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Comment by jarym | Hacker News Reader

I live in Europe and I never understood the in-network and out-of-network concept (I know what it is, I just see it is ripe for abuse).

So I wonder, why hasn't Congress enacted legislation to put a ceiling on out-of-network charges to (say) 2x the median in-network charge?

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Copying another comment that was downvoted out, because it is 100% accurate:

> why hasn't Congress enacted legislation to put a ceiling on out-of-network charges

Because they are bought and paid by the same people profiting off the system.

>Because they are bought and paid by the same people profiting off the system.

I know broad sweeping characterizations feel good and are easy, but I can't help but feel they help those taking the most money from lobbyists hide from view. And I can't help but feel they encourage giving up entirely on government and voting in outsiders regardless of their actual qualifications, who double down on the problems instead of fixing them.

It takes a lot more effort to name some specifics either rules or people, but broad sweeping statements don't usually help.

Sometimes broad problems demand broad statements. We could get into the specifics of the two-party duopoly and the legacy of kowtowing to healthcare and health insurance industries, but the examples are far too numerous and stretch back far too long.

I will provide two examples, one from each party, so as to be less divisive:

Affordable Care Act: Democrats controlled the house, senate, and presidency. They could've passed any bill they wanted. Instead of medicare for all or similar, they passed a bill that required everyone to purchase a 3rd party product called insurance. The overhead and profits of the insurance industry add to the cost of actual healthcare.

National Health Planning and Resources Development Act: Nixon signed this in 1974. It mandates that anyone trying to build a healthcare facility apply for and receive a Certificate of Need. This creates local monopolies for existing healthcare facilities by eliminating new competition. It's a blatant form of protectionism.

To pass ACA the Democrats needed 60 out of 100 seats in the Senate and they had 58. To pass it they caucused with two independents, and one of them, Joe Lieberman, specifically would not vote for it if it had a public option.

They needed 60 to avoid a filibuster. A filibuster would've required Republicans to obstruct the vote by speaking continuously on why Americans don't deserve healthcare. Democrats had them backed in a corner. All they had to do was propose a bill that benefited everyday Americans instead of corporate backers and they would've made the Republicans look like absolute fools for speaking endlessly against it. A filibuster only lasts as long as the opposition keeps debate open.

The Overton window wasn't that far left in 2009. A good deal of the Obamacare messaging was focused around telling middle class Americans that no, they would not lose their existing employer-provided coverage. And even if you could pull out all the data that would show that Medicare for All benefited people more than existing coverage no one would've believed it.

> I can't help but feel they help those taking the most money from lobbyists hide from view.

If everybody takes money from an industry, no one has to hide because it will never be pointed out. The only way you can look bad is in comparison to outsiders, and many voters automatically disqualify outsiders as not being good enough to be insiders. We filter for bad apples, then call people who point out that we get exactly the results we would expect cynics and nihilists.

> It takes a lot more effort to name some specifics either rules or people

You can literally google who takes the most money from the industry. It's not a secret, and sunlight doesn't kill it.

> voting in outsiders regardless of their actual qualifications, who double down on the problems instead of fixing them

While the spirit of what you’re saying is right, the media and the Democratic National Committee portray Bernie Sanders as an outsider, even though he’s been in politics for decades. The difficulty for lobbyists to influence him is well publicized and considered mostly true. His proposal to fix this specific problem - Medicare for all as opposed to free market healthcare pricing - is certainly consistent, cogent, and likely to work, even if you disagree it is the best one.

It goes to show that the original comment you are reacting to many not be as partisan as it appears. It may simply be reactionary.

I have friends in Netherlands, where "medicare for all" is reality.

What you get for it is doctors prescribing you paracetamol for most ailments, after you waited for a week or two for your turn to visit the doctor. Or with doctors not treating your chronic and deteriorating condition for months and years, because they only have the resources to treat such a condition in those who already have it much worse. I'm talking about real cases my friends faced.

Despite that, Netherlands' health care is considered the best in Europe [1].

Maybe in your book it's strictly better than the current US system, but I suspect there's still room for improvement.

[1]: https://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands#...

Sounds a lot like the UK. Healthcare here seems to be very optimised for the most common ailments, and you're basically screwed for anything else unless you strike it lucky with a good doctor.

For example, here your typical endocrinologist will easily be able to treat diabetes and hypothyroidism - but will tell you you're a crackpot if it's anything else. Similarly neurologists will only easily treat brain tumours, etc.

