Congress is set to ban most surprise medical bills | Hacker News Reader

Congress is set to ban most surprise medical bills

nytimes.com

463 pointsjseliger419 comments

That it takes such effort to pass a bill like this - 80% public approval, banning a clearly predatory practice, has turned me from a pure free market thinking into a believer in single payer healthcare. The free market just doesn't work when there is very little elasticity in consumption. I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room?

> What are you supposed to do, interrogate every person that comes in the room?

I'm curious too. Some people must have tried filing a lawsuit... what do judges think people should be doing?

In my case it was the anesthesiologist who was out of network. Looking at the bill, they looked like just another practice. When I found their phone number and address, however, it turned out that their practice was part of the hospital.

I called their number and ended up talking to someone in their office and they agreed to waive the fee. I wonder if this is part of their process: if there's pushback, waive the fee.

> I wonder if this is part of their process: if there's pushback, waive the fee.

This is 100% how a lot of medical offices and/or insurance operates. For some practices that perform complicated procedures bills will get sent with a "catch-all" sort of approach of all possible scenarios that could have happened and you have to go back and tell them what treatment you actually got.

Insurance companies will also just initially deny claims in the hopes that people won't spend the time to debate it. My wife had to get back injections for a bulged disk and insurance initially denied the claim on the basis that "it was not inhibiting her daily function". The original request from the doctor included the wording of "this is medically necessary because the pain is inhibiting her daily function" because he knew that was their criteria. Insurance still just rejected it because it is easier for them to do that and only accept the claims people fight for. Luckily in this case the doctors office was on our side and called the insurance company to get it approved. The doctor said that this kind of shit happened all the time.

Huh. My wife is actually having the same procedure done for the second time after Christmas. Naturally the doctor is in-network, but his surgical facility (on the same floor, immediately adjacent to the doctor's offices) isn't. So it's fork out $1500 and fight insurance to reimburse us after the fact.

In her case, the epidural really does give her life back by completely killing the pressure and migraines that otherwise plague her daily. Insurance can kiss my butt. Single payer would be fabulous in this case.

There's this idea that "single payer" will pay for "anything I want" and it seems to me that evidence for this is sorely lacking.

Does the NHS not cover treatment for documented, debilitating migraines? I would be shocked to hear that it doesn't. In fact I think I would be surprised to hear if the NHS doesn't cover anything as long as it isn't something like cosmetic surgery.

There is no reason single payer shouldn't or couldn't cover 99% of most medical needs.

I had to go into surgery last year and had to sign a "I will pay whatever my insurance doesn't" form. I wrote in a clause saying that any out of network elements (persons, etc) must be personally approved in writing by myself or my proxy before they can do anything they bill for. I don't know if it would have held up in court, but it made me feel a little safer.

The existing health insurance industry is far from free market. Try getting a price for a procedure or visit beforehand.

Compare that to dental insurance. I’m always shocked when I get a treatment plant after 5 minutes that outlines exactly what the dentist needs to do, how much insurance will pay, and how much I will need to pay. Of course the set of possible treatments for dental work is a lot smaller, but it seems so much more straightforward.

> I’m always shocked when I get a treatment plant after 5 minutes that outlines exactly what the dentist needs to do, how much insurance will pay, and how much I will need to pay.

What you don't know (unless you get 2nd/3rd/4th opinions from good dentists) is how necessary those truly are. Some dentists just work around things by recommending things you don't need. (Fill teeth, taking panorex, etc. unnecessarily)

Seriously, I’ve had dentists differ in opinions by an order of magnitude. Turns out “necessary” is a pretty broad grey area.

True, but at least the dentist can tell me how much I will need to pay.

Which one is better probably depends on if you value your money more, or your body.

That's because most common dental procedures are relatively straightforward and the mechanical processes of the mouth are relatively well understood compared to most of the rest of the body. Plus most dental procedures are elective in the sense that you can usually just have an offending tooth pulled if it gets too bad, so for most people there's a price ceiling that is much lower than say a lifesaving heart procedure.

Why can't a hospital tell me how much an xray costs then? If I come in with a broken arm, why can't they tell me how much it will cost to get it xrayed yet the dentist can do the exact same thing with a broken tooth?

A dentist office is more comparable to an urgent care clinic than a hospital. And in many cases an urgent care clinic can tell you what simple procedures will cost. There are imaging services companies that can tell you upfront how much diagnostic tests are going to cost as well.

A broken tooth is a much less complex injury than a broken arm. In many cases you don't even need to be a dentist to diagnose it. Try walking into a dentist office with a more complex injury that could involve multiple different dental specialties and severe underlying complications. You aren't going to get an immediate upfront price.

I don't understand how this answers the question about X-ray cost.

1. Dental x-rays are more straightforward and involve fewer people, so the price is easier to calculate.

2. Dental x-rays are more often than not elective procedures. It's much easier to comparison shop elective procedures than emergency procedures. Therefore market forces frequently compel the dentist to come up with an up front cost for an x-ray.

The same market forces don't apply to hospitals because you can't wait a week or more while you shop around for treatment for a shattered hip.

I consistently tell my dentist to make treatment decisions as if this were her mouth/teeth. Of course, I'll never know if that gives her a license to "go profitable" over "go optimal", but I'm also extremely unlikely to go chase multiple opinions over a cracked tooth or filling.

Doctors disagree about medical treatment too. At least with the dentist you'll know how much each opinion costs.

I asked my new dentist why her recommendations were so different from her predecessor.

She said that there's not always one "correct" treatment. Some dentists will try to nip potential problems in the bud, lest they get worse. Others have more of a wait-and-see attitude which can avoid some procedures but make others worse.

Doctors, plumbers, builders, and mechanics all do the same thing. Do you replace the brake pads now, while the wheels are off anyway, or do you squeeze another season out of them since there's still a bit left? Rebuild the whole deck, or maybe just replace the more banged up boards and wobbly railing?

Difference being is all break pads eventually wear out and need to be replaced and all decks need regular maintenance. Not all teeth are going to eventually need work.

Plus the huge disparity in recommended treatments is an indication some are just throwing shit at the wall to see what sticks:

https://www.theatlantic.com/magazine/archive/2019/05/the-tro...

>Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader’s Digest, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000.

Same as code refactoring, needing it is a very subjective matter even is similar circumstances.

Price discovery doesn't help you. If you get knocked out, heart attack, your arm cut off, whatever (i.e. a lot of the expensive stuff) you just go to the nearest hospital, no consumer market finagling is even possible other than trying to live near a good hospital.

Other times with chronic conditions where theoretically price discovery could help, the problem is that you need care badly so all the chronic care providers jack up the prices super high beyond what is needed. Treating this as a market in any way is a crazy system. If the government pays market rate, they jack it up even more. So the solution has to be that the government has to set the prices either directly or by negotiating with an entire population at its back and no competitors (i.e. monopsony in the public interest).

The sad thing is, as expensive as healthcare is they probably have to jack up those rates because they are getting screwed everywhere else. In the end, though, the consumer is always the one who ends up getting the ultimate screw... exactly why healthcare shouldn't be seen as a service to consume.

You don't really need anyone else screwing over the hospital to have for-profit hospitals be incentivized to screw the patient by jacking up prices on demand inelastic goods. Not to even mention that many times the patient chooses these procedures while not thinking clearly, when under duress, etc.

These organizations charge exorbitant amounts of money for the care they provide. This is care which very few people are able to refuse. And if you do refuse care you are likely to die. What hospitals do would be considered extortion if a private citizen did it.

I have no sympathy for them whatsoever.

Sympathy has nothing to do with it.

While so much of the cost is the care that the organizations provide and what they choose to charge there is some truth to what you are saying.

Had to get an MRI and the lab corporation that performed the MRIs said that it would be ~$850 if billed through insurance. This included the total cost minus what was covered by insurance so the initial cost of the procedure was in the ~$1200 range. BUT, then they said if we just paid them directly and they didn't have to bill through insurance it would only be $650. So our insurance didn't even cover the absolutely ridiculous amount of overhead that was added just to deal with our insurance provider.

The biggest fuck you is that Medicare can't negotiate.. it's actually written into the law.

I believe that’s specific to drug prices. Services are interesting in that they just dictate it.

That's not true. Medicare can and does negotiate the cost of procedures and doctor's services. What the law says is that Medicare can't negotiate prescription drug prices. That's because Medicare doesn't directly pay for drugs, except what's used incidentally in the course of covered hospital stays.

Medicare didn't provide coverage for prescription drugs until the adoption of Part D. That is structured differently than other parts of Medicare. Instead of the government serving as the insurer directly, the government subsidizes premiums for a private Part D insurer. The private insurer can and does negotiate drug prices.

The fact that Medicare can't negotiate prescript drug prices is often invoked as a talking point, but Medicare prescription drug spending accounts for a relatively small proportion of. overall Medicare spending: https://www.heritage.org/medicare/commentary/good-and-bad-id... ("Consumer choice and competition have made Part D the rarest of government programs: one in which spending hasn’t spiraled out of control. In fact, government actuaries report that federal general revenue spending on the program was $67.8 billion in 2018—that’s less than what it spent in 2015 ($68.4 billion).").

That's 1/10th of the military budget for drugs that can be often be manufactured for pennies (drugs with biological elements requiring glass column filtration and such are a different story but are far more rarely used).

A point in case is the Hep C vaccine: https://www.medicalnewstoday.com/articles/323767#drug-types-...

And the Moderna vaccine was designed in two days: https://www.businessinsider.com/moderna-designed-coronavirus.... Is that all there is to it?

There was 10+ years of research prior, but much of that research was academic. Phased studies must be conducted regardless of whether manufacture is public or private. There does not appear to be any need for private profit, we are sufficiently motivated to research this stuff out of a desire for self-preservation.

I'll admit that profit seeking would work better* in a society that doesn't have a strong state or other coordinating body, but given that one exists to counterpose our existing system is not reasonable.

EDIT: * In the sense that products might be produced at all. Without a strong regulatory body, the market would be flooded with snake oil medicine and the average consumer would not be able to make heads or tails of things. This is because it's much cheaper to make a fake medicine than a real one, which is what profit optimizes for: the cheapest solution with the highest payoff for the seller regardless of costs not borne by the seller (such as death and destruction writ large).

The manufacturing costs are irrelevant for new drugs. If the drug companies couldn’t sell them at a profit, they would never develop them in the first place.

There is an issue with some old out of patent drugs that costs a lot despite being very cheap to manufacture, but that typically has to do with FDA certification deciding who can be allowed to produce what, which is also expensive to obtain.

Blackmail. I believe that is the word. Then end of life care comes along and you better own your house, because that is going to be gone after all the bills come in for end of life care.

> The existing health insurance industry is far from free market. Try getting a price for a procedure or visit beforehand.

Oh, I know. I've tried getting prices in the past. Traditional providers can't do it. One thing that has opened my eyes is using a Direct Primary Care (DPC) provider. I pay $75 a month for direct access to my doctor (email, text message, cell phone etc.). The access is great, but an unexpected side benefit is that a large percentage of their patients are un/underinsured. They can quote the prices for most common procedures from memory.

The other day I was getting a blood test and they asked if I wanted to bill my insurance or pay cash for it. I asked about the cost and they said "two-sixty". My response: "For two hundred sixty bucks we better bill the insurance. They laughed: no, $2.60 (it was an add on to another test for my physical). When I got home I googled pricing - the exact same test normally bills for around $65.

We do not have a free market. Other countries seem to have solid solutions for "socializing" medicine. I can't think of any highly functional system that is a free market. I don't even think that one is possible without people dying in the streets. Thus the best way forward is to try what has been successful elsewhere.

The annoying thing is, most people would agree that the whole system sucks... until you start talking about politics and suddenly you'd think a bunch of people have a love affair with their insurance company and healthcare providers.

"People love their insurance!" Is a dead giveaway that a politician is a sock puppet. Biden kept saying it during the primaries.

I'm not a politician and I will say: I love my insurance. Because it's actually pretty great.

My insurance is good, but I wouldn't need it if we had a sensible alternative, and neither would you. And many other less fortunate people (including those in my immediate family) wouldn't need it either. Not wanting to give up your insurance because you "love" it (fucking gag me) is "fuck you I got mine" energy. Cancerous to a society.

I hate my insurance. I hear its great for America, but it's shit compared to back home

> until you start listening to politicians who have a vested interest in making the general public believe such things

FTFY

People "love their health insurance" when they have it forever through their employment, and feel safe in their position.

80% of people in the US, including 50% of Republicans, support M4A precisely because they are not part of the upper-crust minority who are afforded such luxuries.

I've never heard of a prominent Republican politician voice support for taxpayer funded healthcare. It would require a significant increase in federal income/FICA taxes. And in the enormous portion of federal spending that Medicare/Medicaid is, it doesn't even include outpatient services/medications for everyone over 65.

Of course, this would be mitigated by the elimination of health insurance premiums and other redundancies, but a federal taxpayer funded solution would result in a more transparent wealth transfer, whereas the employer sponsored tax deductible health insurance gimmick allows for better discrimination on who receives healthcare, and ideally reduces the amount of wealth transfer by reducing the healthcare many people receive.

> I've never heard of a prominent Republican politician voice support for taxpayer funded healthcare.

Just goes to show where our "representative" democracy has gone. The number I quoted is for voters registered Republican.

People will talk the talk, but they won’t walk the walk when it comes to paying.

My conversations are usually reminiscent of this:

https://www.youtube.com/watch?v=r2TxX0E4U1A

> We do not have a free market. Other countries seem to have solid solutions for "socializing" medicine. I can't think of any highly functional system that is a free market. I don't even think that one is possible without people dying in the streets.

The government is perfectly capable of ensuring access to a market without regulating it to death. The SNAP program (Food Stamps) is a great example of how this works in a separate market with very little elasticity in demand.

I don't understand this.

Almost every other developed country has a system that works for healthcare. It's almost always single payer or something where you definitely don't go shopping around for hospitals.

Doesn't it start to feel a bit like indoctrination when arguing for a "free market" when no other developed country has a free market for healthcare?

Is everyone else stupid? What aren't they seeing? Especially in the age of the internet?

I just can't follow this logic.

I would love to get someone who argues from the "free market" point of view do some introspection and explain the logic in a way that doesn't feel like repeating the same 2-3-4 ideas which as far as I can see, are common talking points in the US.

So, repeating the question, what is every other developed country missing?

Why aren't they all doing this, if it's obviously superior?

I look forward to the utter absense of any answers to this question, or the entertainingly inventive ones.

I’m very much a free marketer for most things, as it seems to work well. It’s possible that it might work for health care too, but I don’t think we really know. For a lot of folks the free market is an article of faith, and I think that’s where a lot of support for this idea comes from.

Even if a free market could work in the US, I have no idea how we could get from here to there without making things worse along the way.

I had a full blood screen....first number $2000, Negotiated price $1600, Out of Pocket $48.

It's all funny money til it lands in my lap, then suddenly it's real.

> Other countries seem to have solid solutions for "socializing" medicine

What baffles me the most is that most "socialized" systems functions much like a tax-paid insurance policy that covers everything and has no profit motive.

Even in a normal insurance situation you're "paying for someone else's treatment". That's the whole point of insurance.

Most of these systems works like an extra payroll tax: it is a tax on salary as percentage, as opposed to a car or house insurance that is linked to the value of the risks insured, not the income of the payer. This is why some people are opposing to that system, the tax vs insurance debate.

It is not just tax-paid insurance. Main point is that single-payer is essentially monopolist buyer and can use its market power to push prices down. Which is good to get cheap and good medical care, but may lead to systemic underfinancing of healthcare and associated problems.

Lab costs are outsourced, and they charge separately from a doctor's bill. Biopsies are completely separate as well.

I see that alot in the stuff my insurance bills. $60 test they paid $3 for, another $180 test they paid $21 for or a $37 test that paid $2.80.

How can you shop around when prices are that distorted?

On the other hand, try calling ahead to various dentists in order to find the one that has the cheapest price for the procedure you need to have done. Surprisingly difficult. Not as impossible as in other aspects of healthcare, but I spent hours and hours and mostly didn’t get the details I wanted

And often every price the dental office provides you is an estimate, as once they enter each procedure’s code the insurance may price that work above or below the estimated price. That’s dental, which often isn’t life or death. If you’re in an ER or ICU you’re not processing “by golly, can I afford saving myself or should I negotiate the hospital’s Tylenol?”

> Try getting a price for a procedure or visit beforehand

"I tried to find out how much my son’s birth would cost. No one would tell me." [0]

[0] https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...

The answer is always “your out of pocket maximum” if it’s all done with in network providers, and infinity if any out of network providers are involved.

Which is a problem when out of network providers sneak in, such as commonly happens with surgical assistants. Have a covered and pre approved procedure from an in network surgeon at an in network hospital, and then oops because the surgeon added someone else to the room they never told you about now here's an out of network bill.

there seem to be alternatives for e.g. non emergency surgeries. this organization has prices listed which include follow ups, anesthesiologist, etc.

https://surgerycenterok.com/pricing/

they also seem to have a lower risk of infection compared to the national average:

https://surgerycenterok.com/faqs/

i'm not sure what could account for that. i was thinking that maybe because they are incentivized to provide the procedure at the baked in rate that there's a strong incentive to get patients out of surgery successfully as best as possible (to free up another bed, etc), but i'm not sure what their demand is like.

a more macabre hypothesis is that hospitals don't care much about patients who end up in their own ICU as it's just additional billable coverage, so the precautions aren't as strict.

