Comment by Amezarak | Hacker News Reader

Comment by Amezarak | Hacker News Reader

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HDHPs are rampant now. I have a $6500 deductible. It's absolutely miserable. I dump all the money I can into my HSA every year and inevitably I spend it all. The magic benefits of HSA as an investment vehicle for retirement or college are vastly overstated. Yes, if you basically never go to the doctor, it might work. Go to the ER or urgent care once a year and you're done. (Further, your investment options and the fees thereof are controlled by your employer's HSA servicer, and tend to suck.) Whenever I have a medical issue, I personally try to just suck it up and wait it out, because just to see a nurse practitioner to see is $150, let alone if they have to do anything. Every time my kids get sick I also have to make the same type of decision: is it worth it? This is an absolutely miserable place to be in, but this is exactly what HDHP proponents think is a great idea.

Meanwhile, my total annual premium cost is still > 20k.

I absolutely do care about prices (which doesn't matter right now, nobody will tell you what they are), and so does everyone I know, most of whom are on these same plans. The only people I know who aren't are unionized. But I have no way of finding out what they are beforehand. I don't even think this mandate will help. Yeah, sure, now the hospital posts the price - but what about the other dozen providers that involve themselves in a single procedure?

For example, my wife underwent a routine procedure a few months ago. I am still receiving bills from different providers. So far I'm at 7. Never mind trying to even audit them to see if they really did anything!

At the same time, do we really want health care to be under intense price pressures? I'm not so sure. I imagine the medical bureaucracy will continue to expand unimpeded while actual quality of care will go down. That's what I already see happening as a result of cost-cutting.

Some cruel reality: you need to ration healthcare to reduce spending significantly. The iron triangle of healthcare: Quality, Access, Cost.

That said, there are definite things that increase the cost disproportionately, and the way the government subsidizes insurance through an employer makes a major disconnect between patients and providers. If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.

The cruel reality appears to be that you ration health care without reducing spending, because medical administration and bureaucratic costs eat the savings and more.

Untying insurance from employment is a great idea, but it won't solve this. With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing. Neither will single payer fix the underlying problem, although at least individuals will be better off.

At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.

There are no effective market forces you can 'unleash' in the case of health care. It wouldn't matter if you removed all government regulation and subsidies tomorrow. Even in a world where it all somehow works out, do you want medical providers in a race to the bottom? In the absence of meaningful quality of care information (impossible), consumers are incredibly sensitive to one thing: price. What you will end up with is cheap(ish) providers providing incredibly substandard care by cutting corners and killing people.

I seem to remember a comment on here complaining about $30 pacifiers. Why do pacifiers cost $30 when they’re post paid from a hospital and not when they’re bought literally anywhere else if not for the presence of market forces? I can assure you this effect is not just limited to pacifiers.

> In the absence of meaningful quality of care information

Except that quality information gets provided quite satisfactorily in plenty of industries, even ones that might appear otherwise quite opaque. Sure, sometimes it is done in distorted and counterintuitive ways (many marketing practices, including many kinds of advertising, are ultimately reputational games that are designed to signal quality), but meaningful info is far from "absent"!

> With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing.

Long way to go for HDHP to take over the market. But its definitely the way to go. It will however attack mostly the primary care market, not the hospitals which are 40% of the national health spending.

> At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.

Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off. I do think that cost is the single most important thing to attack, and the policies to do so are very easy to enact. They are just very unpopular, because the democratic party wants to increase the state, not make healthcare cheaper, and because republicas have their head up their ass on this topic for reasons I dont understand.

According to Kaiser, HDHPs are the second most common health insurance plan and account for 28% of all insurance plans.

> Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off.

Yes, if the problem is skyrocketing demand. But it isn't. Yes, if we waved a magic wand and provided unlimited free access to medical care, demand would rise somewhat. But demand is not the reason for the current high prices, and it's not the reason costs are outpacing inflation. Medical care in the US is much more expensive than in comparable countries, but demand is not appreciably different.

As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved. The fundamental problem isn't that demand is too high. The problem is cost disease, the root of which consists of dozens of different factors. This is a decent article, albeit one that barely scratches the surface.

https://slatestarcodex.com/2017/02/09/considerations-on-cost...

Look at those graphs! It's mindblowing! Medical costs have increased ten times more than inflation, while doctor and nurse salaries were flat (actually worse, since now their salary goes to paying off educational debt) over the same time period. If there's a demand problem, why aren't salaries of medical professionals rising faster than inflation?

Lastly, I think most people would disagree that cutting costs is the most important thing. Going bankrupt is better than dying of pneumonia because you were worried about wasting money on a doctor visit.

> As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved

There is definitely a sort of impasse on both ideological positions. The forces that be for some reason have not agreed to test out their ideas: a public option and deregulation simultaneously. But neither policy is popular in neither party.

I disagree with your diagnosis, but I'm willing to do a policy that satisfies both your ideas and mine. Support a public option that will not have the issues you mention, and let me have my unlicensed, foreign, cash-pay, non-subsidized doctors, non-FDA meds and malpractice waivers.

