminate billions (estimates are ~$20 billion/annually) of marketing spend by pharma, and therefore costs they will desire to recoup.

* Let Medicare negotiate drug prices. This reduces profit realized from pharma concerns.

* Remove limits on medical students and residencies to increase GP and specialist supply. Streamline the process of nurses leveling up to nurse practitioners. This reduces the profit motive for practitioners; you'll make a decent wage, but not Lambo money.

* Subsidize medical school to prevent the need to go hundreds of thousands of dollars into debt to become an MD.

The flow of funds is something like "obviously" in the direction of the uninsured, not from them.

Uninsured people with means will pay high prices, it's just that they aren't the big percentage of uninsured people...

I'd argue that care is directed in the direction of the uninsured, of course, but depending on your state's creditor laws, they are still the rock squeezed for blood as the last resort. The cost is minimal for the hospital to shovel their stale patient receivables off to a collections company on a schedule.

Ha, most of the nonprofits in health care are actually extremely profitable.

Like most non profits in tech (Mozilla, Wikipedia, EFF, ...)

Being a non-profit exec is often extremely well-paid.

Nonprofit means there aren't investors being paid a dividend, you can still have a cluster of management parasites getting paid $1M/yr.

The same thing applies even to Mozilla https://news.ycombinator.com/item?id=10101637. Wikipedia is significantly better but still not perfect https://foundation.wikimedia.org/w/index.php?page=49&title=F....

I honestly believe any company as well as everyone responsible for abusing the term "non-profit" in order to make money for their personal gain should be punished accordingly and be treated as scammers.

Most egregious might be the National Football League.

Oh, and (mega)churches.

The NFL is no longer incorporated as a non-profit.

Thank god. Now we just need to not exempt the megachurches.

From the article:

> Ms. Grupp, 66, said she wasn’t rich, and was disturbed by the letter. “I kind of resent it,” she said. “I don’t think they need the money.” The hospital last year reported nearly $48 million in net income and paid its chief executive officer $1 million.

This is where it goes. That said, if I could spare $200k, I would if I had the information about which % of that money went to actual equipment and patient services. I think that information is available for non-profits, but I am not sure about hospitals. There will always be admin waste, but the best way to decrease it is to reward more efficient hospitals.

> I would if I had the information about which % of that money went to actual equipment and patient services

Money is fungible.

I still wouldn't even if I had the money because if you get 500k in donations for equipment and staff salary thats 500k you can take out of your revenue to line the pockets of executives.

You can get these ratios for many charities and nonprofits from the combined federal campaign: https://cfcgiving.opm.gov/offerings

Some really popular charities go well above 25% towards non-cause expenses like administration/advertising.

Advertising for charity has some funny game theory implications. A given charity often observes that every dollar of advertising increases contributions by 2 dollars. They the justifyably continue increasing their advertising budget until it reaches saturation, and every dollar of advertising only brings in $1.01 (more or less).

If you assume that this advertising in net increases the size of the pie of charitable giving, it can be considered an overall good thing. If you assume that this advertising in net just redistributes the contributions that would go to one slice of the pie to another, it is wasteful. Data on which side is true is hard to come by.

> ... if I had the information about which % of that money went to actual equipment and patient services

That wouldn't give you the whole picture on waste. A big chunk of high health care costs is hidden inside the equipment and patient services. American hospitals have a habit of doing things in much more expensive ways than is strictly necessary.

A 1 million salary for a CEO of a hospital is nothing thogh. Any specialist doctor makes that much.

Hospitals are pretty expensive and probably super inefficient: they are 30% of NHE spending.

Specialist doctors do not make 1 million dollars (exceptions are generally those who run/manage their own business, or run a hospital - basically it's their business role that puts them at that salary range). You can easily look at job ads and see common salaries for different specialties, they very dependent on specialty but they do not even approach 1 million.

You can also look at public incomes of physicians in for example, transparent california. Single phsyician practices with over 1mil in income is pretty common.

Is that gross or net revenue or income?

the only way a specialist makes more than 200k is: 1)owns a significant interest in a surgicenter 2)is a dermatologist 3)is an administrator 4)works to death (>100 hrs a week and dont forget the on call)

Reimbursement is set by the fed (medicare rates) and ins cos base their rates off of that.

Mean pay for GPs in the US is over 200k...

https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...

It would of course take a hell of a lot of variance for a significant percentage of doctors to be pulling in a million plus. With 713,000 working doctors, there will be a fair number pulling in lots more than average.

GPs are the lowest paid doctor by a factor of 3 to 5.

Feel free to look at the BLS mean pay above there. They do surveys to determine those numbers.