How is that not a "free market"? Private, corrupt back room business deals dictate the prices that screw over patients. It's entirely determined by the private market. That sounds like a free market to me.

My dentist obscures things... I have msrp then estimated personal contribution. Only later do I get the final negotiated rates. Usually I get money back. Also with a dental PPO to go out of network you have to negotiate yourself! Insurance will only reimburse zip code rates.

It won't work. They'll still charge you for the interrogation!

Is this a snarky comment or is this an actual experience that’s happened to you or someone you know? I’m genuinely curious, I can definitely imagine hospitals trying something like this…

I've never "interrogated" a medical professional about their in or out of network status, so I have no first hand knowledge. But I have been charged their ridiculous hourly rates for 5-10 minute "consultations" so I have no reason to believe they wouldn't charge you for this.

My wife was charged $65 "to meet the surgeon" that would be performing procedure if she went ahead with it (she didn't ask to meet him, btw). It was basically just "Hey Bill, can you come over here and say hi to this patient". She had the charges waived pretty easily, but, if you don't call and ask and/or complain, those charges stand.

> The free market just doesn't work when there is very little elasticity in consumption.

Should we have single-payer markets for auto repairs, then? Or how about toilet paper, especially in a pandemic? Both of those are very inelastic, yet socialism has a particularly poor record of producing either reliably.

> I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room?

Yes, this is frustrating. It also has very little to do with a free market. Health care (and health care billing and insurance and medical devices etc.) have been regulated into oblivion, to the point that the prices make no sense and are more like Monopoly money than anything real.

If I had my way, I'd have a high-deductible (at least $10k) universal single-payer system supplemented by individual private insurance. Most routine costs would be paid directly by patients at the point of care, and providers would have to suck it up to figure out what their prices actually were.

That would actually give us much more of a free market than we have today, despite the large welfare-state component.

EDIT: Meant to include a link to the classic Arrow paper about health economics.[1] My own comment about it is that third-party payers are the only robust reason for increases in health costs over time. We see that in every market where third parties subsidize transactions between first and second parties: health care/insurance, tuition/student loans, even housing/subsidized mortgages.

[1] http://public.econ.duke.edu/~hf14/teaching/socialinsurance/r...

> Should we have single-payer markets for auto repairs, then? Or how about toilet paper, especially in a pandemic? Both of those are very inelastic, yet socialism has a particularly poor record of producing either reliably.

Why do you segue from single-payer to “socialism”?

Btw not sure about the states, but here in Europe, Single-payer works fine for auto repair, it’s exactly what happens when your car breaks down during the initial warranty - the garage is paid by the car manufacturer, not you. Far less stress than having to tow your car from garage to garage to get quotes :)

State control of the means of production is a common (though not unique) definition of socialism, is it not?

I think that would be more a definition of communism than socialism?

But single-payer (and not single-provider) is not state control of the means of production. The means of "production" remain private, it's just that everyone is covered by basic state insurance.

Honestly, having lived and worked in several single-payer countries, it works really well - I'd even say that it works better than pure state-run systems like the UK

Toilet paper shortages this year occurred in capitalist economies.

Only because retailers were not allowed to raise prices to meet demand.

Where did this happen?

All over the place. Many states have "anti-gouging" laws.

https://www.fmi.org/docs/default-source/gr-state/price-gougi...

$1M for one single ply roll is no different than a empty shelf

But it brings out a lot of inventory...

It's worse than that, my wife got one of these bills from a provider who was never in her hospital room. The bill ended up getting waived but it was for more than the rest of the stay.

Yeah, we got a bill from the hospital once with a footnote saying, some of these procedures may have actually been for another patient, not for you, we don't have complete records. But your insurance agreed to pay it, so we recommend you don't worry about it.

How is that not straight up fraud? If you don’t know if a procedure was for me or someone else, you’re lying by billing me!

Insurance and hospitals basically do bulk deals. Insurance is probably paying for the service one way or another, so they don't care much to whom the record is attached. And if you're not out of pocket, doesn't matter much to you either.

I imagine that the charge can be used to raise your rates though?

There's no "market" in healthcare in the US.

Long ago, it became illegal to open a hospital without a 'certificate of need' from the State. That's why so many towns have only one hospital - it's a government granted monopoly like cable companies in the 80s.

Differential pricing is also illegal. You fly cheap on Sunday at 3am, expensive on Monday at 9am. Healthcare providers are not allowed to charge less when it's cheap to do so, for example allowing you to do an MRI cheaper at 3am.

Your employer picks a monopoly insurer for you to chose a plan from.

The list goes on and on. There's no market here, it's a set of monopolies. It should be legal to open a hospital. Differential pricing should be legal. Your employer should let you chose from at least two insurers.

Exactly. Many people think that free market healthcare is bad because the US healthcare system. Once you are pointing out it is not a free market system they are surprised. The 20% profit cap also not very open market like.

The so-called by many, Father of Capitalism, Adam Smith, only defined market in terms of a free labor market.

He also wrote that whatever type of government existed in a nation, it would likely need to enforce equality of condition to avoid what we’d call monopoly of labors agency.

He was openly hostile to extreme division of labor, paraphrasing, it would turn humans into the dumbest creatures to ever exist.

Labor hardly seems free when Fed policy has been to tighten screws on workers, growing worker insecurity, to keep them circling back to that cubicle every morning: https://www.nytimes.com/1997/02/27/business/job-insecurity-o...

Look at that. Hundreds of years ago humans realized exactly what humans are capable of emotionally and warned against it.

Reminds of me of the ancient Greeks who, again paraphrasing, wrote they hope the rubes do not some day realize there are no gods atop Olympus. Just men on thrones manipulating their fears.

"Health care in the United States is provided by many distinct organizations. Health care facilities are largely owned and operated by private sector businesses. 58% of community hospitals in the United States are non-profit, 21% are government-owned, and 21% are for-profit."

Makes me wonder, why people think it is free market healthcare?

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

I find this idea interesting, but I'm extremely skeptical. If we are thinking about this as being a startup, how can we outsource the cost of building the hospital to the doctors and nurses? That way you might be able to build a billion dollar business by tricking people into owning all the downsides while you own all of the profits?

I'm just joking of course... the idea that the market can optimise every problem is simply incorrect. There isn't a move fast and break things for doing startup hospitals, it's simply a problem that central planning can organise effectively. Unfortunately, the American allergy to government means your healthcare system costs twice as much per capita for the same outcomes.

>how can we outsource the cost of building the hospital to the doctors and nurses?

This is almost reality in the US. Lookup "Ambulatory Surgical Center" investments.

Free market principles fail for healthcare for reasons entirely unrelated to those things, as has been pointed out up-thread. You're advocating for regulations to be eliminated as if that would fix unrelated problems. Do you care if healthcare is improved, or do you just want to see free-market-style reforms for their own sake?

In 2013, 64% of health spending was paid for by the government [0]. The non-profit hospitals share of total hospital capacity has remained relatively stable (about 70%) for decades [0]. The regulation section of Wikipedia is a litany of anti-free-market policies [0].

You can argue that free market principles fail in healthcare, and I will happily disagree and we can all have a cheerful time. But the US hasn't tried a free market approach to healthcare in at least decades. The free marketeers lost the argument; all the dials were set to non-free market and people argued that the quality/access to healthcare would rise to offset the cost of regulation. I'm not totally sure why people keep buying that argument.

In a free market:

1) Employment status would be irrelevant to healthcare.

2) People would be legally allowed to provide healthcare as long as treatment met whatever minimum quality standards the government sets on healthcare.

Saying "it became illegal to open a hospital" is unrelated to high costs is a serious failure of imagination. A ban on allowing people to provide competing services is a serious concern.

Also, people arguing for socialised healthcare aren't arguing to bring down the absurd costs, they are mostly arguing that the absurd costs should be shouldered by the middle & upper classes instead of the people consuming healthcare. It is unfair to first being in policies that inflate the costs, then dump the costs on taxpayers. If the argument is dump the costs on someone else then a decent effort should be made to reduce those costs.

[0] https://en.wikipedia.org/wiki/Health_care_in_the_United_Stat...

People arguing for socialized medicine are arguing for bringing down the absurd costs, by virtue of having a very strong negotiating position and economies of scale.

Canada's single payer system is an example of that.

In a free market, employment status would still be related to your healthcare, eg. through credit checks to see if you're moral enough to get surgery. Theres no reason companies would stop providing healthcare coverage, and for providers to bump costs to match the extra spending power

> a very strong negotiating position and economies of scale

Pretty sure that the US Federal government is the most indebted entity on the planet, and they'd be subject to exactly the same forces that have currently made them upregulate the cost of healthcare.

There is no reason to think they'd use a good bargaining position to bring down costs - the US Federal government is the most cost insensitive entity in history. And a free market is totally capable of finding economies of scale if it is cheaper.

Are most of the costs even accumulated in hospitals? I'd imagine the price gouging certainly is. We arbitrarily restrict the number of MD students so why shouldn't we expect $1000/hr. bills for care?

Every country in the world restricts the number of MD students, bit only the US has truly mind-blowing billing practices, and care costs, and puts the average freshly minted doctor half a million dollars in student debt.

I don't think Cuba does?

They instead send their extra doctors out to other countries

Something is going to have to be done at some point. Even as much money as most of us make, HC will become too expensive for us in the next decade or so, especially for any of us with a family.

I think there's a difference between your philosophical ideal and the way you would set a society up and the approach you believe would best address the problems and situations we currently face.

We don't have a free market in health care at all. In a free market you would be able to buy a coronavirus vaccine right now, instead of waiting months to get it for free. We haven't had a "free market" in health care in my lifetime.

Instead, we have people like @marcorubio, who downplayed the virus, jumping to the head of the line.

Are you suggesting that it's better to distribute the vaccine in a way that keeps those most likely to get it vulnerable for longer (i.e. inefficiently)? What's exactly is the benefit of a free market in a situation where it's less efficient at allocating resources than central planning?

I don’t think he’s suggesting it insomuch as providing an example.

> In a free market you would be able to buy a coronavirus vaccine right now, instead of waiting months to get it for free.

Give it a few weeks ...

> has turned me from a pure free market thinking into a believer in single payer healthcare

The current trend in 'free-market economics' is to call captured markets free and then argue for the relatively lax regulation.

Most markets are not free markets and the healthcare definitely isn't. There's very little true choice, participants are typically under duress when seeking expensive services, and prices are hidden.

If there was ala-carte transparent pricing and no insurer lockouts things may be a bit better.

My suspicion is that Private Equity has been funneled in healthcare for two decades intentionally distorting the market behaviors for increased profitability which is why the US has such excessive healthcare costs without any apparent justification.

> and prices are hidden

I believe the Trump administration is addressing this:

https://www.hhs.gov/about/news/2019/11/15/trump-administrati...

https://www.hhs.gov/about/news/2020/10/29/trump-administrati...

> The rule requires that most health plans and health insurers not only provide easy-to-understand personalized information on enrollee cost-sharing for healthcare services, but must also publicly disclose the rates they actually pay healthcare providers for specific services.

> Through a shopping tool available through their plan or insurance company, consumers will be able to see the negotiated rate between their doctor and their plan or insurer, as well as the most accurate out-of-pocket cost estimate possible based on their health plan for procedures, drugs, durable medical equipment, and any other item or service they may need.

> Consumers will also have access to accurate price and plan information that allows them to shop and compare costs between individual doctors before receiving care, so they can choose a healthcare provider that offers the most value and best suits their medical needs.

But it'll be another couple years before it's all implemented it seems

We still need up-front transparency on what codes will be billed to whom, from whom, and for how much. I want a comprehensible restaurant-like menu. And we need to break up regional monopolies so that there's actually a choice of provider. Further, agreements to pay whatever, whenever, before any diagnosis need to be banned as contracts under duress.

If we want the free market approach to work, we need to make it possible, easy even, to make informed decisions among competitors.

But fixing this is increasingly feeling intractable, and this pushes me further and further towards believing a single-payer (maybe not exactly, but that's the buzzword) system is the better fix.

I want a comprehensible restaurant-like menu.

Likely not going to happen purely out of complexity if nothing else. Look at the list of ICD procedure codes[1] and imagine all of these with a price attached. Comprehensive, sure, but comprehensible? Ehhh.. pushing it.

[1]: https://www.icd10data.com/ICD10PCS/Codes

Yup! And what will you do about it anyways? Like "Oh, you need xyz, it will cost $1000" Ok. Now that I know that, what am I supposed to do? Shop around? What if I'm in the emergency room, what then? Are they supposed to give me a price menu for every single drug or treatment they need to perform against me?

"Hey, we'll do CPR, but that'll will be $100, please sign here so we can save your life".

The ala cart method seems like it might work until you start thinking about the logistics. If someone goes to a doctor complaining about chest pain, do we really want them to leave because an EKG and blood test are going to cost $200. No matter how much the doctor explains to them "You might be dying" plenty of people will walk out of the hospital once the bill is presented. In some of those situations, that's going to be deadly.

For some perspective, I’m pretty sure there are a lot of non-Americans reading this thread amazed at just how comical current US thinking around healthcare has become.

Absolutely. By the way, in most cases you don't have to bill it at all, because the actual cost is negligible.

Yes, we need price transparency, but the last time I had a surgery, it was an emergency surgery, in the sense of "get him to the nearest ER or he'll die."

By the time the anesthesiologist came around, I was drifting in and out of consciousness -- no way to ask if they were in-network. (They weren't, by the way.)

This isn't an uncommon scenario, and one where price transparency isn't really going to help.

Also, what am I supposed to do, decline the services of an anesthesiologist and request an in-network one? What if there isn't an in-network one on duty? What if they're busy? if I need a surgery now, what choice do I have?

Part of the problem is that the coding happens after the doctors do their thing, are incredible complex, and have to be checked/fixed by a specialist before they can be sent onwards.

This doesn't even begin to address the real problem: emergency care.

Sure I can shop around and do a bunch of research for something that I know is coming up, but when the out of network specialist drops into my wife's hospital room as she's having an asthma attack and can't breathe I don't have the temporal luxury of vetting how much that particular specialist is going to cost out of pocket and can I please have one that's in network.

And we didn't even take an ambulance to that ER. When I had my motorcycle accident I was definitely not given a choice of which ER I was being hauled to - they stuck me on a back board and away we went.

The issue isn't just transparency it's also coverage. We can get the menu of prices from the hospital but the specialists do their own billing so won't be covered on that - you're back to an "MP" on the menu.

I worry that it will lead to much worse treatment on top of that.

Even if it's a non-emergency, getting the prices up front will cause a lot of people to chose to either go untreated or to delay treatment until a problem becomes far worse.

Just having prices available does nothing to improve the costs. People with type 1 diabetes know the cost of insulin. Has that prevented it's price from moving to levels that many can't afford?

It doesn't matter if the costs are known up front when drug manufactures end up with patent help that allows them to gouge. When medical devices are often produced by very few manufactures. When hospitals enjoy local monopolies.

The thought that the only thing missing from keeping medical prices down is the price tag is just absurd.

Wouldn't that be even more pressure on the pricing system, though?

If statistics about refused services were kept, we could see where the various providers are pricing in-demand services out of reach of those who need them. Or conversely, what services were advised above and beyond actual need.

We could see pressure on providers to bring costs in line with the benefits of each code/procedure, and the ripple effects could help reduce the premium->insurer->provider cost overages for everyone.

Mind you, I still believe single payer will be the eventual end game, but this could be a solid step in the right direction.

> Wouldn't that be even more pressure on the pricing system, though?

Why would it? They can literally just raise the price and those that have insurance are going to get it which ultimately covers the loss in those that refuse service due to price. That ultimately is reflected to the customer in the form of higher premiums which they pay regardless of whether on not they get EKGs.

Further, with less people getting services it really is as simple as cutting nursing, doctor, and lab staff because there isn't as much demand.

It may make a difference if the market was completely unregulated and insurance didn't exist at all. In that case, some guy could do EKGs out of his van at a much lower cost.

However, that's not the market we have. Doctors command high salaries and we've regulated that only those with medical licenses can practice medicine.

Medicine is not a free market and it's a bad idea to ever make it one. There are already major issues with unlicensed quacks selling placebos.

Price transparency would help, but it wouldn’t solve the duress problem. After a car crash we all want to go to the nearest hospital rather than the most price efficient one.

That's probably true but a lot of medical cost is scheduled like follow up or specialist visits, surgery and things of the less urgent nature.

How is that solving the car crash situation?

It's not, but if 50% of your business cares about prices and 50% doesn't, that's still a lot of pressure to have competitive prices.

It sounds like this conversation needs a usage breakdown to see where most bills come from from a total price experienced perspective.

It seems like most people's greatest fear around hospitals is a surprise ER visit that blows through their savings.

The same way you don't get super gouged when choosing a restaurant while hangry - non-urgent shoppers keep prices down across the board, even for urgent participants.

I'm not saying this makes for some total solution - just reacting to rejection of the market dynamic having any worth. It's foolish to cast aside entire paradigms of approaches because they don't fully solve every corner case. (The dual would be to ask how single payer healthcare solves purely elective procedures like cosmetic surgery. It doesn't.)

Obviously any market dynamic for urgent care needs to recognize that no contract has been formed, and so hospitals can't unilaterally set charges under a fallacious idea of contract. For instance when your car gets towed under duress (accident on the highway, expired papers, etc), the state sets the rates they're allowed to charge. They're still inflated, but at least within a factor of 2-3x the usual market.

