Hospitals still not fully complying with federal price-disclosure rules | Hacker News Reader

Hospitals still not fully complying with federal price-disclosure rules

wsj.com

319 pointsarwhatever224 comments

Straightforward healthcare reform would start with eliminating this unprecedented and nonsensical ability for hospitals to engage in arbitrary post facto billing, require well-defined contracts for non-emergency care, and require providers to publish a uniform all-payer rate schedule for emergency/urgent care. Any deviation should result in a non-enforceable invalid bill, with easily claimable punitive damages if such fraudulent charges end up being mistakenly paid.

When I walk into a grocery store, buy some items, and leave there is absolutely no chance that I will later get a bill in the mail from the cashier for their bagging services. If I were to, it would be laughably unenforceable. And yet, this is precisely what the medical establishment feels entitled to do when they refuse to answer basic questions about prices or "network" status of providers, and then send you multiple bills for a single engagement!

While this would do little to help healthcare affordability for those who truly cannot pay, it is a necessary step to creating a functioning market regardless of who is paying. The point we're at now, where even people with the ability to pay have no clue how exactly the system will attempt to screw them, is utterly untenable.

For what it's worth, this is the kind of reform the Republican party could be loudly and persistently pushing if weren't primarily interested in dysfunction. As it stands the only popular avenue for reform I've seen is to punt the whole thing to the government, which I'm forced to reluctantly support even though it feels like giving up on actually solving the problem and letting the organizational cancer metastasize and feed on taxpayer money.

So as you fly through the air after being ejected in a car crash, make sure to pull out your phone and negotiate upfront pricing with your providers before you hit the ground and are rendered unconscious.

While I agree after the fact billing is stupid, your scheme implies people choose their hospital based on rates as they are flying through the air after being ejected from a car in a crash. Make sure to choose wisely before you black out!

Or, every doctor visit has an attending billing assistant to explain costs of care to both the doctor and the patient.

Because the doctors don't know and don't have time to know.

In the end this is all Republican laissez faire fantasies. We need socialized medicine, like ever other civilized and (by our standards) uncivilized country has.

I have no clue when the Republican party would have been able to push any coherent reform to the health care system. 50 years ago? The modern Republican party exists solely to defend entrenched oligarchies and anticompetitive cartel dominated markets. That's what campaign finance rules reward.

The Democrats also perform the same function, but at least with some attempts at reform around the edges, because that's what their voting block demands.

So many words could have been avoided if only you haven’t missed “non-emergency” words in the comment you replied to.

> require providers to publish a uniform all-payer rate schedule for emergency/urgent care

What I described is just laying out a bare minimum for some semblance of sanity. Your laissez faire straw man fantasy extrapolates as if I am pushing this as a complete solution, but I am not.

In one complete solution most everyone would still have insurance (actual insurance) for such catastrophic events, either purchased themselves, packaged as part of auto insurance, bought through the government as a provider of last resort, supplied as part of a minimum social safety net, etc.

Alternatively, keep right on pushing for Medicare for All! It's orthogonal because there are many things that wouldn't be fully covered by M4A, even in the emergency context (eg a single occupancy hospital room).

The point is that there needs to be some market dynamic to keep prices "real" and allow for straightforward competition between different providers, regardless of who is paying.

(FWIW you could also do some research ahead of time about local urgent care providers, or hear recommendations from other people - for most urgent situations you would not be unconscious and could choose where to go.)

This. Something I've come across is that most of my friends who have ended up in better insuring (and often paying) jobs are somewhat blind to the thievery happening in plain sight because the monthly premiums are conveniently out of sight.

As a thought experiment, congress should simply ban and outlaw employer provided healthcare and force everyone who desires to be insured to make contract directly with Kaiser, Blueshield etc. When you pay north of $2k / month (for a family of four) out of your own pocket for the pleasure of being able to make an appointment in hospital, that just might draw enough ire to effect change.

Of course that should also make employing someone equally cheaper, or allow for equally large salary increase.

I'm one of those people in a better-insuring job, and I still see a lot of thievery happening in plain sight. I recently had a telemedicine visit with my doctor, and the hospital sent me a separate "facility fee" bill for that. Apparently because the doctor was in his office at the hospital, I need to pay out-of-pocket for this non-medical facility charge. Since it's non-medical, my health insurance company doesn't even negotiate a rate for that charge, let alone pay it.