Take a look at what University of california pays the medical faculty through ucsf!

https://transparentcalifornia.com/salaries/search/?q=PROF-HC...

You've linked the highest paid individuals at a research university in a high cost of living part of a high cost of living state.

I've linked the mean salaries for the US as a whole.

https://transparentcalifornia.com/salaries/2017/university-o...

Plenty of specialists make > 1m without running a hospital.

Twice this claim is made with no reference. If there are plenty, it would not hurt to cite a source, rather than make a seemingly baseless claim to the contrary.

Depends on if a hospital takes medicare/low income people (and if they do what % of them make up their patient population). They do not make profits off them and instead rely on wage earning people with insurance to cover the loss.

government rules and regulations have so distorted the health care system that the system is breaking. it isn't that health care is expensive, its the hoops and restrictions placed on it that make health care expensive.

recent new hospital in my area of the country was only allowed to open provided they did not take away business from other hospitals. This includes opening a second outpatient surgery room in an existing hospital to offering advanced cancer treatment. This is very common in the US. It usually goes under the name "Certificate of Need".

The reasoning is that health care is improved if health providers do not duplicate expensive services. this has grossly driven up costs in many areas. then throw in rules which can force Emergency Centers out of network for ALL insurers. See a recent example in San Francisco with a PUBLIC hospital [1]

TL;DR Health care is only this overly expensive because politician meddling. From preventing competition among hospitals to preventing competition among insurers, unless of course you donate properly.

[1] https://www.beckershospitalreview.com/finance/zuckerberg-hos...

> recent new hospital in my area of the country was only allowed to open provided they did not take away business from other hospitals. This includes opening a second outpatient surgery room in an existing hospital to offering advanced cancer treatment. This is very common in the US. It usually goes under the name "Certificate of Need".

> TL;DR Health care is only this overly expensive because politician meddling.

Certificated of Need were something _hospitals_ themselves lobbied for. It's a case of "this is awesome when it protects me, and an aberration when I'm on the losing end".

Certainly politicians enacted such things, but I'm not losing sleep over the hospitals. Only us mortals, stuck with the cost of the system.

Nonprofit hospitals soliciting donations from former patients is the least controversial thing possible. The part where they screen patients and give them preferential treatment is worrisome. I think the cited bioethicist had it pegged with the "not illegal but unseemly" (paraphrased).

If hospitals are going to treat indigent populations, absent universal healthcare, they are going to operate at losses and require grants and donations to operate.

Non-profit is just a tax structure. They make plenty of money and reward themselves handsomely.

A quick first point: you're making a blanket statement against a heterogeneous population. Some non-profits are definitely not efficient, and some are very efficient.

The big difference, and there is one, is related to ownership and operations. There are no distributable earnings, and they cannot be sold/acquired. This definitely factors into decisions balancing profitablity and ethics. There are laws about nonprofit compensation, too: https://www.guidestar.org/ViewCmsFile.aspx?ContentID=3890

I'm a physician for a non-profit and I'm going to continue making my blanket statement. But thanks for the link.

I am not a physician at a non-profit! But I had read a few years of Tenet and HCA annual reports a while back, and have a few other points of exposure to non-profit vs teaching vs private systems. Perhaps we can agree that there are many opportunities to improve the system in many ways.

> Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.

> Those who seem promising targets for fund-raising may receive a visit from a hospital executive in their rooms, as well as extra amenities like a bathrobe or a nicer waiting area for their families.

Fabulous.

So when my parents are in their 80s and out of it on painkillers after a surgery, they'll be preyed upon for donations by some fast talking executive who has trolled through their public records to see how much their home is worth.

Are your bedsheets uncomfortable? (guess what - everything is uncomfortable after major surgery) Just donate and we'll fix that for you.

Sleazy to the max.

I wonder what their approach is to 'ungrateful' patients – the ones who get billed every little things, or are otherwise unsatisfied with the service?

It is after all a service in the US. It's transactional. I'm happy medical science solves my complaints, but the way it's set up I'm not often left with an overwhelming sense of gratitude to the hospital.

When my Dad told me he was going to donate his house to the local hospital I told him “I’ll support whatever you decide.”

I pointed out that they weren’t a charity and that the CEO of the hospital was paid $1.8 million year. [1]

He changed his mind.

[1] http://www.mainebiz.biz/article/20150924/DATAJOE/150929969/m...

I am so thankful for the NHS when I see things like this.

I like a lot of things about the U.S. over the U.K. but our healthcare system is definitely not one of them.

This happens in canada too, so im not sure its uniquely a problem of private vs socialized healthcare.

Yeah but U.S. and Canadian corporate culture is pretty intertwined.