(FWIW I think single payer is a good pragmatic way forward)

I didn't mean to suggest that there shouldn't be the option to freely chose alternative treatment options under a free market model, in cases where you're not happy with what a single payer model would cover.

Rather my point was that when you need urgent or critical medical care there should be a baseline assurance of a solution to your predicament as you may not be in a position to shop around.

Your analogy with restaurants is not a good one, since you are unlikely to be in a situation where you're about to starve to death, and the only restaurant in town has 3 Michelin stars, grocery stores don't exist, and passers-by are not qualified to give you food :)

The problem is that we've taken on this hidden assumption that "free market" somehow means that a hospital can create an arbitrary bill for urgent care, and you have no choice but to pay it. That's not really intrinsic to the free market paradigm, but rather an orthogonal corruption pushed via the legal system.

In a different thread I pushed the lack of a contract argument, and got back a more fitting legal theory that hospitals are allowed to charge you under the idea that you not paying would be "unjust enrichment" - they treated you, incurred expenses doing so, and therefore its your responsibility to compensate them. But that still doesn't support them charging you some arbitrarily high price, rather just expecting to be reimbursed for their costs. And so such bills should actually be constrained by the lowest rate they have with contracted insurances.

As for the analogy, I've been pretty hangry to the point where I wouldn't have been able to form a contract. It was also just a more straightforward example than the overall food market still functioning even though we're all just three weeks away from starvation.

> It was also just a more straightforward example than the overall food market still functioning even though we're all just three weeks away from starvation.

Eh, the overall food market doesn't quite fit as an analogy here. I know I'm not alone when I say I have close to a year of food storage; it's not really the same for surprise healthcare bills.

There are still people who don't have such stores of food though. But sure, another example is a pedestrian with a gas can arriving at a gas station. The point is there are many things that are necessary for modern existence, yet there's a competitive market of not-completely-powerless actors keeping prices in check for the nearly-powerless ones. Healthcare is an outlier by being an extreme market failure, through both not enough regulation and too much regulation (that is to say, corruption).

(Although maybe with the rise of big surveillance and fine grained price discrimination we'll start to see these situations in other markets get exploited more)

Emergency care seems to account for less than 10% of healthcare spending in the US [1].

[1] https://www.annemergmed.com/article/S0196-0644(13)00313-2/ab...

To me, that sort of proves a point.

Cancer and other disease are extremely expensive to treat and fairly common in the population. Yet, somehow, emergency care which is a minority of health costs, eats up 10% of the spending.

Anyone that's been to an emergency room knows how excessive the price gouging going on there is. Pills that cost $0.10 OTC (or less!) routinely see 100x markup. That same pill can cost anywhere from $10->$15.

It also doesn't help how insurance handles ER visits.

I was in the ER earlier this year. Had an ultrasound done and a BUNCH of labs. $500 copay for the whole visit and insurance eats the rest - regardless of where I am on my deductible.

I'd had the exact same ultrasound done "routinely" 2 days prior, at the same hospital, and similar lab the week before.. I had to pay about $1,300 for the privilege because that all falls to my deductible. (Insurance paid nothing)

So it cost me almost 3x as much to go during the day than it costs during the ER - but my insurance paid out about 6x as much for the ER visit. I wonder how many "ER Abusers" have figured out it's actually cheaper for THEM to go to the ER than "normal doctors"?

That makes perfect sense, assuming your annual deductible was met after you paid your $500 copay. Deductible means you pay for the first $x in a year. After that, your insurer starts paying some portion (your portion is called copay). Then you hit your out of pocket maximum (for in network services), after which insurer pays 100%.

No - I hadn't hit my out of pocket max, by a long shot, even after the second encounter. They could have happened in either order - and the emergency visit would have been MUCH cheaper out of pocket for me.

Then I don't know what definition of deductible your insurance company is using, but it doesn't match my experience with any insurer ever, health or otherwise.

It's simple - I have a flat $500 copay for an "ER encounter" regardless of what they do in the ER. Just like you have a $40 or whatever copay for a regular doctor visit.

The deductible must be paid before copays come into play. If you have a $2,000 deductible, then you will pay whatever the insurance company has negotiated with the in network provider for the billing codes the provider bills, up to $2,000. After that, the copays amounts come into effect.

https://www.investopedia.com/ask/answers/051415/what-differe...

No, that's not how it works.

Most health insurance plans have a few services that are copay-limited even before you hit your deductible. i.e., the $40 for an office visit to your primary care doctor, $90 to see a specialist, and in my case $500 for the ER visit. Imaging and procedures are my problem from the start, up to the deductible though ... apparently unless they happen in the ER.

Like I said way up-thread, the way it's structured puts the incentives in the wrong place for me. Had my two visits for ER and scans been in the opposite order, I would have been out of pocket the same total.

Anyway - I'm done arguing with you. I know how my plan works and what I've paid this year, whether you believe me or not.

I also had an emergency hospital visit a few months ago. Multiple X-Rays, a CT scan, two surgeries and innumerable drugs. I don't have health insurance. Cost to me? Zero.

But then I live in Australia.

There is a lot of overhead in a hospital ER. You need medical equipment to handle all types of injury/trauma. You need advanced and very expensive diagnostic equipment (e.g. MRI, CT scanners). You need treatment/operating rooms and all the supplies. You need physicians and nurses and supporting staff. You need lab services. All of your patients arrive more more or less at random, unscheduled, so you can't really optimize any of it. It's probably the most expensive way to deliver medical care that you could think of. Even if it's only a minority of the care delivered, it's very expensive to deliver it.

I agree, yet other countries have and operate ERs at a fraction of the cost of the US simply by virtue of having single payer healthcare.

> You need medical equipment to handle all types of injury/trauma.

This is equipment that most hospitals already have for other reasons. It's not like they have ER MRIs that sit idle and then an MRI for everyone else.

Further, a lot of that diagnostic equipment simply isn't needed in most cases. For ER related problems, xray machines are commonly all that's actually needed. Those are fairly cheap in the grand scheme of things.

> You need physicians and nurses and supporting staff.

A lot of the need for that gets cut dramatically by having a single payer system. The reason we have big ERs is because they are required to treat before seeking payment. As a result, many uninsured and underinsured people are using the ER as a primary healthcare system. Give everyone 0 or low deductible healthcare and you'll see the number of ER visits drop dramatically.

> Cancer and other disease are extremely expensive to treat and fairly common in the population. Yet, somehow, emergency care which is a minority of health costs, eats up 10% of the spending.

Emergency care is not actually uncommon. Heart attacks, car accidents, these are the leading causes of death. It's completely reasonable to expect this to legitimately consume 10% of healthcare resources.

> Anyone that's been to an emergency room knows how excessive the price gouging going on there is. Pills that cost $0.10 OTC (or less!) routinely see 100x markup. That same pill can cost anywhere from $10->$15.

This is just opportunism, but it isn't really the core of the problem.

Emergency care is inherently expensive for a specific reason. You need an emergency heart surgeon on premises in case anybody needs heart surgery regardless of whether anybody does at any given time. You also need a neurosurgeon and one for every other specialty, and all the supporting equipment. It's very expensive, which is why it amounts to 10% of healthcare costs.

They then try to recover some of those costs by massively overcharging for ibuprofen and band-aids, which is silly (charge insurers the actual cost for emergency heart surgery instead), but it's not going to be a source of major net cost savings just to do the accounting differently.

They also mark up everything to cover uninsured patients. Who by the way commonly use the ER for primary care and probably explain a lot of that 10 percent.

Pricing transparency through a public ally available database would at least help with more competitive or uniform drug/scheduled treatment costs?

Some level of price transparency becomes law in under 2 weeks on 1/1/2021.

https://www.foley.com/en/insights/publications/2019/12/price...

I believe this was fought out in court this past summer and upheld.

> Private Equity has been funneled in healthcare for two decades intentionally distorting the market behaviors for increased profitability

But that is precisely a market effect of PE being able to do this due to lack of effective regulation, isnt it?

Ok, there could be multiple problems.

One problem with health care in the U.S. is that prices are hidden from the customers. That interferes with a free market. Tax regulations incentivized tying health care to employment and Obamacare making it difficult to get catastrophic care both interfere with a free market, etc.

Another set of problems, as you describe, is the ability for private equity funds to collude and impeded free markets. Especially lobbyists getting laws passed in their favor, medical associations limiting the supply of doctors, doctors incentivized to prescribe opioids, etc.

The original post in this thread referred to our current health care system as a free market, and that is not accurate. That's probably just as wrong as saying that we currently have socialized medicine, and its not working.

I would say that our current health care system is a not a free market and is not socialized, it is broken mix of the two.

It won't be reformed any time soon because millions of insurance industry jobs would need to be eliminated to save any money. Good luck with that.

I've that this before, but I like my markets free as in GPL, not free as in BSD. That is, I want the markets themselves to be free, even if that means that participants in the market have limitations put on them to keep them from capturing the market, forming monopolies, etc.

It's the regulations / limitations you are proposing that make it possible/likely that a monopoly will form. See Milton Friedman on this. There's basically no example of a monopoly forming outside of government regulation.

That is a completely bizarre claim. What is Google? A highly regulated search monopoly? I think not.

DMCA

DMCA? Let's see...

Does this example of a bad government regulation come from the government? Or the people voting and demanding it from the government?

No, it comes from business. DMCA is an example of the badness of private business if allowed to do what it wants.

That was a purchased law. The failure on the governments part was in allowing itself to be for sale.

So you are right, even though I bet this is just about the opposite of the conclusion you thought citing the DMCA resolves out to, we should definitely stop allowing the government to be influenced by the private sector.

Look, it's government power behind it. I don't fundamentally care how it's gotten rid of as long as it is. Weaken businesses, weaken the government, weaken the links between the two, whichever way is fastest/most effective- in principle. I just don't particularly trust your prescription, as you don't mine. This situation is, of course, exactly as the government-business complex wills it.

There are actually quite a lot of government regulations without which a search monopoly would be less likely, from the patents Google holds to the CFAA creating uncertainty for small competitors to do the scraping that would be necessary to get as comprehensive an index without being large enough to have sites request indexing to the GDPR increasing compliance costs to the RIAA/MPAA and news sites flinging lawsuits left and right based on overbroad copyright laws to the FCC rules that impair last mile competition that could result in higher upload speeds and thereby greater P2P content hosting which is more easily indexed by search competitors.

That's because there's basically no example of advanced economies that are not regulated by government. It's not the regulation that makes monopolies happen, it is that regulations only exist in markets which could support monopolies.

> There's basically no example of a monopoly forming outside of government regulation.

That's tautological statement. There is no free market without private property protections which do not exist outside of government regulation either.

Some people view the protection of individual intrinsic rights (freedom from violence, protection of property, the right to move freely about) as a separate thing from regulation.

Government protecting people's rights, vs. government protecting people, or government prohibiting consensual business dealings.

Yes, if you want to demonize something you also depend on, it is hard to do so without some rhetorical dodge.

You don't have to fall for it, though.

So I can just claim that none of the things that cause monopolies are regulation, then regulations don't cause monopolies?

> There’s basically no example of a monopoly forming outside of government regulation.

The monopoly on force which defines the state must first form before there can be any government regulation, and thus must inherently form outside of government regulation.

Once that forms, of course, there is virtually no example of anything in human society forming outside of government regulation.

But taking the absence of evidence of how things behave “outside of government regulation” for evidence of ones preferred view of the difference between life under government regulation and without it is rather unwarranted.

I think they mean government regulations providing protection from competitors specifically. Not just all possible govt protection that everyone gets including competitors, for example from being robbed or invaded by Russia or whatever.

There’s also no example of a monopoly forming inside the molten core of the earth, but that doesn’t mean sunshine causes monopolies.

> There's basically no example of a monopoly forming outside of government regulation.

Facebook has a monopoly on the social network.

TikTok, Twitter, LinkedIn and pretty much every forum and IM network.

I don't think so. It is notable that many monopolies sprung up in the US in the late 1800's/early 1900's before there was significant regulation, which is what in fact lead to the first significant laws related to monopolies and "trust busting".

There is certainly the danger of regulatory capture that increases the costs for competitor to enter a market, but that is different than regulations on how large corporations are allowed to wield their power as market leaders. You need to distinguish between regulations that increase the costs for new competitors vs. those that prevent bullying/price fixing etc. For example, it was anti-trust regulation that gave rise to popularity (not initial creation) of Unix, and interoperability regulations that further expanded competition in the telecom industry.

>> If there was ala-carte transparent pricing and no insurer lockouts things may be a bit better.

Posted prices, and provider always charges that price weather its paid by insurance or not. Then insurance companies can compete on how much they cover at what premiums.

That leaves too much patient money on the table, and will lead to patients doing comparison shopping, which is not something the healthcare industry wants.

You've described every service provider on Earth, and that's not a justification for them to avoid transparency in pricing or billing.

Yes, it should be "free markets...until the wolves take over the whole system". It's impressive how quickly those profit maximization ideas have caught on, driven by technology (I blame Excel more than anything), and throughout the entire system. The healthcare cash-cow benefits a LOT of people, workers, suppliers, and (especially) administrators at both hospitals and doctors offices. A poor healthcare system is a great way to create BS jobs, and have a de facto welfare system while not actually legislating for it.

It is remarkable how quickly and completely the noble ideals of the professions (medicine and law) have totally fallen to the profit motive. Now, you are a fool if you show self-restraint, because no one will notice, and your unscrupulous competitors will eat your lunch. It's the kind of pervasive corruption that can only happen when literally everyone in the system, including the victims, have given up.

I think the argument you are responding to is not the one the previous user presented. This issue isn't that people are trying to maximize profit leading to issues. The problem is that there is undue government interference in the market leading to all of the negatives that come from people selfishly trying to maximize profit in a cynical way with none of the benefits of people trying to maximize profits by providing a product that people will prefer over the competition.

Free markets generally work better the less leverage one party has over another. When the negotiation is "pay up or die" then it's de facto not a free market [1] and the government has a responsibility to step in and address it.

The minimum viable remediation is a two-tier system in which the government takes the "or die" out of the conversation. The best approach IMO is single-payer where the government takes the "pay up" part out too, as it allows the system to be globally optimized.

At the end of the day health insurance isn't insurance, it's at best a structured payments plan. You buy insurance against things that may or may not happen. You will get sick and you will die. That's not insurance.

[1] https://corporatefinanceinstitute.com/resources/knowledge/ec...

Personally I've never been told to pay up before receiving treatment at a hospital. Especially when I arrive there unconscious. And Herb Cohen would say once you've received the service, you're actually in a great negotiating position. People actually negotiate hospital bills all the time. Especially in those crazy stories you hear about.

And you need a citation for your claim about when free markets do and don't work.

> Personally I've never been told to pay up before receiving treatment at a hospital.

Of course you have. The first thing you did when you walked in was hand them your ID and coverage info. You think hospitals operate on the honor system?

As a Canadian I've never been asked to pay up before or after receiving treatment [edit: at the point of care].

And before you jump into taxation, Canadians pay less per capita in taxes than Americans ($13K vs $14K), and that's before you factor in the $600 per month in private tax you directly (or indirectly via employer) have to pay your insurers.

> Especially when I arrive there unconscious.

You either have insurance or you're driven into Chapter 11. Further I suspect this is not due to good will but rather government intervention.

> And Herb Cohen would say once you've received the service, you're actually in a great negotiating position.

The debt was incurred once the service was rendered, and you are now liable. 66.5% of all bankruptcies in the US are medical -- are they just bad negotiators? I'm not sure what point you're trying to make but it's not in good faith.

> People actually negotiate hospital bills all the time. Especially in those crazy stories you hear about.

That sounds the worst.

> And you need a citation for your claim about when free markets do and don't work.

Voluntary contractual exchange is one of the undisputed key pillars to a free market economy. If you're being told you will die without the service it is a coercive exchange and therefore violates one of the key tenets. [1]

If I hold a gun to your head and tell you to buy my oranges for $1000 or I kill you, is the free market price of oranges $1000? If I tell you that you have cancer and you'll die unless you get $48,000 worth of chemotherapy, is that a free market? [2]

A free market requires both the voluntary production and voluntary consumption of services.

[1] https://en.wikipedia.org/wiki/Free_market

[2] https://www.asbestos.com/featured-stories/high-cost-of-cance...

As a Canadian you pay up every time you pay taxes, and you don't negotiate because you take what the government gives you. If they say your orthopedic surgery happens in six months, then that's what you get, or you start shopping south of the border.

Re taxes: I explicitly addressed that. The government negotiates with the drug companies and sets pricing for an efficiently functional health system. I don't have to and shouldn't have to negotiate. The system costs half per capita to operate and covers everyone.

Re: waiting times, take it from the horses' mouth, you've been fed a crock [1]. Of course the system could be better, but on the whole you're just wrong. The insurance lobby has spent a lot of time, money and effort to convince you of that.

The data backs that up. A small handful of Canadians go to the US to "shop for orthopedic surgery" out of millions of visits per year in Canada. After all a hip replacement in America costs one hundred thousand dollars. Just how many Canadians do you think there are with a spare $100K USD ($128,500 CAD) kicking around in the old piggy bank for a new hip that'd be free in a few months? [2]

If you see 50-60,000 ish numbers they tend to be the 'snowbirds' - Canadians living in Florida for half the year who choose to seek care close to their winter homes. These are folks wealthy enough to have winter homes, and also maintain private insurance.

