Hacker News Reader

Comment by throwaway09223 | Hacker News Reader

My understanding is that the ER system is especially expensive because paying customers are subsidizing non-paying customers (homeless) who use the ER as primary care.

That said, I don't think this excludes the possibility that the insurance companies and the hospitals are also not telling the full truth.

View on HN

I find it hard to believe the small non-paying contingent is unique to the US or even a significant % of daily patients, plenty of other countries have homeless who end up in ED's.

America somehow spends far more than any other country on healthcare and yet patients still have some of the highest out of pocket costs even when they have expensive private insurance schemes, something is clearly broken to anyone looking and it's not the homeless causing it.

The US's non-paying contingent doesn't need to be any different from any other countries in order to cause the problem. The issue is that the uninsured subsidize the non-payers alone. This is radically different from countries with universal health care where the costs are spread among the entire tax-paying population.

As for why the US spends more than any other country: it's due to an overabundance of caution among the comfortably insured. It's much easier to get a variety of expensive (and often unnecessary) tests and scans (such as MRI scans) in the US. In countries with universal health care these tests and scans are restricted only to those with demonstrable need and they may be subject to long waiting lists.

> As for why the US spends more than any other country: it's due to an overabundance of caution among the comfortably insured. It's much easier to get a variety of expensive (and often unnecessary) tests and scans (such as MRI scans) in the US.

Countries with universal healthcare also tend to have private health companies which can provide tests and scans at a higher speed, either on an insured or a pay-as-you use basis, typically at much lower costs than the US. Yet there doesn't seem to be the same "overabundance of caution" elsewhere. To the extent that precautionary procedures are responsible for high US spend, I don't think that can be decoupled from a system designed to ensure that primary healthcare providers are sales outlets for those procedures.

Do you have numbers for that? Even the comfortably insured in the US have to pay a fee when they visit a doctor, typically around $35 for GP and $100 or more for a specialist.

My last 5 insurers had copays between $0 and $20. Same price whether it's a specialist or primary care.

If it's an HMO, often it's just free entirely. PPO plans tend to have a small fee -- it's never been enough that I've given it a second thought -- and have wide coverage with few limits.

My wife and I never pay a fee to see our doctors. I pay $30 for sick visits for my kids. $100 seems really high. I’ve only had something like that for a test.

Imaging is used as a revenue center. Many states restrict CT and MRI machines based on the broken thought process that restricting capital spending will lead to lower overall prices. Of course in reality you also restrict investment and competition.

The out of pocket costs are high here because of an $8k deductible, it is a choice.

The issue is why it costs $6.5K to get the stitches rather than who pays for it.

I mean, it's clear that it's not sustainable to have a healthcare system in which stitches cost this much. Things are not made any better or less outrageous if these costs are transferred to someone else or if they are paid out of pocket.

The only thing that is particularly unusual about the US is that private insurance companies are probably not very efficient (admin costs are multiples of similar mixed healthcare systems).

But if you look at healthcare spending as a % of GDP: the US has the largest public healthcare system in the world, and it has a private healthcare system that invests very heavily in people's health (I think people get confused about this because US life expectancy isn't much higher but that is largely a function of things like obesity that, ultimately, aren't solvable without people eating less...the US does very well with quality of life and difficult to treat stuff like cancer, I am in the UK and a lot of cancers are treated properly, there is just no money to do so).

So, imo, the US is more expensive than similar systems like Germany. But incomes in the US are much higher, people are willing to spend more (particularly on quality of life stuff like joint replacements), and a lot of the additional cost is not in treatment but admin. Maybe moving to a public insurance system would help but look at France: public healthcare system, and doesn't spend that much less than the US (and in the US, public healthcare prices are cheaper than private but private does subsidise the public...and the gap isn't huge)...doctors don't work for free, medicine isn't free, nurses aren't free, you just pay the same but in taxes (btw, I think a public healthcare system would reduce costs by removing admin...would they like it when they couldn't get a knee replacement? No. Would they like it when a parent got cancer or their kid has a rare type of epilepsy and they can't get medicine? No...there are trade-offs, fully public healthcare systems generally do not perform as well as mixed systems like Germany or Netherlands...making insurers non-profit might be a good first step).

The US conducted the experiment to limit insurance companies' profits. A component of the ACA (Obamacare) was the 80/20 rule, where at least 80% of all premiums collected by health ins. companies had to be paid out for care. That was a failure. In the 10 years or so since that rule, premiums have increased dramatically.

Your reply is well-stated. There isn't one single 'bad guy' in the US system; it's more a function of a bunch of little factors that nobody wants to change: the US has the best, highly trained doctors (expensive), best equipment/hospitals (expensive), subsidizes much of the drug development for the rest of the world (for better or worse), and a weird public/private system where the private insurers make up for lower payments from public insurance like Medicaid/Medicare.

In talking with a number of physicians, my biggest concern is that they're starting to feel like most of the 'reforms' and changes the US is making are impacting them the most. None of my physician friends recommend their children go into the profession, and many are leaving poorly-run hospital systems to focus on boutique, private practice (catering to the rich.) We have a huge healthcare provider shortage coming, and I'm terrified the system is straining hard as I get older and will need to start relying on it.

Premiums haven't increased any faster post ACA (maybe a bit slower even).

https://www.ncsl.org/research/health/health-insurance-premiu...

We are already in the midst of a provider shortage.

They didn't stop increasing or go down, was my point. One would expect that if insurance company profits were a large component of the premium cost, limiting that to 20% would lead to some beneficial reduction in premiums.

Hospitals publish data on overall non-payments. There's a significant amount of cost there but not enough to be driving prices.

https://www.aha.org/fact-sheets/2020-01-06-fact-sheet-uncomp...

The EU also have non paying non insured ER patients, it still isn't that expensive. So this seems strange.

Except if the US is literally falling apart and had ab endless amount of non paying people?

I think it is more that prices are not transparent. Instead they are impredictable.

And you can't shop around for cheaper treatment. Partly because you are not in position to do so and partly because no one will tell you full price in advance.

I agree that those are problems with American healthcare. I'm describing why ER prices are specifically so much higher than care in other areas of the hospital.

Reply on news.ycombinator.com