We already donate a shit ton, like $5000 for a 8 minute ambulance ride or $1300 for an 5 minute assessment in an ER

I’d like to throw something out here as maybe a starting point for a discussion: we should immediately make it illegal to have medical insurance in the US. Everything should be out of pocket. Period.

After initial chaos, misery and death, we would have no choice but to restructure healthcare system in a manner that its costs are in line with what people can afford to pay with their salaries.

Ok, that was pretty radical. :)

I wouldn’t make insurance illegal, but as a thought experiment I think if you banned employers from providing health benefits then you’d find a sudden huge pressure for change. If the wealthy class in the US had to deal with what the self-pay / self-insured deal with, there’d be hell to pay.

I'm completely on boar with preventing employers from providing it as a benefit, but I think you may be overestimated how much the wealthy class will give a shit. They can foot the bill for their care.

You propose that sick people just die?

No. I’m suggesting we fix our healthcare system so that fewer people die, and no one is driven into financial ruin because they need to see a doctor, and that it’s available to every citizen of these United States regardless of their financial status.

And worry not - those with deep pockets can always pay extra for premium treatments, but some baseline should exist.

>Ok, that was pretty radical. :)

It's not radical, it's an old enough form of cruel indifference that it was mocked by Dickens and Swift.

It makes sense to insure against events that can wipe you out financially. Don't insure your car against theft, if you can easily afford to replace it. But unless you have north of about $5,000,000 that you don't really need, and you live in the US, you need health insurance. I've had a single operation for which the "chargemaster" cost was over $800,000 .

Next thing you know they will have a patreon.

I'm sure they'd be very happy to set up a recurring donation.

If they can get more in donations than the cost of procuring them, why not ask?

Universities ask alumni to give all the time even though they have already paid. Why not hospitals (many already attached to universities).

To be clear, I think it is a terrible practice but if your hospital sees that it works for the university it is attached to, why not explore the opportunity?

I can also walk up to anyone in the street and ask for a hand job. Why not ask?

While I tried to make it clear that I found their behavior inappropriate my direct answer in the context of universities and alumni and hospitals and patients is:

If your dad was walking around asking for and getting hand jobs left and right so brazenly that the givers wanted to name your father's dick after then, then you would probably be foolish not to at least try to ask for one yourself and see what happens.

Sure, I'll donate $15 but ask them to consider it a $1000 donation

What, this doesn't make sense? So, about that...

Tip for good service? 20%, 25%, Other:

This isn't new. There was an episode of Scrubs that brought up patient donations.

there are a few hospitals i'd say that's okay for.

https://www.deborahfoundation.org/pages/about-us

Doesn't seem so radical compared to other systems. I have heard in China doctors will give preferential treatment to patients who give sufficient 'hongbao' (red envelope = money). I imagine (with no evidence) this might be common in many developing world/traditional societies.

So we are just evolving toward that kind of system.

If anything this provides another lever for free market principles to decide who survives based on willingness to pay (WTP - likely familiar to those who went to business school).

> I have heard in China doctors will give preferential treatment to patients who give sufficient 'hongbao' (red envelope = money).

Yes, this is true. Hospital admissions requires approval of a doctor, and you essentially have to out-bribe other patients to get a bed, or even convince doctors to pay attention to you. [Personal experience.]

Are hospitals actually struggling?

If you read the article you'll see that the reasons they're asking is for improved "amenities". But its a bit misleading since they also charge through the roof for said "amenities".

Depends on the hospital, but very possible. It's also very complex.

Sometimes it is just a matter of what you offer as a hospital, the volume of people you bring in, and what you do.

Example:

Obstetrics is becoming a major money looser due to changes in the insurance market. So insurance companies how require a hospital who handle's births to also have a surgery center and be able to handle c-sections in order to insure any birthing. The thing is that requires an on call surge and staff and things that previously a lot of hospitals didn't have.

So in order provide that service the overhead just skyrocketed. Many rural hospitals just don't offer it anymore or if they are / are taking big losses to provide the service.

That's just one area.

Thank you for the insight! Can you reveal where you learned this? I would love to get a better understanding of the financials of the healthcare industry.

Sadly it's not from an site that covers it all. I too am interested in the topic.

This was just a local news story, they tend to do a good job:

https://www.mprnews.org/story/2019/01/22/rural-clinics-end-b...

waste of money.

Now, funding a free clinic in a poor area for 50 years is a great idea.

Good move. The closer we move our healthcare system towards "pay what you want" and get rid of all middleman positions (both private and government-based), the better.

> "pay what you want" In this case what determines what you get?

How do you envision "pay what you want" healthcare working?

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