[1] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...

[2] https://www.vox.com/2016/10/9/13222798/canadians-seeking-med...

> You either have insurance or you're driven into Chapter 11. Further I suspect this is not due to good will but rather government intervention.

You really are making a lot of bold assertions. If you declare bankruptcy, the hospital gets zero. Negotiation is a process by which both sides give something to meet in the middle. Yes they do it.

https://www.cnbc.com/2020/10/28/you-can-negotiate-your-medic...

> The debt was incurred once the service was rendered, and you are now liable. 66.5% of all bankruptcies in the US are medical -- are they just bad negotiators?

The overwhelming vast majority of people have health insurance. However, due to taxation of privately-purchased insurance but not insurance that's a work benefit, people are driven to get insurance through their job. This was the government's fault, by the way. If people lose their job, they lose their insurance along with it. People without jobs have lots of financial problems. If they have a medical problem this situation gets far worse and results in a lot of bankruptcy. You seem to think bankruptcy is worse than negotiating. Clearly, it is often preferred.

As for your oranges question, no.

For the cancer one, possibly.

> For the cancer one, possibly.

Do go on. Why is dying due to an explicit action any more of a free choice than dying of an explicit inaction? Why is one any more coercive than the other?

The only point I'm making is that healthcare is not a free market due to lack of voluntary agreement between buyer and seller. Once you accept that it's not a big jump to say the system should be remediated.

> Do go on. Why is dying due to an explicit action any more of a free choice than dying of an explicit inaction?

Because one is coercion and the other is simply an economic system. Which by the way is also used for all the other necessities of life too. How about food?

The whole point of a free market is competition, so if you were at least arguing for emergency situations there's be something to talk about since it's rather hard to shop around. But we'd still need to compare it to how well the government handles economics of emergencies. So far we have the govt driving up the cost of emergency care by requiring the ER to provide primary care for everyone without insurance.

I provided two examples of a coercive economic system. Just because it's an economic system doesn't make it any less coercive. The dictate is clear. A free market requires a voluntary participation of both the buyer and the seller. Threat of death is not voluntary participation, so it is not a free market. In a car crash you are not in a position to negotiate or make providers compete for your business.

In functioning systems the government drives down the cost of emergency care by setting the price and insuring everyone, and the results are clear. Canada's health care system costs $5447 USD, and Americas costs $10224. That's basically all I'll say about that.

Other necessities like food are in fact subsidized or socialized.

- The freeways? Socialized.

- The schools? Socialized.

- The police? Socialized.

- The fire stations? Socialized.

- The army? Socialized.

- The post office? Socialized.

- Healthcare for 40% of Americans? Socialized. (Medicare, Medicaid, VA). Medicare is socialized medicine. [1]

Food is also very much provided for if needed. SNAP and food banks provide socialized food to the poor. Americans pay less for food than anyone else on earth in no small part because the Farm Bill subsidizes production of corn and soy to the point these staples are sold at below cost to end users.

Either way that's a distraction and a red herring. Americans pay less for food than anyone else and more for medicine than anyone else. Eyes on the prize here, and stop carrying water for the insurance companies taking advantage of you :) All we're talking about doing is moving the percent of Americans covered by socialized medicine up from 40% to 100%.

[1] https://en.wikipedia.org/wiki/Socialized_medicine

> - Healthcare for 40% of Americans? Socialized. (Medicare, Medicaid, VA). Medicare is socialized medicine.

> Americans pay less for food than anyone else and more for medicine than anyone else.

Is your point then that food is cheap because it is socialized at a 100% rate as you want healthcare to be? Or that your references to socialism are all red herrings?

Poor people can get free healthcare the same ways they get free food, Govt programs and charities. Food banks are private charities, by the way.

You are not defining coercion properly. It means force or threats of force.

Freeways are not a necessity of life, though we are certainly coerced into paying for them. At least they aren't as expensive as that Army you mentioned. Apparently you define all government spending as socialism, making the only other possible form of "govt" anarchy itself?

> Is your point then that food is cheap because it is socialized at a 100% rate as you want healthcare to be? Or that your references to socialism are all red herrings?

My point is food is cheap because the government intervenes, it's not a free market as you make it out to be, and yes food is provided to those in need. However, there aren't many in need in no small part because food is already the cheapest in the world in the US. That's not an exaggeration [3].

If medicine were the cheapest in the world in the US then nobody would be calling for its socialization. The current system is an abject failure. The food market, while I disagree with it, would likely be defined as a success.

I'm saying that in other countries with socialized medicine costs are controlled far better. Medicare controls costs far better than the private sector. Canada's system costs half as much, covers everyone and is ranked better along basically ever major axis. Life expectancy is declining in the US. Healthcare in the US is among the worst in the OECD and far more expensive. [4]

I'm saying that it's not as big a leap as you make it out to be, and that there's lots of precedent, domestically and abroad.

> You are not defining coercion properly. It means force or threats of force.

Coercion (/koʊˈɜːrʒən, -ʃən/) is the practice of forcing another party to act in an involuntary manner by use of threats or force. Threats or force. Pay up or get out and die is a threat, IMO, levvied by the system.

But even if you choose not to take that definition - it remains true (the only thing I've been arguing) that health care is not a voluntary contractual agreement but one taken out of necessity on an uneven playing field. This makes healthcare not a free market under most circumstances.

> Apparently you define all government spending as socialism, making the only other possible form of "govt" anarchy itself?

"In the theoretical works of Karl Marx and Friedrich Engels and subsequent Marxist writers, socialization (or the socialization of production) is the process of transforming the act of producing and distributing goods and services from a solitary to a social relationship and collective endeavor." [1]

Socialization in a primarily capitalist economy is defined as taking a for-profit institution and transforming it into an institution collectively funded and carried out for the public benefit. If the government owns and operates a service for the public benefit it is a socialized service. It is socialism - well, democratic socialism/social democracy. It is not incompatible with freedom, or democracy, or private property rights.

Yes, these are all socialized services. Explicitly yes for Medicare, Medicaid and TRICARE. [2]

The alternative to socialized services are privately owned and operated businesses. Not anarchy, necessarily, but libertarianism.

[1] https://en.wikipedia.org/wiki/Socialization_(Marxism)

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

[3] https://www.ibtimes.com/us-spends-less-food-any-other-countr...

[4] http://www.oecd.org/health/health-systems/health-at-a-glance...

So food is cheap because the govt intervenes, ignoring the giant private market, and healthcare is expensive because of the private market, ignoring the massive govt intervention. How convenient.

"Threatening to not perform a service for someone" is not coercion, and does not invalidate a free market. A market is a place where scarce products can be exchanged between buyers and sellers who meet at an agreed upon price. The ability to refuse service is a prerequisite for having a market and the idea of private property itself, not some kind of unexpected flaw. The fact that something is scarce may well be problematic for some who cannot afford to outbid others who can afford it, but no system eliminates scarcity. Ask Venezuelans, who I am sure you were dying to talk about, what happens when you try to overcome scarcity with price fixing and free money. You simply achieve shortages.

In the 1980s the US did not have a 40 percent socialized system. The fraction of people on medicare was far less. Yet it was not the most expensive system in the world then. The US system is definitely failing, but it isn't the 300-year old market system that is causing it.

> So food is cheap because the govt intervenes, ignoring the giant private market, and healthcare is expensive because of the private market, ignoring the massive govt intervention. How convenient.

The only thing convenient is you not addressing my point :) The government intervention is a desparate attempt at not letting people die of disease and pestilence literally outside a point of care. You're asking for a dystopian hellscape. And that's what much of the last 300 years was with respect to medical care.

> In the 1980s the US did not have a 40 percent socialized system. The fraction of people on medicare was far less. Yet it was not the most expensive system in the world then. The US system is definitely failing, but it isn't the 300-year old market system that is causing it.

Yes it is.

Canada had a similar system until the 1970s, and it was bad. Then it switched over and things got better. America remained on the private system and it just got worse and worse.

Venezuela is totally and utterly irrelevant to this conversation. There are so many functioning systems with socialized medicine (all of Europe, especially the Scandinavians, Canada, Taiwan, etc, etc), Venezuela is an outlier and not even worth discussing. It's a failed state.

Whether you call it coercion or a power differential (you will die, the insurer or provider won't) this precludes a voluntary meeting of the minds necessary in a free market. Period.

> Yes it is.

No it isn't. Speaking of dodging the point. The US didn't remain in the private system, it half-socialized it. And you must know Canada's system has been increasing in cost like everyone else's.

And speaking of magic single-payer economics for the good of all, what's up with that "socialized" army you mentioned? Most expensive in the world also. I expect the very same wanton mishandling of other people's money when it comes to the eventual govt takeover of healthcare. Hell they are already doing it as that 40 percent govt part is outpacing world spending all its own.

Venezuela is just a difference of degree. The same effect is seen in everyone's lack of R&D spending outside the US.

The way a market works is people find ways to serve people at a price they can afford. When you always force others to pay for the cadillac service for them, no one bothers to find cheap ways to provide healthcare.

> The way a market works is people find ways to serve people at a price they can afford. When you always force others to pay for the cadillac service for them, no one bothers to find cheap ways to provide healthcare.

How can you be so twisted up about this? Americas system is the expensive one, everyone else's is cheap, and controlling costs better. Medicare may not be doing a perfect job but again it's controlling costs better than the private sector. What you are saying is strictly and objectively false.

Healthcare is optimized and improved in single-payer states, because there's still budgets.

You're defending the worst system out there from a cost perspective, and not top 20 in outcomes. And you're doing so by saying the system other countries are successfully using to control costs would fail to control costs, and using this to defend American's failure to control costs? You're telling me Canada is doing a bad job of controlling costs when it literally costs half as much per capita? Because their rate of cost growth is in line with their peers while America's is way, way beyond?

Your mental gymnastics are giving me a headache.

> Venezuela is just a difference of degree. The same effect is seen in everyone's lack of R&D spending outside the US.

And that? Also false. Venezuela is a difference of degree? What on earth are you talking about.

R&D spending? Guess which healthcare companies spend the most on R&D? It's not the American ones. It's all the European ones. #1 is Switzerland's Roche. #4 is Switzerland's Novartis. #6 is France's Sanofi. #9 is the UK's AstraZeneca. #10 is the UK's GlaxoSmithKlein. [1] This is yet another failed talking point.

Guess which country developed the first COVID vaccine? Germany. BioNTech's vaccine was paid for by Germany's government. Pfizer took $0 of US money and is productionizing a Turkish immigrant in Germany's German government funded research work.

You're just not right about this one, time to move on lol.

[1] https://www.fiercebiotech.com/special-report/top-10-pharma-r...

> R&D spending? Guess which healthcare companies spend the most on R&D? It's not the American ones. It's all the European ones. #1 is Switzerland's Roche. #4 is Switzerland's Novartis. #6 is France's Sanofi. #9 is the UK's AstraZeneca. #10 is the UK's GlaxoSmithKlein. [1] This is yet another failed talking point.

Roche has over 8000 employees in the US. https://www.roche.com/careers/our-locations/americas/usa.htm

A handful of giant international companies who obviously make a big fraction of their money in the US market (selling at higher prices due to the lack of price fixing) do not provide a useful metric. Try overall stats, such as here: https://efpia.eu/publications/data-center/the-pharma-industr...

And that'd just pharmaceuticals. The US has far greater dominance over other areas of biotech.

But you're right, I do need to move on. This immature flaming behavior is why I avoid toxic places like reddit.

Just as a final note, that chart of EU vs US spending paints a very incomplete picture.

1. That's in "millions of national currency units" (except in Japan which is in "hundred millions of national currency units") so the Japan bar is in 100M JPY, the Europe bar is in 1M EUR, and the US bar is in 1M USD. It was clearly not meant for comparison against regions, just over time.

2. Not only is the currency inconsistent the values weren't adjusted for purchasing power parity, i.e. how far a national currency unit goes in that country relatively.

If we convert the values to USD adjust for PPP the picture changes completely. All values in USD, PPP adjusted:

2016 - USA: $52.4B

2016 - Europe: $46.16B (PPP factor 1.225, EUR:USD factor 1.11)

This is about a 13% delta, not the seemingly 53% delta represented on the chart. Also, this is limited to EFPIA member companies.

> The alternative to socialized services are privately owned and operated businesses. Not anarchy, necessarily, but libertarianism.

Privatizing these would mean anarchism as there's no longer a monopoly on force.

>- The freeways? Socialized.

>- The schools? Socialized.

>- The police? Socialized.

>- The fire stations? Socialized.

>- The army? Socialized.

>- The post office? Socialized.

Ah yes who can forget the Armed Postal Forces and the Teachers Brigade. The Fire Fighters Battalion really whipped the enemy in Iraq. It's strictly not true that privatizing these would risk losing a monopoly on force.

It's not anarchy to pay the fire department to put out your fire. It's libertarianism. Just like paying your doctor to splint your leg.

Even if I agreed with you, whether it risks losing the monopoly on force or not doesn't make it any less a socialized service.

This might be a fun read for you: https://www.newyorker.com/humor/daily-shouts/l-p-d-libertari...

Coercion is simply an economic system too?

I tell you to do work, and if you don't I shoot you. It's just economics; I'm trading not shooting you for your labour and everyone comes out happy

No, economic systems are a superset of systems with coercion, and also include systems without coercion. So when I said "simply" an economic system, I meant lacking in coercion. Your example includes both. Also it's silly to call it trade.

Were you making an analogy for the economics of socialized medicine with the forcing of labor?

> Of course you have. The first thing you did when you walked in was hand them your ID and coverage info. You think hospitals operate on the honor system?

They mail you these paper forms known as "bills". I have examples I can show you. Insurance only pays a portion. I suppose you can call it a kind of honor system.

And given your examples, you apparently aren't aware that when it comes to emergence care in the US, hospitals which have an emergency department are required by law to provide emergency care as needed to make sure a patient is stable. One's ability to pay is not a factor.

I've lived in the US for more than 10 years. What you're saying there is a mix of half-truths.

One is of course that "I suppose you can call it a kind of honor system," no, you can't, it's enforceable by law and actively collected upon. That's not an honor system.

> And given your examples, you apparently aren't aware that when it comes to emergence care in the US, hospitals which have an emergency department are required by law to provide emergency care as needed to make sure a patient is stable.

Yes, the bare minimum, then ejecting them out the back door as soon as they possibly can. Of course by waiting until they require emergency care you're fleecing everyone. Minor issues that could have been addressed earlier for pennies on the dollar are instead allowed to fester until they become life-threatening, then when the poor can't pay, it's socialized across those who can at the worst possible time for the highest possible price.

Not to mention, this is an argument against the free market approach which would just be to refuse service. This is actually bolstering my case that healthcare is not a free market because of a lack of ability to form a voluntary contract.

> One's ability to pay is not a factor.

Oh come on now. Who doesn't have health insurance? The poor. Who's going to get the bare minimum treatment required be law and getting booted out the back door? The poor. Who's then going to get a bill for it forcing them to declare bankruptcy? The poor.

This is strictly about one's ability to pay.

If you're already poor, bankruptcy isn't really the biggest of your worries. You can't get blood out of a turnip, as the saying goes.

> Yes, the bare minimum, then ejecting them out the back door as soon as they possibly can.

New goalpost eh? No they generally just treat everyone fully and pass the cost on to people with insurance. Trying to transfer uninsured people out leads to lawsuits.

Nope, I've only got one goalpost. To express that healthcare cannot be a free market.

This was a digression and exploration of how your specific situation exists because of government intervention. The alternative is to let poor people die outside, and that's distasteful to me, and to most.

No the poor received charity, directly from the hospitals. In fact historically, hospitals were charities, many still are. And the rest still provide it too. In the story I linked the uninsured person's whole problem was that he earned too much to qualify for the hospital's financial aid program, so had to negotiate to get a lower bill.

lol, why on earth would we want to advocate for a system where the poor have to rely on the charity of for-profit institutions? Try that at the grocery store. We already have kickstarter campaigns for insulin. What you're advocating for is inhumane and shameful for a first-world country. It's shameful. And it's all besides the point.

A voluntary exchange between buyer and seller prior to exchange is necessary for a free market. You're describing a failure mode where a service provider is about to be screwed out of compensation and is willing to settle for less just to get something.

It's hard to believe you're advocating so hard for something so inhumane and dysfunctional.

Ironically the proposed solution is usually to put the government in charge, which is far larger and more violent than any private company.

Every medical insurance claim denied in bad faith is an assault if it leads to delay in care, and if it leads to death, is a murder. I suspect if you take that lens, you will see that the government insurance is not the violent one here.

45,000 people die each year in the US without care. Ending that would go a long way to reducing government violence. [1]

[1] https://news.harvard.edu/gazette/story/2009/09/new-study-fin...

And if you define paper cuts as murder, then libraries are the real killers. Do you really want to put your insurance paperwork on the same level as innocents getting bombed?

If they're dead either way, then the same liability should exist. Does it really matter how?

Who's dying of paper cuts? It's easy to see who's dying of denied insurance

That's a non sequitur. Even single payer systems deny certain treatments or force patients to wait in order to control costs. Every healthcare system has some form of rationing.

I said denied in bad faith - not due to capacity constraints - which roughly amounts to claims denied with the intent of maximizing profit instead of upholding the duty of care.

It’s also a poverty of imagination that death is the worst thing that can happen.

Further there is also a general societal argument that we all benefit more from having a more healthy population than dealing with the external costs of a less healthy one.