Fortunately my state requires that such fees be disclosed to the patient ahead of time, so I'm going to send in a written complaint pointing to that law and count on this fee being reduced or dismissed. However the fact that I even have to be able to find, interpret, and apply that law is a systemic failure.

holy crap. For the life of me, this is such an incredibly broken mess ! I am amazed that how this medical system came to fruition. Clearly, a functionally medical system is _needed_ (not _wanted_) for a developed country. USA is I guess an exception. p.s.: come to India, I cant overstate how much better it is.

It’s easier to remove the FICA tax exemption from employer health insurance.

I expect the main difficulty this presents to hospitals isn't that their customers will be informed, or even that their competitors will be advantaged, but that they will be unable to engage in price discrimination (charging different amounts to different customers, based on their willingness and ability to pay). Or at least, they'll need to do so transparently.

My kid recently needed a script. We had to go through a specialty pharmacy that ships directly to home because it apparently wasn't carried in the pharmacies like CVS. The script was over $400.

Insurance denied the claim.

They "applied a coupon" and the price magically became $35.

In this one transaction there's multiple layers of corruption most likely starting with the prescribing doctor.

Some doctors are certainly corrupt, but usually they have no way of knowing how much a particular medication costs since many do not buy or handle medication beyond what they would stock in their office.

Your post lacks information such as whether or not the specialty medicine would’ve been approved with the proper paperwork from the doctor, but what likely happened is that someone at the pharmacy put in the effort to find a manufacturer coupon for the medicine for you.

Interestingly the pharmacy doing that is generally forbidden in agreements with the insurance companies. That’s corruption imo.

The insurance PBMs forcing you to use their designated specialty pharmacies is part of the massive healthcare consolidation over the last couple of decades and it’s full of corruption as well.

Of course my post lacks information. It's not a persuasive essay, it's an internet post about an experience I had. Humans tend to prefer brevity over exactness, particularly on internet posts.

I prefer brevity over irrelevant information, but mentioning the specific type of drug, the name of the insurance and the type of coupon being applied would be highly relevant in determining whether the story has merit. Leaving it deliberately unspecified triggers all my bullshit detectors.

Please familiarize yourself with the site guidelines.

> Have curious conversation; don't cross-examine.

> Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith.

It wasn’t intended as criticism. I thought it was clear I offered that bit because I was speculating based on the information given.

Many insurers have rosters of meds they approve. Kaiser is one, just for a specific example. Everyone in the system is encouraged to prescribe from that list, even to the point of making clear medical trade-offs to do so.

This was all explained to me when we had to switch plans, ended up with Kaiser for a while, and needed to renew blood pressure meds for my wife.

She was in good control, no side effects, on meds for a decade. Those were not on the list. Rather than prescribe off list, that doctor increased her risk to benefit Kaiser, not her. And this was even made clear at the time! (maddening) Just to be ultra clear, it was that doctors "opinion" the various meds were all equivalent.

For a lot of reasons, none of which are medical, we went with it, and sure enough, she was not in good control, and had side effects.

Went back, got the meds that worked prescribed, (which cost me visit co-pays and some non trivial time and effort to basically demand the medication needed and proven) and found ourselves in the same "coupon" scenario above. Base cost of the medication was quite expensive, and a "coupon" was found to bring it roughly in line with the "on list" meds tried earlier. Of course, that all had to be done at another, outside pharmacy, due to the Kaiser one not carrying what they consider special order meds. That isn't a super big deal, but the whole mess involves bulk buying to gain price advantages, and the real worry point is cost being primary, with medical being secondary.

The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health.

In my case, the pharmacy was Walgreens and yes they signed me up for some plan or other, GoodRX or the like, handed me a card and said I needed to use it to get the much better price. Was on the order of a few hundred dollars being discounted to a few tens of dollars...

Have had similar experiences at CVS, Bi-Mart, Safeway... Indie pharmacies, usually niche places that offer things like compounding, are particularly good at this sort of thing and it's one of the ways they attract and keep patients. I used a good one for years, until I moved. Miss those people. They would do that automatically for anyone struggling with med costs of any kind.

> The whole thing caused me to very seriously question the strength of "medical opinion", given patient history, a routine request to simply continue proven treatment turned into a risk scenario for no reason other than the tangled mess of insurers, agreements, drug manufacturers, and the like all more focused on profit than they are patient health.