Also, doctors and "specialists" are extremely conservative. Many seem to have had zero training since they left medical school 30 year ago, and never so much as glanced at research since then. Many won't prescribe treatments they haven't prescribed before (what the hell kind of logic is that?!). Almost all will prescribe based on cost before anything else - let's say there are 4 treatment options, A, B, C and D. D is most likely to work, and least likely to have negative side effects, but costs £1k/year; A costs £5, is not particularly likely to work, and has a small chance of destroying your life through negative side effects - yep, let's go with option A first!

Oh, and unless it's cancer, you'll have to wait for treatment. A long time - you'll often wait several months after a referral from your GP, and then 6 months between each appointment after that. There are supposed to be maximum waiting list times mandated by law, but they game the system - "yes, I realise you've been waiting more than 3 months, but that was just for our pre-waiting list!"

It's a good enough system for a lot of people, but also badly fails a lot of people too.

Source: I'm a Brit with rare and chronic medical conditions, and had the misfortune to suffer badly at the hands of several arms of the NHS. It took 20 years to get a diagnosis for one of my conditions.

You've just made a bunch of broad sweeping statements, and they are based on feelings not evidence.

Any Dutchie correct me if I'm wrong, but some degree of this concept has already arrived here as well. We have two types of health insurance, and the cheaper kind gives you less freedom to choose your care unless you're willing to pay extra.

I have no idea how much extra that is, or how particular the insurance companies are about where you go, though. Last time I looked into my health insurance the slightly lower cost didn't really seem worth the hassle.

Even better would be to limit what providers can charge to 105% of what they charge Medicare and Medicaid. You can put it in the Medicare contract with the provider that if you want to get paid by Medicare, you can't charge anyone more than Medicare. With about 50% of hospital and doctor spending coming from Medicare and Medicaid, they already have monopsony pricing power.

What happens to an effective treatment Medicare pays under cost? Those exist and right now are subsidized by the higher paying private policies. Do these treatments just go away?

The rates get renegotiated so they aren't being subsidized by the uninsured and those with poorly negotiated prices.

As much as I hate the in-network vs. out-of-network concept because of the risk to the patient, this story is a good example of why some providers are in-network. The in-network providers are (or should be) less likely to overbill because they have negotiated contracts with the insurance companies. Providers that don't have a contractual agreement with insurers are therefore out-of-network.

The best part is when you go to an in network hospital, and one random doctor that worked on you is out of network. Oops 10k surprise bill

Observations about US policy and behavior is fundamentally a stencil of the balance of power. It's a democracy after all, balancing all those powerful interests and alliances is guaranteed to result in a mess known as “politics”. That's the tradeoff.

Congress is the political wing of American capitalism. The #1 way they get there is by appeasing moneyed interests. Only by pissing off just enough voters, do they lose elections in favor of some other person who has already appeased enough moneyed interest. Appeasement is necessary because elections are expensive and aren't publicly funded.

Because "muh free market".

Even in 2020, both conservatives and liberals (the non-radicals on both sides) still cling to the idea of lack of regulation being a good thing, despite decades of evidence to the contrary.

The liberals are softening on this because they don't counter-signal the radicals on their side, while the conservatives actively demonize the radicals on theirs.

As a result, only one radical fraction of one half of the political duopoly actually has both the desire and energy to enact this kind of legislation, and that isn't enough.

Healthcare in the US is incredibly regulated already. And one reason for the wacky pricing is bad regulation. Well, regulation with good intentions and bad outcomes.

For example, there is a law that all hospitals need to maintain a chargemaster list and that no customer can be charged more than the price listed. Sounds great!

Well, because hospitals are allowed to negotiate discounts, the most rationale thing to do is make your chargemaster price so high that it will never impact your business.

Have a procedure you charge $1,000 for typically? Make the chargemaster price $10,000. That way it will give you some room to up your price to customers (say double it to $2,000). Problem solved for the hospital!

So the regulation solved nothing and actually incentivized negative behavior.

Couldn't you argue that's not over, but under-regulation? The problem is, as you said, "make your chargemaster price so high." Such things are not allowed in many countries with national insurance options. Why not? Simple: because governments are paying, and governments can negotiate the prices or simply enact laws or regulatory bodies that determine the fair price of procedures, and especially, drugs.

You could argue it's the wrong kind of regulation, but at least in terms of level of regulation, I'm not sure I'll describe it as less.

> I just see it is ripe for abuse

Insurers not having control of which hospitals they associate with is ripe for even more abuse.

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