Why doesn't the pay-up-or die model apply to food or shelter?

If you found yourself in a situation where getting food or shelter now was a matter of life and death, and you effectively had only one supplier, it would. But you usually have time to find alternatives, and usually can skip the shelter altogether, and the markets are so large that it's usually hard for a supplier to form a monopoly or a few to form oligopoly.

On top of that, even "pay-up-or-die" doesn't mean that the price will be a billion dollars. Instead, it means that it's the price that maximizes total profits. Suppose that no one could ever pay more than $30,000 for the medical helicopter. Then the helicopter people would set a price that prompts people to pay as close to $30,000 as they can. Perhaps if patients see a bill for $50,000 they negotiate down to $30,000, but if they see $500,000, they go to court and only at the end pay $30,000. Similar dynamics can limit food prices in areas that really only have one food supplier - there's only so much you can charge, and if you charge more than that, you won't succeed in squeezing more out of them, but you may attract all kinds of trouble - violence, or legislation, or competitors, etc.

So you think that farmers sell corn at the prices because they fear they will get robbed or plundered otherwise, but hospitals fear no plunder?

No. I think I covered that with "the markets are so large that it's usually hard for a supplier to form a monopoly or a few to form oligopoly."

Healthcare market is really big as well. Why is it easy to build a monopoly there?

It's really not. Generally you're limited to two or three insurance providers in a state and in range of your car accident, about one hospital.

The thing is, government intervention is probably the biggest way the wolves take over. They distort the market to their benefit using governmental force (aka. regulation)

I can't imagine why I am so unmoved by this tale of woe of the horrible government intervention.

This article may change your mind [1].

It's an NPR interview with Cigna's former head of corporate comms, an executive in charge of pushing lies about socialized medicine. He has since come to terms with what he'd done and is working to undo the harm he has caused to the American people.

"Canada has done a better job [re: COVID], I think, because of having the kind of health care system you have in making sure that everyone who needs to be treated is treated. And so that was what prompted that. And I felt that to provide some context, I needed to describe what I used to do for a living to try to scare people away from the Canadian health care system because insurance companies fear that. They know that if the U.S. moves to a system like that, it would certainly put a real crimp in their profits."

"Our industry PR and lobbying group, AHIP, supplied my colleagues and me with cherry-picked data and anecdotes to make people think Canadians wait endlessly for their care. It's a lie. And I'll always regret the disservice I did to folks on both sides of the border."

[1] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...

Who are wolves, the government? If so, I'd be open to suggestions on how the problems can be solved some other way. There's not much regulation related to healthcare pricing at the moment, and between bankruptcies related to medical debt & lack of coverage leading to preventable illness or death, it seems like the wolves are already in control of the system.

> This issue isn't that people are trying to maximize profit leading to issues.

This is exactly the issue. You cannot seriously think that the trainwreck that is US healthcare is what it is solely because of government intereference?

Would Cigna fund and run the tiny little community clinics that serve with sliding-scale pricing? Would Kaiser willingly insure students with preexisting conditions at a fair price? (I know that in my case, they wouldn't)

What "free market" incentive is there for these insurance companies to cover people that would clearly cost them more money than they receive? Those people need help and sickness/viruses do not have any concept of money, and they effect people indiscriminately.

You are promoting a healthcare system for the wealthy and privileged, which is exactly what we have right now and what needs to be torn down.

For actual free market, you would need to get ride of most regulations.

Basically like going to the vet. Or dentist or cosmetic surgery.

Fairly cheap, fine “most” of the time. Sometimes it’s not.

Even then it would not be truly free because you would need to make decisions in a medical emergency with limited options. It would be like shopping for a dentist with an abscess that could kill you tomorrow.

That would only apply to the 10% of medical costs spent on emergency care. It makes little sense to operate the other 90% based on requirements that don't exist in those cases.

Emergency care is also inherently local. You could operate emergency rooms under the same framework as you do fire departments.

Which doesn't require a national fire department to manufacture the fire extinguishers you buy for your house or repair the damage to your car a week after a car accident.

But also doesn't require fire insurance for someone to try pulling you out of a burning building.

I think diseases that take longer but are still affecting your quality of life are just as important to consider, but also think they distort decision making and fail to work like a free market as a result. The "free market" has failed to provide affordable dental care outside large insurance policies, which are inaccessible to almost a quarter of americans, for example. https://www.coloniallife.com/employer-resource-center/2018/a...

> But also doesn't require fire insurance for someone to try pulling you out of a burning building.

Right, so your city should operate an emergency room funded mostly by taxpayers, and then just charge a fixed deductible (e.g. $1000) for emergency care, which isn't enough to induce bankruptcy in general but is enough to deter people from using it in place of primary care.

> The "free market" has failed to provide affordable dental care outside large insurance policies, which are inaccessible to almost a quarter of americans, for example.

Your link is to the promotional material of a dental insurance company.

Dental isn't generally a market that requires insurance. You need health insurance because heart surgery or chemotherapy is a six figure expense that would bankrupt nearly everyone. Paying $1500 for dental work doesn't require insurance, it requires a payment plan. It isn't an expense large enough to require insuring against.

> Right, so your city should operate an emergency room funded mostly by taxpayers, and then just charge a fixed deductible (e.g. $1000) for emergency care, which isn't enough to induce bankruptcy in general but is enough to deter people from using it in place of primary care

This is just a public option that covers little and without the bargaining power on price a state has versus a city, right? Why wouldn't the same logic go for a larger entity taking up the mantle? And if we treat only emergencies with the plan, we incentize poor people to ignore cheaper preventative care in the market based system, and to wait until it becomes an emergency that costs many multiples to fix.

> Dental isn't generally a market that requires insurance.

Also from that link, in practice most uninsured americans just don't seek dental care. This matches my personal experience of being uninsured.

The latter is probably not causal - poor Americans have no money for either insurance or dental care, whereas non-poor would pay for retail dental anyway, but they also mostly have insurance.

The end result is still broken for nearly a quarter of americans and could be fixed with state sponsored care. That dental care is tolerated to be this way is not a good argument for free markets in healthcare working, to me at least.

I do not believe that is the primary driver of costs, but it definitely does not help.

For those who don't know what we're talking about, private equity looks for companies with stable revenue streams such that if you find days to make lots of cuts, the revenue stream will continue for a long time. They then strike an agreement with the current owner to buy the company by having the company take a large loan (actually issue bonds, but it comes to the same thing) to pay off the current owners. That's called a "leveraged buyout" (in finance debt is often called leverage).

They then make those cuts and use the difference between revenue and costs to pay off the debt. They then try to juice up the corpse in various ways to find someone to sell the company to before the long-term impact of the cuts becomes obvious.

This happens in any industry with stable revenue streams. And healthcare has exactly that characteristic.

See https://ourfuture.org/20120913/sick-money-how-mitt-romneys-b... for an article on this exact phenomena.

Has anyone tried to figure out meaningful changes to to laws/regulations to make such private equity raiding unprofitable or attach financial/legal liability for the negative consequences to the people responsible?

It has completely ruined hundreds of industries: driving out all of the experts, wrecking product quality, making companies unresponsive to customers, eliminating good jobs, ....

For notable examples, Sears & Toys R Us make for interesting reading.

If they do actually exist - free markets only work when there is a clear distinction between the buyers and sellers of the good and services.

This just doesn't exist in healthcare in the US.

IMHO, healthcare should either be full retail or single payer - nothing in between. Even if you are a "free market advocate", the current system doesn't reward the customer (unless you rightfully deem Carrier's as the customers).

In practice, "free market" as a historically implemented policy has meant "remove all oversight and revoke any protections or governing laws and thus legalize all business practices (such as scams, collusion, price fixing, market manipulations) regardless of ethics and hand the legislative pen to the business leaders to write their own laws.

Ban all forms of community governance, municipal ownership, or a people doing something for their community without using a for profit private company middleman.

Defund and gut any form of a social safety net. Disallow people to challenge a company polluting their drinking water and shut down the agencies tasked to inspect it. Forbid places from passing clean air laws or having the power to say no to any predatory company that wants to come to town

Allow companies to sue entire countries in secret tribunals if a country decides to not eviscerate their health and safety standards. Disallow countries from preferring local industry or keeping out vulture capital doing pump and dump schemes on their water and food supply. Protect these companies by international private militias that have an authority which overrides the country's own military.

Enshrine this right in treaty law so no sovereign people can possibly override it or fight back without severe consequences. Embargo, tariff and boycott them if they don't join in.

Permit companies to hide how their products are produced, lie about abusive and child labor and hide their profits in tax shelters without any consequences whatsoever.

Allow banks to defraud customers with phony accounts, car companies to lie about emissions, energy companies to crash entire state economies, insiders to manipulate the libor rates, and create shell companies using tobashi schemes to hide losses and reverse tobashi schemes to hide profits, and then bail them out with public money when it doesn't work out.

And finally destroy public education and replace it with whatever influence peddler with deep pockets wants to pass off as curriculum so that the public doesn't ever catch on to how much they're getting robbed."

Then there's this slight of hand where the advocates talk about the theoretically heady version of free market and then do mental acrobatics to bridge the policy and theories together. It's a distraction so that all the effort to combat the chicanery is instead exhausted on debates and theory discussions so obtuse intellectualism instead of meaningful directed focussed political action occupies all the time of thought leaders.

It's just coercion exploitation and oppression based on raw capital wrapped with the union busting techniques that keep the con game going without any consequences. It's a giant hustle to snatch and grab profit while turning our back on centuries of progress all under a fraudulent banner labeled "freedom".

Even the right wingers on gab and parler are seeing this now. It's so clear.

Such a scam.

> In practice, "free market" as a historically implemented policy has meant "remove all oversight and revoke any protections or governing laws and thus legalize all business practices (such as scams, collusion, price fixing, market manipulations) regardless of ethics and hand the legislative pen to the business leaders to write their own laws.

The rule of law is important for free markets and breach of contracts needs to be punished to have a vibrant market.

Historically, those who legislate and wield power have not invoked it in that way.

That's the point. "Deregulation" is code for taking hundreds of laws and dumping them in a garbage bin. "Privatization" is code for stealing tax dollars and hiding it in offshore accounts.

I only care about the actual, real world material reality that has historically factually happened. The champions politic in a way that tends strongly away from rule of law as quickly as possible.

It's a framework that gets invoked to go both ways. It's a vendor's "freedom" to not have to label, say, gmo, but then it's the vendor's "rights" to prohibit soy milk from using the label "milk".

"Freedoms" and "rights" get interchanged to rationalize the preconfigured results. The dogma is a general tool.

It was the "freedom" of agrobusiness to flood mexico with corn after NAFTA and run the local farmers out of business and then it was their "rights" to the marketplace when mexico pushed back. The farmers didn't have that same right to the marketplace, they didn't have the same freedoms, only international capital does. How convenient.

That's why the zealots always think it's the right answer - it can be reshaped like a mound of clay to justify and rationalize whatever they want.

For instance the sanctity of contract matters when it's with the gas pipeline company but not when it's with the american tribes

When instead it's a pipeline of people via a subway through a wealthy neighborhood like the purple line extension in Beverly hills, all of a sudden the free market gets invoked to guess what? Reach the opposite conclusion.

It's fundamentally a convenient power tool of capital. They used to use the Bible, now they use Friedrich Hayek. Skullduggery with the purest, most heavenly goals. Sure...

In practice, free markets are lawless raw power that bend the state to do their bidding like some feudal king, but now it's wearing a bowtie and a cardigan instead of a sceptre and a robe.

Same thing, different era.

> "Deregulation" is code for taking hundreds of laws and dumping them in a garbage bin

Or regulation is taking things from the garbage bin and make them into law.

> "Privatization" is code for stealing tax dollars and hiding it in offshore accounts.

If tax dollars are being stolen, it is the government that is doing both the tax collection and allowing the tax plundering.

> For instance the sanctity of contract matters when it's with the gas pipeline company but not when it's with the american tribes

What you really want is more free markets: that is, more rule of law, law that can be applied systematically and with no discretion and discrimination. You mention the enemy over and over: the coerced state that does terrible biddings. But you then exempt government as if it were innocent first and corrupted later.

It is the mechanism by which you decide on economic matters by power that produces the vast majority of the issues you mention, way above the famous "market failures" and unaccounted externalities.

Every business offense I mentioned is orchestrated through government. As a tool of exploitation and enforcement, they're utterly inseparable. Concentrating the gain + spreading the cost requires both.

Capital and governance (CG) have been the internal organs of the body politic forever.

Hacker news, facebook, an elementary school, every institution is CG.

The theoretical framework of free markets requires the fiction that they are somehow separate and independent!

It's imaginary rubbish.

Corporations were started by the crown and modern political empires grew because of their corporate needs.

They expanded together. Every. Single. Time. Always.

The free marketeers think they can ignore all history and merely, through zero evidence intellectual exercise, derive absolute truth that needs no confirmation, measurement or testing because by logical deduction alone they know The Truth.

They use rubbish homo economicus behavioral models, rubbish ideas of clean governance and capital separation, and the rubbish assumption that companies win by playing by the rules instead of the reality where they find a new exploit.

That's why it's a scam. It's based on a classic scapegoating shell game and then uses classic cult systems to ignore evidence or question a priori assumptions.

It's the same internal logic as astrology and horoscopes. Complicated models, no reality check, cherry picked evidence, projected interpretations, same thing.

Total nonsense. It belongs in the spirituality section

I agree with the notion that everything is related to governance, and free markets are not anarchy. But it is a proposal of a system that requires a set of rules, some nowadays unavoidably performed by government, but the key are the rules not the government.

In any case, I see the same corruption you see, and the question is how to go about it. If the state is powerful and corruptible, I want a smaller state, with less surface to be corrupted. And it is surprising how you can reveal most corruption by just the simple application of freedom: that's whats appealing of the free market framework.

My advocacy is to reject all dogmatic ideological frameworks, they are fundamentally the wrong approach.

"Smaller state, larger state" no... Those are answers without considering the questions.

Heterodoxy, material analysis, material goals, provable statements, methodologies of measurements and metrics...

That and not disconnected faith based theory opinions are what matter. Labeling things as whatever-alist is a just a silly sports game for tribalists as if it's more important to pass a purity test than it is to construct a positive functioning society.

Whether a solution makes the state bigger or smaller is irrelevant.

What is the efficacy for the effort trade-off, that's really it.

Any commitment to a theoretical purity sets one up for a blindness and bias of analysis and an easy way to be exploited.

That's why televangelists can so blatantly and openly rip people off. The purity theory blinds the faithful. This is true for socialism, capitalism, syndicalism, anarchism, all of them

Having capital is power though, so by that logic, having capitalists in a free market causes market failures

Power is being used very loosely here. The power to use violence is very difference to the "power" you get from producing something that is so good that gives you a lot of leverage.

The best way to beat a company that has market power is with other companies that fight in the same space or around it. And if there is one last man standing to reap profits from the victory, its again not necessarily bad. Market monopolies are overblown ghosts.

Nonsense. The absolutely last thing a company wants to do is compete. They avoid competition at all costs.

The first instinct is to buy, then shut it down, then smother it out with sheer capital, then retreat either up or downmarket.

That's why when you go in to the supermarket to look at commodities, they're often owned by either 1 or 2 companies that are mutually invested in each other.

You see a bunch of brands, but the capital ownership structure is almost entirely consolidated. Better products get dragged to court by existing players who try to shut them down or legislatives get greased palms for new regulations ("protected" terms).

In instances where this can't happen there's cartel systems which is why the dominant grocery store changes city by city.

The Austrian model of how humans work is dead wrong, how markets work is dead wrong, how capital flows is dead wrong, they're just wrong wrong wrong.

That's why they never use any examples and only have theoretical exercises, because there's absolutely zero evidence for their claims. Any observation of reality would show they're incorrect in a multitude of ways at every step.

That's why when you look at economics texts before the classical liberalism hubris, it is full of actual historical events, actual earnings and economic history to use as evidence and it's why the Chicago quacks had to tear those parts out, because their ideas don't work when you look at reality. If you look at evidence, their theories don't agree with it. They know this and that's why they don't use anything more than broad non-specific folksy anecdotal stories, because narrative fiction is the closest thing to reality they can get.

What a bunch of baloney.

Enter any store in a free market economy and you’ll see a plethora of excellent products brought about by competition-driven innovation.

Enter any store in a planned-economy country and you’ll see empty shelves.

I completely reject your red-baiting witch-hunt assuming I'm a socialist because essentially all of mainstream modern economics have been calling the austrians out on their bullshit for almost 20 years now.

The ideal "free market" requires an insane level of planning.

Perfect knowledge. Perfect competition, no friction to switch loyalties, oversight of m&a to avoid the different classes of -opolies. Securing those rights are insanely complicated.

It's extremely bureaucratic and has vast overhead costs. Regulatory bodies, thousands of pages of rules, committees, it's insanely mind bogglingly planned.

That's why you need certified specialists to do anything in free market societies.

It's planned but this planning is not based on reality which is why everything keeps going crazy all the time.

The free market is a purely dogmatic ideological project, not based on any actual material evidence.

So I totally reject that bogus Hoover institute style premise.

These theoreticians set up a fraudulent spilt that doesn't exist, then states a false thing about them, and says 'ho take that'.

It's like someone trying to prove things with astrology charts. There's an internal logic to it but that actually doesn't matter because it's all disconnected fakery to begin with.