The flip side of this is the "pharmaceutical representative" entire job description. Basically, your doctor has a wide range of words they use to describe how to treat you. Some of them wind up with the insurance company paying $15 for generic medication, while others wind up doing something like spending $400 on something under patent protection. Pharma's reps jobs are to talk to physicians and educate/convince them to use the expensive words instead of the cheap words out of force of habit.

Anyhow, that's why HMOs and insurers have approved medication lists - to push back against doctors writing down a $400 word instead of a $15 because a pharma representative said that FooBar XR treats Baz syndrome and the doctor wrote that down instead of the generic BarFoo.

The whole thing is an insane mess. Our family has been impacted multiple times, both in terms of cost and health outcomes.

Count me as a strong supporter for reform. I quite frankly, hate it.

The scary truth is that the prescribing doctor probably prescribed what they thought would best treat their patient's condition, and access to that medication requires hundreds of dollars because the manufacturer can simply charge that much, so why not? Your insurer denied you, again, because they can, so why not? Manufacturers give coupons that bring down the cost of their medications by hundreds, even thousands of dollars, so they have something to point to when they're accused of profiteering and exploitation. Your life and the lives of your family members depend on this system not fucking any of you over for a buck, despite fucking you over for a buck every step of the way.

Do you have any factual evidence of corruption by the prescribing doctor? It is illegal for pharmacies and drug companies to give kickbacks to doctors. While that might still happen occasionally I guarantee you it is very rare. The vast majority of doctors write prescriptions based on what they think is medically best for the patient. If you have concerns over costs you can always ask the doctor if there is a cheaper alternative treatment to try.

The kickbacks are indirect of course. BigPharmaCo tells BigPharmacyChain their new wonderdrug is wonderful, expensive, and ought to be popular, and therefore well advertised in the store. Meanwhile, BigPharmaCo sends reps to hospitals and clinics to offer doctors extremely well catered business lunches and complimentary luxury vacations -- I mean "seminars" -- to encourage them to prescribe the correct medicine. It is understood but not stated that if the doctor does so, the lunches and seminars will continue, as will the flow of large quantities of drug "samples" and other medical supplies. This situation incentivizes price gouging and over prescribing.

Insurance companies are thrilled with high prices because they reinforce the idea that medical insurance is critical infrastructure. Liberal politicians love taking credit for throwing money at the problem they helped codify into law, and conservative politicians love being able to decry out-of-control, cradle-to-grave socialism at every campaign stop.

So yeah there are multiple layers of corruption there.

As someone in the industry I can assure you this doesn’t happen. Or at least if it does, it rare and illegal.

Drug coupons are common in the United States. AFAIU, they're issued by the pharmaceutical companies, but as few people know about them (or how the pricing system is structured in general) it's often doctors and pharmacies that seem to help broker their distribution. The coupon system permits pharmaceuticals and friendly politicians to deflect criticism about drug pricing strategies by providing plausible deniability regarding costs to the uninsured and underinsured.

I remember reading several years ago reports that drug companies were favoring coupon distribution to doctors according to how often doctors prescribed the issuer's name-brand drugs instead of generics. That is, a doctor who prescribed a designer expensive drug, Foo, more often might get more coupons for name-brand but boring drug, Bar, for distribution to the doctor's indigent patients. I don't remember, however, if or which reforms were enacted as a result. Also, I'm not sure if it was nearly as big of an issue as actual kick-backs in the form of vacations, etc, which (AFAIU) were made illegal years ago. The opacity and overall baroqueness of the coupon system is precisely why there's not much opportunity for doctors to personally benefit from the scheme, yet why it works well as a tool for pharmaceutical companies to maximize profits while staving off political reforms.

See https://en.wikipedia.org/wiki/Drug_coupon

I only watch TV when there’s a sports championship or presidential debate. Even on those rare occasions there’s ads for GoodRX.

Over time coupons could become valuable unto themselves as collectibles. I've seen collections of old South American mining town currencies (the highest denominations, in excellent condition), very colorful, all kinds of designs.

Patient financial assistance has a safe harbor cutout for private insurance. It’s illegal for public insurance.

Those coupon programs aren’t used for indigent patients since they reduce the co-pay/co-insurance the patient has.

Some not so great insurance plans will pay 90% of drug costs. Great when the drug is $300 per month. Not great when it’s $3,000. So manufacturers will directly pay an additional portion to cap the patients part at say $50 per month.

Drug companies also kick back to patients. My wife started $65k per year infusions and the drug company paid our entire deductible for us after the first treatment.