Medicare for All will solve a lot of these issues. Look at the healthcare prices in Japan, which has a single payer system. Insanely cheap, high quality, and more doctors per capita than the USA.

The other part that someone like Sanders is pushing is tuition-free colleges. If doctors aren't burdened with half a million in student debt, maybe we can get cheaper care.

You combine both programs and you get a real win.

Medicare for All would help individuals, but does too little to stop rising costs - you get the benefit of government negotiation and annihilate insurance overhead, but it’s not enough. You help people in the short term, but ultimately you only delay the day of reckoning.

I already posted a link showing doctor and nurse compensation have been flat in the same time period that medical costs increased 10x faster than inflation. While free university might be a good idea for other reasons, this isn’t it.

> you get the benefit of government negotiation and annihilate insurance overhead

You don't have the benefit of government negotiation today and you cant seriously say that the government runs without overhead.

I'd be all in favor of that, but it's not quite as easy as it sounds. A lot of labor relations has resulted in health care being used as part of the total compensation package, a carefully negotiated, hard-fought conclusion. To wipe that benefit away would be a step backwards for a lot of people.

It should be possible to reopen those negotiations and reach a fair conclusion, but there's going to be a lot of fighting on a case-by-case basis (with a lot of cases). I believe it would ultimately work out better for everybody, but the "ultimate" would be years -- if not decades -- away.

> To wipe that benefit away would be a step backwards for a lot of people.

Welcome to vested interests.

> It should be possible to reopen those negotiations and reach a fair conclusion

As much as Uber can negotiate with taxis. The solution here is to cut all the bs out and dereg. Import free doctors from all the world for cheap, by allowing them to practice medicine and to apply to a Doctor visa. US can triple its doctoral staff in 5 years with no educational cost by simply doing less things.

> If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.

That's exactly how things were in the 1930s. Healthcare was unaffordable to the degree of public outcry, which is why universal healthcare legislation was introduced repeatedly and stifled by the AMA every time. In fact, early health insurance programs were designed to bypass pay-as-you-go medical fees because they weren't meeting the needs of the hospital or patients. It wasn't a tenable system.

It seems we're regressing.

In 1930's the national spending of healthcare was like 4% of GDP, while now it is like 17%. If we could go back to the 1930's on that I'd take it.

The problem is not that the AMA was able to attack socialized healthcare, but that the AMA was able to dictate who would be able to practice medicine, what their education should be, how much they should charge and how they would organize.

Any american could go abroad to a country like say, Argentina, get free medical education and come back and treat patients without half a million dollars debt. But its illegal.

Are you sure it's illegal? Like 80+ percent of the doctors in my metro area got their degrees in India (where they immigrated from). There is some form of reciprocity going on.

I don't know what india has, but i can assure you that India's doctors would all emigrate to the US if they could work as a doctor there.

Foreign doctors still need a US residency. The number of slots for residencies is capped. I could imagine a world where the US signs reciprocal agreements with EU countries to honor their medical professional training without a residency. I cannot imagine the same for India or Argentina.

We live in an aging society, so the GDP metric is misleading.

Although, we certainly do spend irrational amounts on healthcare, partly because consumers don't bear consequences for going with the pricey procedures.

There's also numerous layers of regulatory capture, artificial scarcity, and rent-seeking in order to protect various industry-wide or regional cartels. The combination of that with consumers who have no reason to care about price is a potent recipe for price gouging.

The AMA is one of those. Hospital associations, medical device associations, phamaceutical associations, electronic medical record companies, and so on all take their cut.

The idea that debt is limiting the number of doctors is laughable.

I think public investment in educating medical providers is too small (it shouldn't be profitable to wrap a provider in like 5 people...), but doctors that aren't total fuck-ups are doing great by the time they are 45. We are likely in a supply constrained situation right now, prices would be nicer if there was excess supply.

It isn't just unionized people that don't care about prices. Most people on Medicare or Medicaid do not care... that's like 1/3rd of the country right there. And among the highest per-capita consumers of healthcare.

There's plenty of people on Obamacare who are getting heavily subsidized low deductible policies, and paying very little.

The government is the largest employer, and most government employees do not care about prices.

Throw in those who are unionized or at cushy stable jobs with low deductible plans, which is innumerable millions more.

I'm thinking at least 75% of the country has little reason to care about prices, and even if they did the system is so byzantine that there isn't much they could do if they did. This is all an interlocking and self-reinforcing problem, which rewards the various layers of the healthcare industry with windfall gains irrespective of their own quality.

And all the staff at every specialist’s office dedicated to navigating the insurance & provider bureaucracy. Or every party having their own crappy payment & client portal - often created from scratch!

I think everyone here recognizes the insane inefficiencies of US healthcare. Maybe single payer could help streamline things. Or what if this price disclosure requirement could be wrapped into a more comprehensive system that allows all parties choice and visibility and interoperability?

FWIW, HDHP+HSA has worked great for me. Low premiums and I’ve built up a significant nest egg in the HSA over the 8 or so years I’ve had plans that used them.

I know it doesn’t work great for everyone though and I’ve seen some discussion that it doesn’t bring down costs because of the lack of transparency in pricing preventing comparison shopping (which is also my experience).

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