Nobody is talking about your "ideal free market". I saw you mention it on another threads and let me make this clear: we are only talking about the regular, imperfect, free market. Free as in free of government interference, not some other ideal. Free as in everybody is free to participate.

And its not binary, either. You can have it completely free, freer, free-ish, all the way to lightly regulated, heavily regulated, planned and completely locked down.

Finally, I am not talking from economists' perspective, but from that of the regular guy on the street who is just able to see policies and their result. But my conclusion is extremely simple: the freer the market is the better everybody (other than profiteers, bureaucrats and politicians) is.

A handy guide to check if healthcare is a free market:

1) Can you buy medicine from whoever sells it cheapest?

2) Can you hire the healthcare provider you want?

3) Are you financially punished for choosing your own health insurance?

4) Can you opt-out of government health services?

5) Can you waiver or partially waiver your right to sue the medical professional in exchange for cheaper services?

6) can you pay any odd person off the street to open you up and take out your appendix?

What a nice world that would be, wouldn't it.

Also don’t forget the supply side: Can you open a healthcare service? Hospital? Medicine factory? If you actually have the required knowledge, how fast can you get the certifications to work as a healthcare provider?

The reason healthcare is not a free market in the US are not market's fault etc. The govt restricts supply, subsidizes demand directly, and also created the system where insurance is tied to work so the major consumers are completely price insensitive... that is why healthcare is expensive.

> participants are typically under duress when seeking expensive services

I'm not from US and don't have personal experience with american health system, but that would only be true if you start shopping for medical insurance when you already have broken your leg.

If you behave as a responsible adult and choose a hospital to register to, or an insurance provider to take care of you, beforehand, how are you under any kind of duress?

> The free market just doesn't work

And where did you experience free market healthcare out of curiosity? In the US there is no such thing.

The only statistic you need to know to justify America being a shitty country with even shittier healthcare is that it is only one of two countries in the entire world that allow pharma companies to directly advertise to consumers.

New Zealand is the other country that allows it and they seem generally satisfied with their healthcare system.

And that the other country only allowed it under pressure from the US for a trade agreement.

I've become more staunchly single payer after I had my first major medical hurdle of my adult life this year. I had switched insurance in January, but apparently my old insurance had a bug in their system. The effect was that they were accepting my claims, but then denying them. So I had to coordinate both insurances and get them on the same page. Then I had to call every one of my many providers, get them to understand, and then get them to reprocess the claim on their end. It was miserable and I had to deal with it while I was still dealing with a broken wrist and just hoping everything would work out.

I feel awful for anyone who has to deal with that and has less time than me. I had to take notes during every phone call and get the numbers of customer reps so they could vouch for what I was saying

Imagine having to do this every time you change jobs.

Yup, last employer had me on a different plan then I signed up for. Went round and round with the employer and the insurer. Of course it was the others fault.

Finally talked to DoL guy and they told me it's absolutely the employers responsibility. They kept going back and forth with me. This was about and $1800 difference in out of pocket max, not in my favor...

Finally they fixed it, but only for my wife. Since she had the majority of the bills due to a surgery, the insurance clawed back a bunch of smaller stuff they had already paid. So that cost me about a $1k. I guess I'm going to have to sue in small claims, which is what the DoL guy recommended.

“The free market will solve everything” is a seductive idea because of its simplicity. “Just let the free market solve it. Oh, there’s a problem? It’s because the market is not ‘free’ enough.” The reality is more complicated. We need a balance of a healthy market forces and regulations to prevent the exploitation of people and the environment. But that’s a lot of work, and not as elegant sounding of a solution as, “let the market figure it out.”

I've been saying this for a long time.

Supply and demand don't apply to healthcare.

You can only adjust supply.

Peoples demand for their health is infinite.

The out of network care at an in-network hospital, is the absolute worst. In a similar vein, my wife's insurance was supposed to cover "out-of-network" ER visits. So one night that we had to go the ER we went to an out-of-network hospital ER because there wasn't an in-network one close by. Turns out that the coverage of the out-of-network ER visit basically just covers the cost of the bed in the ER, every treatment that you get (IV, vitals check, medication) is considered out-of-network treatment. This resulted in an absolutely insane bill with charges like $250 for administering oxygen monitor (you know the things you can buy at Wallgreens for $30) or $300 for ibuprofen.

Network scope existing at all baffles me. Insurance companies become the ultimate deciders of which hospitals are worthy and which aren’t instead of government certification agencies. Seems like an open door to malevolence.

While being only slightly sarcastic, maybe it's time to put a sign on the door "If you're not covered by health plan XXX, please do not come in this room." That we have to even joke about such things is beyond ridiculous.

>the out of network specialist at an in-network hospital

The worst. After a $2k bill, I learned my lesson to check every doctor that attends me for coverage even if it is in an in-network hospital.

I don't have any opinions about what the perfect system here is, but I think it's safe to safe say that medicine does not work well as a free market. You don't get to access a free market within the confines of hospital walls when there is an emergency. Moreover, your decisions as a rational actor are impaired because you are being asked to put a price on your own life or quality of life. There is almost no way to make this business not predatory under those circumstances.

We just need to mandate reference based pricing. This automatically goes away and also removes other huge parts of the wasted health care spend. Additionally, it doesn't require new taxes at all.

As an immigrant coming to America, honestly the most shocking and surprising thing (apart from the state of homeless in San Francisco being tolerated as normal) is the medical care expenses. How on Earth is it that I can walk into a doctor's office or hospital to get medical treatment and have no idea how much it's going to cost? $10? $100? $1000? Who knows. I had an ear infection once, went to the doctor who looked at it for a minute and said "give it a few days". I assumed this would cost maybe $20 or something? Nope. $400. There's just no way of even knowing. In no other industry would you buy something without knowing the price ahead of time. With medical care it's even more screwed up because, well, it's your health? You're generally more desperate for services now, so it's not like shopping around for clothes or something.

It's safe to assume talking to a doctor is a minimum of $400. Any labs or testing, another $400. Surgery starts in the thousands. Life saving care is the same cost as a house.

It's not though. Sometimes a simple visit is like $20 or even free.

If you have insurance that doesn't have a deductible or it's preventative care, sure. I'm talking paying cash or insurance with high deductible

As someone who is now figuring out how to deal with a 20K charge because one of the surgeons consulted was out-of-network (and EVERYTHING including the anesthesiologist, primary surgeon, hospital care was all in-network)... that last part is the most insane for me...

Before my last surgery they offered me crutches and I asked if that was all covered by my insurance and specifically was it in-network with my provider. Imagine if it wasn't and some poor sap thinks... yes I should take crutches after a leg surgery and gets stacked with a massive upcharge

15k for an airlift honestly sounds cheap all things considered, but the surprise out of network doctor is such bullshit it should have been fixed ages ago. It's one thing when you had to go to the ER, but even when your visit was planned they can spring you with that.

> into a believer in single payer healthcare.

That isn't the part of the market which is broken though. The insurance companies want their vig, and they have no objection to cost increases because then they get the same percentage of a larger pot, but they're not actually where most of the money goes.

It's really going to drug companies and medical devices companies and doctors and hospitals. Which all still exist even with single payer, and not only that but then have even less price sensitive customers (more unnecessary tests/treatments/procedures) and have a greater opportunity to have their lobbyists turn open the money spigot, because now it's tax dollars -- or government debt -- instead of insurance premiums that customers would balk at and switch to a less expensive plan when the price exceeds a given threshold.

So you still need the very things they're lobbying against. You need something to make patients price sensitive enough to refuse over-treatment. You need some kind of price setting mechanism that works better than giving the most money to the company with the best lobbyists. Single payer doesn't get you that.

What you're saying is that health care needs to stop being about health, I think.

The price sensitivity you're looking for is "yeah, you can pay 5k less for your broken arm, but they'll be cutting it off instead of setting it"

I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room

That could present a rather interesting legal challenge...

Say you state "I can only allow care from in-network physicians/personnel" - will they take that as you outright refusing care if they're not in-network?

And if they decide they're not going to care for you because of this, and you end up dying, what would be the recourse? Did the personnel (esp. doctors) still have a duty to care for you? Or else on what exact basis would they conclude you refused care and let you die?

It's good to keep in mind that not all medical services are price inelastic in the sense that ambulance costs or emergency hospital visits are.

GP visits/non-emergency general surgeries/general medicines - just like food, are all necessities for survival, and are all locally price elastic, with the exception of medicines that have regulatory capture - not a free market, such as insulin which is many X the cost in the US because of a government-enforced oligopoly.

This means that no single supplier (whether of food or non-emergency medicine) can raise their prices because consumers have time to find a cheaper alternative. Unless they collude, which is illegal, and impractical for many markets such as GP visits.

For these particular goods, does your view differ, when compared to emergency services which we agree are price inelastic? And if not, how do such services differ to the foods market - holding aside regulatory capture of things such as insulin which we both probably agree is not a good thing?

What if they don't even come into the room? I experienced this incredible phenomenon a couple years ago after taking my son to the ER while out of state on vacation. We were there for a few hours to have a very horror movie-esc swollen lymph node looked at. He needed a CT scan to confirm that it was not an abscess and some IV antibiotics for strep. The doctor and nurses were great, I paid up front, and additionally provided insurance. Seemed like everything went smoothly. Three months later we received a bill for $2500 from a doctor we had not seen. Insurance had adjusted it from $3800. Perhaps he was the attending physician and the doctor we saw consulted with him. I have no idea and no one told me anything about it.

My wife, being the litigious trial attorney that she is, sent the physician's group a letter disputing the bill, requesting documentation that this doctor did in fact work on my son's case, and putting them on notice that she would fight them on principle over the amount of the bill. A couple of weeks later we got a letter stating that despite the fact that the charges were in fact valid, they would adjust the amount owed to $0.

A friend I related this to commented, "yup, they just wrote you off because there are so many more people that they can go after and not fight with that it just isn't worth it to them."

What a sad commentary on healthcare in America.

So they are basically bullies that exploit the weak and defenseless and are afraid of people that fight back.

Nothing is "free market" about a current system.

• You're forced to buy health insurance.

• You can't choose any doctor you like one you have the insurance.

• You can't shop around for the best price, because the prices are not shown.

• You're not given an estimate of how much a procedure would cost.

• You can't choose which doctors visit your hospital room (and every time they do, you pay for it).

> Surprise bills happen when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to a hospital that accepts their insurance, for example, but get treated there by an emergency room physician who doesn’t. Such doctors often bill those patients for large fees, far higher than what health plans typically pay.

How do courts uphold this? You go to a restaurant, they say you can buy the tasting menu for $100, but they have a temp chef working that day which will cost you $50 extra, which you find out as you're paying.

I mean you might even be unconscious when this is happening?

EDIT

Actually someone brought up an important point. If you go to a restaurant, you are kinda expected to know that there's taxes and tipping to pay. Do the US courts think the same of healthcare? "You were in a hospital, you should have known that the bill is always higher than the sticker price?"

It would surprise me as a European.

From what I know about the US even your restaurant example has hidden service fees and mandatory tips and taxes that aren't on the menu?

But generally the tips and taxes is something you know about if you are a US resident. And you might not be unconscious at the time of payment :) And restaurant staff getting paid a decent wage without relying on tips is also something that should get fixed sooner than later.

Every restaurant I've been to with mandatory tips or fees has it written on the bottom of each page. The only shady thing I've seen them do is add the mandatory tip, then give you the bill with an option for an additional tip, hoping people will forget that the tip was already included in the bill.

not really the same. tipping is a custom, but it's not legally required unless the restaurant clearly states that it will be added to the bill.

sales tax is not really a hidden fee. americans usually know the general sales tax for their state. it gets a bit more complicated with specific excise taxes (eg, alcohol), but these rates are publicly available. if you're really concerned, you can always just ask your server or their manager what the after-tax cost of an item on the menu is.

even if you know exactly what medical procedure will be performed, it is still pretty hard to get an exact quote for the cost. it certainly can't be calculated from freely available numbers.

No hidden service fees. Taxing is not so simple in the US. My county has a lower sales tax rate than other counties around me. When I worked as a waiter the municipality had a special tax on alcohol in addition to the county and states alcohol and regular sales taxes.

> Taxing is not so simple in the US

Isn't this an argument for including taxes final prices, so people don't have to keep track of this? Maybe you're travelling. And it isn't like businesses don't already have to keep track of it for the bill. But instead of requiring businesses to print accurate menus or price labels, the burden is put on the customer to have this detailed knowledge, no matter where they go?

I guess the only two reasons I can think of for this not to happen is so that people have a less intuitive sense/transparency in what taxes the municipality/county/states impose, and so big multi-nationals can show the same "price" in different locations or ad campaigns. None of which ultimately helps the consumer.

To bring it back to the original issue, I guess people don't usually notice because taxes aren't orders of magnitude different, unlike some medical expenses. If you had a beer on holiday, and then found out it was taxed at 200% or even 2000% instead of 20%, you'd be rightfully mad.

Psychologically, if they quote to you the price without taxes, it looks cheaper even if you know about the extra 20% in sales tax and service fees and city tax and and...

Someone showed me the bill from some street corner food vendor in SF. It had like 4 taxes on it over the advertised price.

Some people wear a tag with their blood group on it.

Perhaps we should be wearing tags with the amount of money we're willing to spend on a hospital visit.

I have joked before that I should wear an undershirt that says “Healthcare accepted only by in network providers <insurance ID #>. If out of network, stay away and let me die”.

I'm curious, would this even be essentially "accepted" by any hospital in the US? Not just a tag, but if you were going in for a procedure, could you even say "I want to be sure I will not be treated by anyone not covered by my insurance plan"? Because basically all the forms you need to sign upon admittance essentially say "We can charge you whatever we want and you are responsible for paying it."

I would probably refer to the ethics dilemmas around "do not resuscitate" tattoos as the closest analog that I've heard about.

They would tell you that you need to talk to billing, and billing would tell you they can't provide pricing at all and they can only tell you after going through your insurance, or they would require a zillion digit billing code that only your doctors can provide, and your doctors are not going to waste their time giving you the list of a thousand codes for whatever operation you're doing, or at least not accurately.

In short there is no way. Either you accept treatment and you're billed what you're billed and you hope insurance only fucks you over a little bit, or you're denied any service short of immediate life saving.

Whenever I took my vehicles in for service at a dealership, they would always provide a form for me to sign to pre-authorize any work they deem necessary. I always leave those forms blank. Never had an issue.

Whenever I go to a new doctor or medical facility, they always ask for tons of personal information such as my social security number. I always leave most of that blank. Never had a problem.

I've never been asked to write a blank check for a medical operation like I have at a dealership, but perhaps we should just make such practices illegal?

That's interesting. My mechanic always provides an estimate, then I sign something authorizing up to that estimate and that requires them to separately approve any further funding.

The courts can only act where there is law. It's a legal system, not an inherent fairness system -- current law upholds the status quo, which is why this measure passing is good news.

> you are kinda expected to know that there's taxes and tipping to pay

Also not reasonable, so at least in Spain the menu has to include VAT.

"How do courts uphold this? You go to a restaurant, they say you can buy the tasting menu for $100, but they have a temp chef working that day which will cost you $50 extra, which you find out as you're paying. "

In the US you go to a hospital and basically sign a contract "you can charge me for whatever you feel like". What surprises me is that they get away with often charging for stuff that never happened. When you confront them they just say "Oops!" ad take it off only to try it again next time. I don't understand how they get away with that.

> I don't understand how they get away with that.

99% of people don't confront them.

> and tipping to pay

Tipping is demeaning and derogatory to the person being tipped, especially in the manner it is done. Also, it can be reason for discrimination against the expected tipper. It always astounds me how people (mostly a lot of Americans) defend this practice just calling it "custom" and that it helps the receiver.

> Tipping is demeaning and derogatory to the person being tipped, especially in the manner it is done.

Why?

> Some private-equity firms have turned this kind of billing into a robust business model, buying emergency room doctor groups and moving the providers out of network so they could bill larger fees.

If this doesn’t describe evil, I don’t know what else would.

It should be illegal

I wouldn't reject this out of hand, but I do find that the complexities around healthcare and the obvious political implications lead to a lot of exaggeration and outright falsehoods being propagated.

it's my understanding that the affordable care act requires insurers to treat any emergency services (if covered at all) as in-network. can anyone explain either a.) how I am wrong, or b.) how this can be circumvented?

> complexities

This. Does anyone know if the Founding Fathers discussed the evils of complexity in law back during the conventions in Philadelphia? Is that a more modern day problem, or is it as old as parliament itself? I don't remember reading anything that said the dangers of complexity in law was on their radar.

Businesses are guaranteed to take advantage of complexities in law. I don't think this is well enough known. Any and every added complexity will therefore be taken advantage of, and should be considered in passing a law, and every law should have some type of way to "expire" itself, so that it can be removed (and the resulting complexity), when the reasoning for such law is gone.

Complexity around healthcare laws is the textbook example.

See here[1] for a pretty good explanation. Importantly, your insurer treating the visit as in-network does not force the provider to treat it as in-network; surprise bills come from the provider, not the insurer. From that post:

If the insurer pays less than the out-of-network emergency room bills, the emergency room can send you a balance bill for the difference, over and above the deductible and coinsurance amounts you pay.

That “if” condition is usually going to hold, so a lot of surprise bills come out even despite the ACA rule.

[1] https://www.verywellhealth.com/get-in-network-rates-out-of-n...

And this still happens in Texas where it is suppose to be illegal as well. I called provider multiple times and explained the rate from my insurer. They of course sent to collections, but they know they can't enforce it in court, but that doesn't matter. Most people are just going to pay.