You're assigning blame to whom you are seeing - the doctor - whom is a worker like anyone else following a system. The true decision makers are people you don't see, like the administrators of that clinic, the pharmaceutcal company, and the insurance company. All business people that count on you to blame the workers for problems created by the admins whom by the nature of costs are trying to assign blame around in a circle. Everything is a company, and companies value profit over people.

These companies are so massive and complicated in their roles and processes you and I cannot easily figure out specific actionable blame onto the specific administrators and processes involved.

You can say that, but the doctors are extremely high paid and exert huge amounts of power.

The corporations involved (pharmaceuticals, insurers, hospital systems) each make 1000x what a single doctor does.

If we want to assign blame by proxy - by virtue of being a citizen in the U.S. people are all paying for other humans to be murdered by the U.S. military. Do we blame the powers that make those decisions and enact against those or do we blame all 300 million Americans and treat them as murderers?

Blame those who made the system. Doctors are forced to work 80 hour weeks for not as much pay as you're thinking. Clinical Doctors don't have the power to better their own conditions, how are do they have the huge power to reform the regulatory issue of medicine pricing?

The only people with enough power in the system to demand a change are doctors. They could, example, refuse to do procedures until the billing department gets its act together and gives patients a price up front. They could demand to know the price to fill a prescription before they write it. If doctors took collective action to resist the horror show that is medical billing it would change overnight.

Doctors work very long hours for not as much pay and are not in general well treated. That does not spell "power". Again, they're workers, they don't make the business decisions. Clinical Doctors don't have the same tools to protest because physical protesting would only lead to the public believing the "evil doctors" are trying to get more and avoiding treating patients. The clinic can replace them, and often times do, with imported degrees.

Start blaming the source of the problem - the business executives whom made these decisions.

Sounds like a doctor's union. Is that a thing?

"They "applied a coupon" and the price magically became $35"

This makes NFTs and drug dealers look honest. Oh, wait, they kinfld of are drug dealers.

The main difficulty is that the penalty is laughable.

$300/day doesn't even begin to cover a single well-paid IT professional who can handle this project, let alone a team with resources.

It may seem trivial to HN audience to comply (hey, just do a SQL query and post the resulting CSV!), but hospital IT systems are oftentimes legacy dinosaurs, so a transparency project like this could cost millions of $ to undertake.

Why pay millions, when you can simply pay a measly penalty of ~$109,000 year after year?

100k is only this year, it goes up to $2mil tomorrow.

Your point still stands though, even that is possibly not high enough

If you can't extract pricing data from your existing IT infrastructure for less than US$2M, you've got deeper problems than this law (or you use one of the Big Three consulting companies for all your IT work)

> charging different amounts to different customers, based on their willingness and ability to pay

I haven't had that experience. That would be like a health dealership.

I didn't have insurance and needed all my wisdom teeth out. I was able to negotiate a cash discount.

How much did you pay if I may ask? It was € 428 a few months back in a Dutch hospital (under a system many people do not like, but I mostly do) with another € 30 for the dentist checking and referring. That’s an all-in price.

Does all-in mean all four wisdom teeth? Because I paid somewhere over $2000 out of pocket a few years back in San Francisco. And that was after insurance.

I paid £200 all-in for an initial check-up, and then a second appointment where a single tooth was removed here in the UK (this was a non-NHS dentist). I imagine they’d have charged more to remove 4 teeth, but not 4x more.

It was for four teeth and with all-in I ment I had to pay for it out of pocket (first few hundred euro are at my own risk) and it (should) cover the whole price. No hidden subsidies. The insurer just billed me the full price they bargained for.

How weird - a few years ago I paid about 250 EUR in a dental clinic in Rotterdam to remove a single wisdom tooth. I did pay in cash (no health insurance coverage as I emigrated already).

I expect yours was pulled by a dentist and mine by a dental surgeon.

The tariffs of dentists do not follow the same pricing as those of surgeons in NL. The former is a mandated maximum based on cost price plus, the latter based on bargaining between hospital and insurer. Given the attention of private equity for the Dutch dentists I would expect the dentist to be more expensive although the team and capital requirements of the dental surgeon are probably larger.

Great: But do you know if how your final price compared with the final price that they charge insurance companies? How would you know that they didn't give you a higher-than-insurance price as your quote, making your "cash discount" not really a bargain?

I'll add that "discounts" aren't always very helpful nor is it something you can plan for if you have emergency surgery.