What really got to me was it was ER visit and the Doc(extortionist) spent maybe 5 minutes with me before having the nurse fix me up. After insurance $250 to hospital, and $2000 bill for the Doc.

Regarding how it can be circumvented, insurance companies, in my experience, try to say that this or that service was not actually part of the emergency.

For instance, they may want to begin some of the long term maintenance of your new condition while you're still in the hospital. Whether the insurance company is successful or not, they may at least try to say this isn't covered.

Eventually, you and your loved one are dealing with one of the worst moments of your life, how much time do you have to fight all their attempts at not paying your benefits? Keep in mind the fights happen during business hours, and you just missed four weeks of work and need the job to keep the insurance you now need more than ever.

Laws that reduce the number of ways insurance companies can avoid paying will be helpful.

> and you just missed four weeks of work and need the job to keep the insurance you now need more than ever.

Just a note, if you're in the US and a loved one is injured or ill there is the Family Medical Leave Act which should protect your job (in the short-term). It's not a huge safety net but if someone needs it it does help.

For my wife's emergency surgery, they paid the surgeon. But the surgery room, recovery room, and anesthesiologist - that was all determined to not be medically necessary. And they fought those bills for about 8 months before paying.

My wife went into anaphylaxis at an urgent care facility. The doctor there administered an epi and then called 911 to get an ambulance to the nearest hospital.

We ended up getting a >$2,000 bill for a 10 minute ambulance ride because the ambulance company was out-of-network. The ambulance company then had the audacity to send the bill to collections before the 30 day pay period even expired...

So yea, even if you have good insurance you can still get bit by these issues in emergencies! Unfortunately, this new bill does not even address the out of network ambulance issue.

It's hard to see how anyone could extol the virtues of a "free market system" where behavior like this exists. It is pervasive in American health care. Just search for "orphan drugs" if you are insufficiently outraged. [1]

[1] https://www.washingtonpost.com/news/wonk/wp/2017/12/18/this-...

the orphan drug issue is a result of pharmaceuticals being very much not a free market. consider how absurd it is that you can jack up the price for a product you don't even have a patent for by several thousand percent and still have it be uneconomic for anyone to undercut you. to me, this implies more of an issue with the overall regulatory environment than individual profit-seeking behavior.

I have some Libertarian minded friends and the go-to "solution" for just about every shortcoming in the healthcare system is for some other company to come along and "compete". In principle this would work (Libertarians are all about principles, by the way). But in practical terms there's too much money to be made using these dishonorable business practices and there is no viable competition.

Yeah most people when they say "free market" they want a fair market.

Capitalism works but the top and bottom and excessive cases need to be contained, usually those happen when there is monopoly, oligopoly, duopolies, collusion or massive wealth advantages resulting in a fixed leveraged market that is almost mafia state like.

The market is a garden, the large overgrown plants taking all resources need to be trimmed back and the seedlings need more support, this allows the garden to flourish for all when the edge cases and extremes are tuned.

Right now the mafia state oligarchy markets, disaster capitalists and state backed whole industries are fixed markets to the chagrin of fair market capitalists.

The game design needs to be tweaked, some overpowered ones nerfed, underpowered ones helped.

We like a game that is easy to approach and difficult to master, not difficult to approach and easy to master buying out competition with all that wealth leverage.

We would do better to say we want fair markets not free markets, because a fair market is more free to all participants, players want to play and can.

>If this doesn't describe evil, I don't know what else could.

Private prisons seem awfully close to slavery/indentured workers.

Nah, being evil implies there being a higher moral cause to one's actions. This is worse than evil, it's only pure uncaring avarice.

MBAs, duhh

Agreed. I read that this morning before seeing it on HN - and this sentence stuck out to me. These are the people who should be on the receiving end of a revolution.

I was working on a health insurance related startup for awhile so I would say I know more than the average person about the space, and even I get surprised on a regular basis by the absurdity in this field.

For example, I was finishing up an advanced degree program between September and January and my University decided to terminate my health insurance in September. Without telling me. In the middle of a pandemic. When I discovered this last week, I attempted to buy health insurance directly from insurers and was informed that I could not get coverage until January 1st of 2021 as I was "outside the eligibility window". They literally won't sell active coverage to me at any price. Apparently you only have two months after losing your insurance to be able to buy new insurance before having to wait until specific times in the year. I can buy home insurance, liability insurance, car insurance, and any other type of insurance whenever I want but god forbid I try to buy health insurance 61 days after an arbitrary point in the year. I effectively cannot go outside until January 1st as if I get covid and have to go to the hospital I'm screwed.

The intent here is to prevent people from gaming the system by buying insurance only right after a serious diagnosis.

There are several qualifying events to be able to enroll outside the eligibility window if you’ve had a job change for example.

>The intent here is to prevent people from gaming the system by buying insurance only right after a serious diagnosis.

Of course.. but, that's basically why health insurance should be "required" for everyone, because then it's not an issue.

Because if you are not gaming the system, and make a simple mistake by OP, it can be fucking life altering.

I was in a similar situation a few years ago. For whatever reason our auto payment stopped on the health insurance on a year-to-year rollover. I didn't notice, everything is on autopay. Sure it was my 'fault', but you know what the result was? I was uninsured for 9 months (except for a garbage plan I could find that I'm sure would have done almost nothing).. if something serious had happened I would have been FUCKED.

So yeah we can sit here and say all this bullshit about eligibility windows. But the truth of the matter is every one of these things just points to why the entire country should be covered.

It's honestly SICK how some people think healthcare should work. And honestly the amount of resources put into all the billing jobs and compliance and all the bullshit is STAGGERING. How much energy is wasted on the bullshit billing systems and rules which are just made to fuck people over who have health problems.

/rant off

Just as a heads up in case you or anyone else reading this is in this position. For the uninsured, if your treatment is directly related to Covid-19, you would be covered under the Covid-19 HRSA program described here. https://www.hrsa.gov/CovidUninsuredClaim

This is a huge relief; thank you for bringing this to my attention!

You can buy short term insurance. It is outside of the healthcare market place and typically does no cover pre-existing conditions (you have to qualify for it). I actually switched to it 100% as the premiums are way cheaper and I just want insurance against million dollar fees on the low chance I get cancer or I'm in an accident.

Would you mind linking to where you did this?

https://nationalgeneral.com/ -- then you want some form of "short term" health insurance.

I had to provide a urine sample to get my ADHD medication. It was sold to me under the auspices of drug testing, even though ADHD meds are out of your system in 48h. A month later I received an explanation of benefits from my insurance company that said they received a 14k bill and had paid 4k of it, so I was on the hook for the other 10k. Furious I went to my psych. They casually said “we’ve taken care of it, you shouldn’t receive an actual bill”. Uh, that’s not the point? The point is why was it necessary to send my urine for 14k in testing in the first place? You cannot convince me they weren’t getting kickbacks from this program. Finding a new psych is difficult, so the next time they asked me to pee in a cup I asked if they’d charge my insurance the same way again. I haven’t been asked for a urine sample since, which is odd considering they have signs clearly posted saying drug tests are mandatory. I guess not _that_ mandatory, huh?

It’s wild that individuals are forced to navigate this system, much less fight it when they’re being fucked. The idea that there are people who’s sole purpose is designing beurocratic gears to grind money out of sick people makes me sick. And they employ an army of low wage call center folks to do their bidding, work that I can’t imagine is super rewarding. How much better would the world be if we tore down these machines and paid all of those people to do literally anything else?

> You cannot convince me they weren’t getting kickbacks from this program.

Given all the problems this caused for the opioid epidemic I'm disappointed (but not surprised) such behaviors are still be legal.

At $14k/test, they could nearly afford to buy a used but functional GSMS system system just for you(!).

> I had to provide a urine sample to get my ADHD medication. It was sold to me under the auspices of drug testing, even though ADHD meds are out of your system in 48h.

FYI, they weren't checking for your ADHD medication. They were likely checking for marijuana.

* Marijuana can introduce side effects that basically make it look like you have ADHD

* Most ADHD medications are stimulants, they have counter indications when taken with marijuana

* Stimulant prescriptions are under scrutiny right now, so places have been doing more diligence

> A month later I received an explanation of benefits from my insurance company that said they received a 14k bill and had paid 4k of it, so I was on the hook for the other 10k. Furious I went to my psych. They casually said “we’ve taken care of it, you shouldn’t receive an actual bill”. Uh, that’s not the point? The point is why was it necessary to send my urine for 14k in testing in the first place?

The underlying problem is how a bunch of stuff gets billed. Basically your pysch and insurance company have a pre-negotiated rate for re-imbursement on this - it has little to no bearing on what you actually pay as a patient. It's pretty much all BS because there's a secondary system for resolving those bills.

It's that secondary system that really should be transparent, not just the "stated price" which everyone knows is BS.

I agree.

I've had some insight on the other side. I understand why it's the way it is, but as a patient/consumer it's impossible to understand what my healthcare costs are going to be.

Kickbacks from test labs, scan / x-ray centers are normal in India.

This is kinda the scary part of insurance, and it happens in every industry where insurance exists. It's very expensive for insurance companies to fight charges, so generally mechanics know a magic number they can give that is way higher than they'd charge you, but the insurance company wouldn't bother to fight.

Ever have work done on a car/boat and have the mechanic offer to pay your deductible? I've had it happen most of the time.

And this part of insurance is hard to fix simply because of how valuable people's time is, and the cost of the insurance company simply being wrong in the end (reputation hit, possible legal repercussions, and cost of the investigation).

The change does not apply to ambulances (except for air ambulances), ensuring the United States remains one of the few places in the world where a seriously ill person needs to debate if they're willing to risk their health and life to avoid a financially crippling trip to the hospital.

I was billed $3000 for a twenty minute ride to the hospital after somebody hit my car. I spent the time chatting with the EMTs. No treatment .

Send them a $4000 bill for your time!

"‘As I was being eaten, I was thinking about my insurance’: Woman who lost face in bear attack on why she’s voting for Bernie Sanders"

https://www.independent.co.uk/news/world/americas/us-electio...

Peak dystopia

/r/nottheonion

How any of you snakes on here can downvote this is beyond me.

I mean, I know who you are. People who have a great job and don't really have to worry about insurance. Or maybe at a university where insurance is probably covered well. So f everyone else, right?

I am self employed so I have to worry about paying all this shit myself; 11k family deductible with 40% co-insurance for $1200.

Every time my young kids have had something that was not like a massive emergency, you know what the thought is? Oh god is this worth going to the hospital for and spending 1k? Or when I had my own person health issues, my first thoughts are always how much is this going to fucking cost?

So yeah, if you think OPs link is exaggeration.. it sure as hell is not.

I found, being self-employed for a long time, that hardly anybody inside or outside the medical establishment understands how much health insurance costs for the self-employed (and what little you actually get for it). My first thoughts re: anything health-related are always costs. The treatment one receives from medical provider when they ask about costs is really degrading, too. (Try asking what a procedure for your _child_ will cost-- you really get treated badly for that.)

I was employed for about 5 years by a small tech firm that did not have a health plan (this was pre-ACA). They did pay a salary that was commensurately higher. I was able to buy an Anthem individual plan (family coverage) and it was reasonable. It was essentially equivalent to any other employer plan I've ever had except notably it did not cover maternity but that was OK as we were not having any more kids at that point.

The absolute best plan I was ever on was an HMO in the 1990s. No out of pocket for anything as long as you were referred by your primary care provider. Our first kid was born via emergency C-section and we never saw a bill for any of it.

I have no great job and I am paying more than 50% in taxes, including health care (not an insurance, but a payroll tax) that I get almost nothing from. That great change described in the article is bringing poor services to everyone, that is the end of it - I saw it in Eastern Europe, I saw it in Western Europe, but people don't want to talk about it. I live in Eastern Europe, decades in a socialist country and decades in a capitalist one, but all with socialized healthcare and that dream of free healthcare for all is an impossible utopia, you just need to think about it to realize.

> socialized healthcare and that dream of free healthcare for all is an impossible utopia, you just need to think about it to realize

I can't understand this argument when Canada, England, France, Israel, and many other countries already have healthcare that is totally free to people at the point of service, and people rave about it. Can you explain why you still think it's utopian when it already exists?

Because of limited resources in Canada they had waiting times of several years (Google can point to multiple sources), UK or Nederlands a few months (I have friends working as doctors in these countries) or, in Eastern Europe, you need to get your own drugs from home because the hospital does not have it. With the perceived "free healthcare" the use increases a lot and the limited resources cannot scale up to infinite, so you either have a very long wait time or get the almost nothing left.

This is the situation in most of countries with this system. It is mathematically impossible to get what you dream of. In countries like USA the demand is heavily filtered by prices, so people get what they afford to, if you take the filters out you will be left with nothing very fast. I hate the system in US, but at least it gives a chance to people who can afford it; here, everybody is equally screwed. The only thing that works well here is giving birth, that is free, you can cover that by the state or federal in US too, but that's about the limit.

> I hate the system in US, but at least it gives a chance to people who can afford it;

This is the temporarily embarrassed millionaire argument.

The system absolutely sucks for you right now, but you're putting up with that, because one day, ONE GLORIOUS DAY, in the future, when you are filthy rich, you want to be able to skip all the queues.

(There are plenty of countries with socialized healthcare that has a parallel private healthcare system that allows you to pay more to receive better/faster/customized care, so that's not actually an argument.)

well it's your word against that of many other people I've seen raving about their system. how about a reliable source that says that people are unhappy with it?

If you don't want to search, try this: https://www.fraserinstitute.org/studies/waiting-your-turn-wa.... Or on camera here: https://www.youtube.com/watch?v=q2jijuj1ysw

And there are more.

your sources are a conservative thinktank, and noted bigot and liar Steven Crowder

https://www.healthcare-now.org/blog/new-poll-shows-canadians... - Canadians Overwhelmingly Support Public Health Care

https://www.kingsfund.org.uk/projects/public-satisfaction-nh... - 60% public satisfaction with NHS

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2071992/ - "US has highest dissatisfaction with health care" (out of 7 industrialized countries they asked: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States)

I am talking about wait times, you are talking about satisfaction; they are different things.

You have demonstrated bad faith by moving the goalposts, therefore I am leaving this conversation.

>Because of limited resources in Canada they had waiting times of several years (Google can point to multiple sources), UK or Nederlands a few months

First, EVEN if what you are saying is true (spoiler alert- it's not). There are always private options if you really want to pay for it. So your argument of "there are wait times" basically goes away, because if you really want something "like you have now", you can pay and get it.

Next, what is better.. never being able to afford an elective/non urgent surgery, or wait 4-6 weeks (or perhaps even longer) for it? The point is you will get it and not go bankrupt.

And if it's urgent, you get it right away. Anything else you have heard is bullshit or has some other context you don't realize.

I mean, do you realize how many people in this country are living with conditions that probably even being able to go to a doctor on a regular basis would massively improve their life? But they can't afford it- even with "insurance".

>I hate the system in US, but at least it gives a chance to people who can afford it;

>here, everybody is equally screwed.

How do those two statements make any sense? You literally just said it gives a chance to people who can afford it... then claim everybody is equally screwed. No they aren't. It's like anything else- the top maybe 10-20% have no issues with it because they can afford it. So fuck everyone else right? The same top 10-20% who just love that the stock market booms during a pandemic because they can just continue to print more money.

Man your attitude pisses me off.

>The only thing that works well here is giving birth, that is free, you can cover that by the state or federal in US too

The hell are you talking about? "Insurance" covers birth yeah, but it'll still generally max out most peoples deductibles so it's still thousands and thousands of dollars... and heaven forbid you have a c-section or some other complicated birth.

Also, I lived in the UK for a number of years. We had so many trips to the doctor for our birth. Cost? Fucking 0. Yeah peoples taxes are a bit higher once you make descent money, but that's the damn point! People who can afford it are paying into a system that makes everyone better off.

We should be trying to make EVERYONE AS A WHOLE better off, not only the top 10-20% which is apparently what your logic is.

After my 2nd motorcycle accident, I refused the ambulance to the hospital to be checked out, because I was more afraid of 4 figure ambulance bills than I was of long term effects to my health

Last time I had to go to the emergency room, I was luckily enough to be in a state where I could just call an Uber.

This can be regulated at the state and local level; current state solutions had no ability to regulate air transit fees.

However even local government is getting in on this revenue stream. The last ambulance bill I saw (for a relative) was from the city’s fire department, which is already funded by (fairly high) property taxes.

I had an ambulance ride earlier this year and got hit with a four figure bill despite having good insurance. I did some digging and found that the ambulance company has an agreement with the county granting them a monopoly on emergency ambulance service. The agreement includes a set fee schedule, but it is very aggressive such that almost all rides will cost over $2000. The company is of course out-of-network for most insurance providers and they bill people for the remaining balance after insurance pays (balance billing). I wouldn't be at all surprised if there was some form of kick-back going on between the company and the county government.

Ambulance companies are flat-out extortionists and they should be charged as such. We've received bills that say in large print "Your insurance will not cover this", then when I call my provider says "Of course we cover it, send us the bill"

While the bill is working it's way though insurance we'll get new bills, every week or so, "We have not received payment and this account will be sent to a collection agency." Call the ambulance company and they say "oh nevermind, it's marked pending".