Many, many medical bills go unpaid. Calculation of likelihood of payment based on customer attributes is being used to consider offering discounts to pay quickly.

I don’t know how this wouldn’t act as de facto price discrimination but it is happening.

>Many, many medical bills go unpaid.

Several years ago I ended up in the ICU, no insurance, got a ridiculous bill that would have taken the majority of my lifetime to pay down. In the end I decided not to even attempt to pay because it was so ridiculously high, decided to just wait the seven years for it to fall off my credit.

If the price had been reasonable I would have paid outright or gotten on a payment plan.

What was the impact on your credit score? I imagine that had an effect on other parts of your life no?

It hurt my credit score(as in the number quite a bit), but not as much as I thought it would, I was really worried I wouldn’t get approved for things, but I was informed that when underwriters are reviewing credit reports, medical debt doesn’t carry much weight, as ‘everyone’ has it and it doesn’t reflect on how responsible or impulsive the debtor is.

My worry is that as this happens more and more, the health care industry will come up with their own score, and will refuse to serve people that don’t pay their medical debts.

A law signed by Ronald Reagan prevents denial of treatment based on ability to pay.

However, it doesn't specify what treatment will be provided, so more likely, hospitals would use that sort of information to limit treatment to ER-level interventions and then recommend a wait-n-see approach as followup.

The Emergency Medical Treatment and Active Labor Act prevents any hospital which accepts Medicare/Medicaid from turning away patients in critical conditions. They have to at least provide stabilization and some kind of basic medical screening services to everyone who arrives.

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

As for other doctor's offices or planned procedures, I think they already can decide to not work with you if you don't pay them. Maybe there's something similar for general practice stuff related to Medicare/Medicaid as well but for exclusively private pay practices I can't imagine something forcing those providers to offer non-emergency services.

As a non-US citizen, the more I read this thread, the more bonkers the whole system is. How the fuck does healthcare even work at all?

>How the fuck does healthcare even work at all?

It doesn't, unless you are wealthy, otherwise you try and 'walk off' any issues until they become obviously life threatening, then you go to the hospital and if you have insurance, you hope the insurance will approve the operation you need, and if you don't have insurance you hope the cost wont bankrupt you.

There comes a point where your credit score isn’t useful anymore. If you have a good house with a good mortgage and the best credit cards and have taken any other long term loans you need, then you’ve reached the end game. After that point maintaining a high score is just for bragging rights. It makes no sense to pay a massive hospital bill the rest of your life instead of just letting it fall off your credit reports in 7 years.

Jobs will also look at your credit score, but for a retired person it can quickly become meaningless.

Why do employers care

Employers are looking for stability, so a poor credit score is a proxy for a risky hire (in their minds). Even if 50% of the low scores are due to either medical debt or student loans, it helps them weed out "undesirables."

You might abuse your position for illicit gain in order to pay off debts.

So they have an excuse to not hire minorities and people of color who have lower scores on average.

What does falling off your credit mean? Do you no longer owe anything? Did you go through bankruptcy?

It means it no longer appears on my credit report or effects my credit score.

You still owe the money though? Do they just stop chasing you after a while?

All US states (I think) have some statute of limitations on debt collection, although each state is different. After this amount of time has passed (assuming that no court case has been filed), the courts can no longer be used to demand payment of a debt and the debt effectively ceases to exist legally. (Whether it ceases to exist morally depends on your personal moral system.)

Interesting, thanks. 3-6 years seems common.

But they will send collections after you long before that no? It happened to me (Scrips, CA), while we were trying to negotiate payment with the hospital and the bill was only $500 - I didn't want to pay it out of principal because we were told it was $150 flat rate at the time of service... they were very quick to pull the trigger.

Is it at all advisable to ignore collections and risk court appearance?

When the collections company called me I tried to negotiate a reasonable price with them but they wouldn't budge, I told them that I wouldn't pay and would just wait for seven years.

Next time they called I told them they had the wrong number and not to call again, and I never heard from them again, no letters, no calls, nothing.

Although I'm in Arizona, I don't know if laws are different in CA.

Calling it price discrimination is generous. Usually you'd call such activity a confidence game.

I don't agree that hospitals charge based on ability to pay. I believe that they generally charge the max and then, maybe, negotiate the price based on your ability to pay (more likely they put you on a payment plan).

I had an accident in late 2010 where I needed to stay in the NICU for 14 days. In January 2011 I had major neck surgery and spent another week in the hospital. SFGH charged me $100K for the NICU stay and $200K for the surgery (plus a separate bill for $1K from SFFD for my initial ambulance ride).