It's a scam. They want to scare you. They want to scare you out of getting a negotiated insurance rate. They want to scare you into paying before the insurance comes though. They want you to have to call them and fight to get your money back after insurance pays

When our youngest was born the nurses (incorrectly) thought his blood sugar was low and had him transferred to a different hospital via ambulance. We were able to fight and get the $2000 bill waived on account of the fact that it was a needless trip. Unfortunately my wife spent the night alone as I was with our son.

On a somewhat related note in the span of 10 years the cost to us to deliver our kids doubled. Same hospital too.

In most of the rest of the western world, the cost of childbirth is mainly the parking fee and snacks from a vending machine while waiting.

In Sweden we stayed at the hospital a few nights with both our sons. The parking was the biggest cost and food for me (my girlfriend got the food for free but I didn't).

This was a serious discussion my wife and I had when we were deciding to have a kid. The maximum out of pocket for both of us could easily wipe out my savings.

It felt really fucked up to have this discussion in what is supposed to be a first-world country. Like we were talking about alternatives like hiring a midwife or a doula because it would be cheaper. I don't even think that would be a discussion in most second-world countries.

The whole system is outrageous.

You probably won't hit the out of pocket maximum unless there is a complication. When my wife and I had our first, I was making decent money, still the hospital wrote off the entire bill through their financial assistance program.

As an immigrant coming to America, honestly the most shocking and surprising thing (apart from the state of homeless in San Francisco being tolerated as normal) is the medical care expenses. How on Earth is it that I can walk into a doctor's office or hospital to get medical treatment and have no idea how much it's going to cost? $10? $100? $1000? Who knows. I had an ear infection once, went to the doctor who looked at it for a minute and said "give it a few days". I assumed this would cost maybe $20 or something? Nope. $400. There's just no way of even knowing. In no other industry would you buy something without knowing the price ahead of time. With medical care it's even more screwed up because, well, it's your health? You're generally more desperate for services now, so it's not like shopping around for clothes or something.

It's pretty tragic that there are so many people like you and me, immigrants who have experienced several different healthcare systems, and we can all testify that the US system sucks on every level compared to other systems.

And yet, there's a huge amount of Americans who have only ever lived in the US, who are certain the US system is the best in the world, and who believe all the scary stories that are designed to make you think so.

You could listen to the people who have actual real-world experience, or you can listen to the lobbyists who are paid to preserve the lucrative US system. How is this even a thing?

I wouldn't say it sucks on every level. The actual quality of care is usually good.

The current US medical system reminds me a lot of very important legacy code that's become unmaintainable. Maybe the best way of rolling out universal healthcare is to take a refactoring approach. Get more and more people onto medicare, lowering the age limit and raising the maximum income threshold. Eventually, it would only be the wealthy who were still on the private insurance only system. Then employers can gradually replace health coverage with other benefits.

You need to reform regulations as well.

Medicare + Medicaid cost US tax payers more per capita as the UK NHS costs UK taxpayers per capita. The UK NHS provides universal coverage.

Part of the problem is that Medicare is actively prevented from being cost-effective. E.g. there are restrictions on its ability to negotiate prices in many instances, whereas the NHS will actively use all the leverage it has by coordinating purchases across the board. I'm sure that alone would not solve the issue, but it's unnecessary hard to get support for universal healthcare as long as Medicare is as expensive as it is.

Fixing that would make it harder to argue against Medicare expansion. To start with you could expand coverage substantially simply by allowing any savings to go towards expanding coverage.

> Eventually, it would only be the wealthy who were still on the private insurance only system. Then employers can gradually replace health coverage with other benefits.

It's worth noting that this is pretty much how it is in the UK. We do have private cover, but only about 10% of the population uses it. Notably it's generally "add on" coverage in that almost all policies expect you to rely on the NHS for basics, but lets you pretty much use the policy to queue jump to private hospitals if the NHS is "too slow" or for services above and beyond what the NHS offers. As such that's 10% despite UK policies being generally far cheaper, since they don't need to cover things like ambulances and ER/A&E (whenever anyone complains about the NHS this is a pretty essential point: the NHS is good enough that there isn't a sustainable market sufficient to compete with it; it's not perfect, but as long as private cover is as limited both in takeup and what it provides as it is, that's a pretty good indicator)

Not a bad idea, but I would like to point out one of the arguments of getting rid of private insurance is that wealthy would need an incentive to not degrade the system. Like it or not the wealthy have have much more political power then common folk and allowing them to have them own system outside of the general public gives them incentive to cut cost with no effect on themselves.

My state (Oregon) has protection against this. Unfortunately my emergency spinal operation was 2 months prior to the bill going into effect, so I got hit by this.

The part that pissed me off was I KNEW about the practice and specifically made a fuss about making sure everyone in that OR was IN NETWORK. I went to an in network facility, my surgeon was in network, and so was the anesthesiologist and every person that entered my hospital room I asked if the OR staff was in network (the answer was always yes). 1 month later I get a bill for a neuro-monitoring team and an assistant-surgeon that were both out of network.

The assistant surgeon charged me about $500. The neuro-monitoring team sent a ~$20,000 bill with the promise that they'd lower it to a reasonable value when I called to pay. Furthermore Blue Cross sent me a letter saying it wasn't pre-approved (even though the procedure was) and they would not cover a cent of it. Imagine the feeling of doom wondering just how low could these shysters possibly go from 20k. Thankfully that turned out to be true, the final bill was $800. Which still made me furious because I made such a huge deal out of not getting into this situation.

So that was $1300 total out of pocket that I was not expecting to pay. Luckily I'm a software developer with a huge savings, but I made several angry calls anyway and even sent an appeal twice to blue cross (which they denied both times). I'm so glad this crap is finally coming to an end, but the right-leaning supreme court makes me afraid some of these laws will get reversed.

I had a similar experience.

* I paid $20K out of pocket for a surgery that my insurer wouldn't cover.

* This was supposed to pay for everything (surgery, anesthesia, hospital stay, etc.).

* About 2 weeks post surgery, I got ANOTHER $20K bill from the hospital AND ANOTHER $1800 bill from the anesthesia group.

* At the same time, I developed a complication from the surgery that put me in EXCRUCIATING pain.

* Wife said I should go to the ER for the complication.

* I said, "NO WAY. We're gonna get hit with ANOTHER $20K bill because I developed a complication from a procedure that my insurer doesn't cover. I will ride this out."

* After 2 weeks of horrific pain, I broke down and went back to the surgical group.

* They told me that the bills that I received were probably an error.

* I calmly explained to the physician's assistant that I had neglected dealing with the complication as a DIRECT result of receiving those bills and I not-so-subtly implied that there might be a lawsuit coming their way.

* Within 20 minutes of leaving the surgical group, I got 3 phone calls from different people at the hospital expressing deep apologies and rescinding the bill.

That sounds like a much nastier experience, sorry you had to go through that. I hope it all works/worked out to your benefit eventually.

When we had our first child, we carefully selected a pediatrician that was covered by our insurance. It turns out that doctor was only billable to our insurance for delivery, any follow up visits were not covered by the insurer because that same doctor was not considered part of that hospital org. The org she did routine pediatric work was somehow different, yet in the same building. We discovered this as we were leaving the hospital and scheduling a follow up visit. It was very urgent since we had a moderate complication and need a doctor immediately. However our insurer (employer provided) was blacklisted by the doctors group that all doctors in our neighborhood were a part of. Ultimately, on short notice we found a new pediatrician an hour away which began ordering lab work. This is not something you want to go through with a newborn and a new mother. It was also bullshit, because we were hit with a surprise caveat to our researched doctor so late in the process even though we had been trying to do our due diligence to get things squared away months in advance.

This was all because our insurer decided that our doctor was billed by different rules depending on what part of the job she was doing for the same patient. I've been an ardent supporter of single payer ever since.

You make it sound like it's the doctor group that chose not to work with that insurance company. The fault probably goes both ways.

They blacklisted our plan for specific visits. That shouldn't be possible.

Having gone through cancer treatment here in the USA, I have received over a dozen 'after the fact bills' over the past 5 years, sometimes over 9months after the procedure, mainly involving blood work and CT scans.

I missed one bill that came months after chemotherapy for $87 in 2015, it only had a 60 day notice before sending to collections. Mind you I was on disability from my employer that paid well. -80pts on my credit score...

It took until last year to get my credit score back to the same level it was prior to starting treatment.

If it's any consolation, that time should now be 180 days, and I'm pretty sure the counter should start at the time the collection agency receives it, not from the date of service.

IANAL, though, so don't quote me on that.

how come in Europe credit score isn't really a thing and everything works fine? that's another thing that needs to go

I don't know if you're counting UK as part of Europe for this purpose, but in the UK credit score is definitely a thing.

It affects whether you can get a mortgage, credit card, loan, purchase credit (e.g. for buying a phone), or even a tiny overdraft, and it enormously affects how much interest you will be charged (i.e. very high or very low), and whether the credit limit you can get is zero, tiny or substantial.

There are credit scores in some places in Europe, mostly in the form of lists of people that may have failed to pay something in the past. It's a pain in the ass to correct if you get there by mistake and it's very opaque. Overall credit scores seem like a great idea with a terrible implementation. In general you as a mindful consumer that pays your bills on time wouldn't want to be paying the same prices for loans (spread, interest) as other consumers that have a history of not paying. A well functioning credit score system makes for a more efficient lending market, allowing consumers to save money if they have a good track record. How it actually works in practice is a joke, though.

Credit scores are very much a "thing" in many parts of europe.

A big difference is a lot of the credit scoring systems outside of the US doesn't take into consideration positive actions - only negative ones. So paying off a loan won't help you show you are a responsible borrower, but failure to pay it will hurt you.

There's also varying definitions of "fine" in "everything works fine." The USA has way more of a variety of financial products and the most qualified borrowers pay much less. One can argue that's a good thing, or a bad thing. (It's a good thing for me, personally.)

Another thing that is needed urgently is uniform pricing. Today healthcare providers charge different amounts to different insurers, and if you don't have insurance you pay list price. The list price is a arbitrary large number (often 3x the price insurers pay) that has no relation to reality. So if you don't have insurance, you are hit with a double whammy: You have to pay the bill yourself, and if that isn't bad enough, they charge you 300% of the "real" price, meaning what insurance companies pay for the same procedure.

Really happy to see this practice banned. Sadly it will not take effect for another year.

Unfortunately, this is only one of many significant issues with US healthcare.

I wouldn’t be surprised if hospitals already have other ways ready to screw people over once this goes into effect. As far as billing goes in my view they are basically criminal organizations that use fraud, intimidation and other things to squeeze people for money.

If the underlying problem (in-network discounted rates for services and out of network excess that the service provider can charge - honestly this practice should be made criminal - imagine Sams club selling a computer to non-members for 10x the cost the members pay) is not addressed, the surprise bill just becomes someone elses prolem (other patients end up paying).

> imagine Sams club selling a computer to non-members for 10x the cost the members pay

I wouldn’t mind that actually. They can sell for 100x for all I care. I can just not buy it. A better analogy would be if you got a letter 2 months after you shopping visit telling you that the the package of cheese you bought is actually $2000 instead of $5, and no, they do not accept returns.

> The new changes will take effect in 2022, and will apply to doctors, hospitals and air ambulances, though not ground ambulances.

From 2022 and no ambulances. This is a joke..

Optimists here would claim that this is slightly less of a joke than the status quo.

How come it covers air ambulances but not ground ambulances?

I know the answer is probably that the ambulance companies lobbied (bribed) the hell out of these laws, but with the ambulance costs this is comical.

California has such a law already. I went to an ER at the beginning of the year for a minor fracture and had a "contract physician". I was pleasantly surprised when the bill was exactly my er visit copay. I had an equally unpleasant experience several years ago that cost me thousands of dollars.

https://dmhc.ca.gov/Portals/0/HealthCareInCalifornia/FactShe...

The CA law is kind of BS. My partner went to see doc, they ran a few tests, told her it would probably be covered by insurance and then we got a bill for $1700. They said it wasn't "surprise" bill because it wasn't out of network. I told them "it is a surprise to us!"

From then on, we always ask the cost of every single test/procedure. (In fairness to the hospital, they did give us a $50/month, interest free payment plan.)

Yeah I agree the name is misleading and it doesn't cover all situations. My specific situation both times was ER rooms with out of network doctors, but I agree that there can be many other situations where the law is not that helpful. My personal opinion is those would be better managed by a single payer system like they have in many other countries. I haven't looked at the federal law close enough to know if it covers cases other than out of network doctors.

Imagine buying a car when the salesman cannot tell you the price, and the lender cannot tell you the interest rate, until after you have driven the car off the lot.

Now imagine you'll die or be permanently maimed if you don't buy the car in the next 15 minutes.

There is no such thing as a surprise medical bills ban. The only thing that will happen, without a complete overhaul of the way medical services are paid for in the US, is that patients will be given one extra form to sign before being allowed any services by any provider:

  Patient waives any and all rights granted by [anti-surprise laws]
  and agrees to indemnify Provider for any related costs.

You have to understand it's not just about the rules, medical insurance companies will do plenty to stay compliant but they'll still screw you. Sometimes they'll send you a bill for something they already said was covered, then suddenly it's on you to fight a several billion dollar company into just doing what they promised.

https://archive.is/50VQv

This essentially takes the patient out of the loop if one of the providers is not in-network / being directly reimbursed by insurance. Now the provider and insurance company have to work together to resolve the bill. Most importantly it would be charged against the patient’s in-network deductible.

It’s really too bad that this bill was watered down in one particular way. The Senate version of the bill would have set the price as the median in-network price for the procedure/service in that market (which ~5x the price that Medicare would pay). Out of network prices are usually another ~5x higher than in-network prices. House Democrats instead pushed for the rate to be set in arbitration, which is the version that will be enacted.

https://www.forbes.com/sites/theapothecary/2020/02/19/house-...

I guess a version that would make them pay what Medicare would pay wouldn't fly?

No, that’s significantly less than the in-network rate.

Not being in the US, I have to wonder - Why aren't the personnel at a hospital not considered part of 'in-network' while performing their duties at that hospital?

If being "in-network" is an important thing, it seems like having "out-of-network" personnel is rather deceitful (I would almost say fraudulent).

As the recipient of a $25,000 bill for an emergency visit to an out-of-network hospital that I have been fighting for two years (still ongoing), this is such an overdue blessing.

FYI -- many individual states ban "balance billing" i.e. hospitals sending you the leftover bill that insurance didn't cover (btw -- hospitals can charge a special "out-of-network" rate, in my case 10x the average cost around the area for the services I received). Problem is, if you are on a "self-insured" plan (your card should say this, these are plans you'll get at university or when working for a large company), the state law can't do anything, and there has been no federal law banning this practice. It's absolutely inhumane.

[US]: "Stop the surprise prices!"

[Hospitals]: "Okay, here's our menu of services: Saline $300, Specialist Consultation (20min) $1K, Ambulance Ride $15K."

[Health Insurers]: "If you join our club and pay dues, you get exclusive menu prices: saline $15, consultation $50, ambulance $200."

The problem is different people being charged dramatically different prices to continue living, because of which health insurance (if any) they have, and not being able to change that fact (except once a year).

The solution is that hospitals—and IMO businesses in general—must not charge different prices to different groups of customers (which single payer accomplishes, as I understand it).

I don't pay surprise bills ... (and I don't think it affects my credit because I had a couple in the last year and my FICO score is still at about 800) ... I'm not going to pay a random bill that comes 3 months after a doctor's visit that they never told me about and I already paid $400 for the emergency 30-min visit (not sure what the insurance paid)

This isn't directly related, but some of the credit reporting agencies can have surprise medical bills written off due to covid related hardships. This is to say, if a surprise bill happens to hit collections, and you're affected by covid, it can be removed through the report process. I have no idea what this looks like in the long term, though.

In India you have these government run hospitals. Entry is essentially free and so is the emergency / opd treatment. For procedures they charge peanuts compared to private sector. The only thing, there is a waiting list and hygeine is not always a priority.

There is an AIIMS hospital in Delhi and I had the misfortune of taking a relative there for treating surgical infection. It was brutal. We got in line around 9 am. Had to put the patient on a gurney and wait. Around 3 pm slowly our place reached to the inside emergency ward. Around 7 pm we finally were attended by an intern. Took 6 pricks to insert a catather then a senior resident was called in to help. Around an hour later the medication started to do some work. Around 10 pm more medication was administered. We ended up asking the doctor to let us go because it was 12 am and we needed to consume some food, pee.

Never again. This was around 5 years ago and I hope things have improved for the sake of patients.

Public services in India, especially ones interacting with people en masse are terrible. No recourse but to go to private hospitals.

they are terrible because they are too less. other than that i would rather get treated in a government run hospital because they employ only the most capable of doctors, senior and otherwise. the problem isnt in the doctors. its infrastructure.

i think people got my comment wrong way. i am very much in support of these hospitals. just that i want them to be in every major district rather than being restricted to major cities. its not like these places would remain empty

What is happening with Ayushman Bharat in held Kashmir?

I feel most comments here fail to separate hospitals and insurance. And that could be separated even more (pharmaceuticals, for example as a separate category).

As an aside, do we expect the rise of medical tourism options to put downward pressure on pricing for medical procedures in the US?

Humana Healthcare CEO Bruce Broussard base salary in 2016 was $1.24 million. No surprise there.

I'm actually ok with that salary as they have over 50B in revenue. However, I'm sure he and all the other execs receive exorbitant bonuses and stocks plans that make that salary look like peanuts.

How about “surprise insurance won’t cover this” situations?

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