I had no job or insurance at the time and was in the process of moving out of my apartment.

Luckily, it was a slip and fall type accident and I immediately hired a lawyer when I saw the bills. I was also approved for MediCal after my surgery and they initially covered the bill. But they put a lien on my lawsuit. I learned a lot during all of this, but my biggest takeaway was that MediCal paid $20K for a bill that was charging me $300K! Less than 10% of what I was being charged!

About 33% of total US healthcare spending goes to the people that haggle over prices for the doctor and the insurance company.

That explains most of the bad pricing behavior in this space. For the law to have any real effect, it would need to force the hospitals to publish prices up front, and also ban discounting the charges after the fact.

(I get the distinct impression high-cost insurance plans get the best deals from hospitals, but could be wrong. Either way, I don’t thing conventional price discrimination is a thing in this US healthcare market.)

I still don't quite get how publishing prices up front is going to solve a lot of the problems. If I'm in an accident and bleeding out I'm not exactly going to whip out my phone and start comparison shopping which hospital to go to. What does it matter if they publish a 1,000 page PDF with tiny fonts of all their prices when I'm in need of emergency medical services and may not even begin to understand all the work I'll need? I guess it helps a bit when you're having a planned procedure done but often when you're planning out a procedure they can give you at least some kind of cost estimate.

Don't get me wrong I do find it terrible that US healthcare pricing is incredibly opaque but it does not seem to immediately offer a lot of benefits. It will probably offer a good amount of indirect benefits as those who are paid to haggle will have more information to haggle with, but to me it seems like it wouldn't really force any of the changes needed.

IIRC only a couple percent (I believe 2-3%, but certainly <10%) of USA medical expenses are related to emergency medicine. So something that does not change anything to situations "in an accident and bleeding out" and affects only planned procedures definitely has the potential to "solve a lot of the problems", specifically, 90%+ of the problems.

While emergency care might only account for <10% of overall medical spending in the US, I would imagine its the leading cause of unexpected medical debt. Sure, over the course of my lifetime all my general practice visits, various medications, durable medical equipment, dental cleanings, eye exams, nursing home, hospice, etc. will probably total to >90% of my overall lifetime healthcare spend compared to the maybe 1 or 2 emergency room visits I'll have. All of that stuff I'm already shopping around for when I determine if they're in-network our out of network. Seeing their list of silly prices does not really make a difference, as those silly prices aren't what I would be paying anyways. That's just their book prices, not the whatever member network special discount coupon haggle price shenanigans the insurance industry is doing.

The big troubling expenses are the emergency room visits where it turns out the guy who set your broken bone is now out of network and so you're billed some stupid price. Or as the above poster mentioned they were temporarily without coverage at that time and had an accident. In this case having the prices published ahead of time didn't really do you any good, as even the basic information of "is this doctor in-network or not" wasn't even able to be accurately looked up and compared.

And as for these stupid expensive list prices being published ahead of time making an impact to those without insurance, it probably doesn't change the math too much for the majority of those people. If they were unable to afford the crazy prices of insurance they're probably unable to pay the crazy non-insured list prices for non-emergency care, so they'll probably forgo it until their ailments get into emergency situations.

I'm still unsure how it actually helps. Can you fill me in on that?

We already have this problem with in-network vs out of network pricing from insurers.

I think you are right about high cost vs low cost plans. The low cost plans routinely get the worst rates... Kind of the opposite of price discrimination if those buyers are poor. This recent WSJ article might be of interest:

https://www.wsj.com/articles/hospital-prices-healthcare-insu...

pedantic noted but I think NICU is for infants… ICU is where you likely were.

The hospital told me I was in the NICU which stands for Neurological ICU.

edit - I was initially paralyzed from the mouth down.

Interesting regional difference. I usually see NICU as in Neonatal ICU.

Yes, I've usually seen it as neonatal as well. It might have just been what the neurosurgeons and nurses on the ward called it.

> I don't agree that hospitals charge based on ability to pay. I believe that they generally charge the max and then, maybe, negotiate the price based on your ability to pay (more likely they put you on a payment plan).

This is my experience as well.

Hospitals won't conform to this disclosure law without a proper stick to get them to. I wonder if companies fought the law in Colorado that stated all job descriptions need the minimum salary for a role to be listed. That's data that could advantage their competitors but I've seen it on Google job listings when looking at roles in Colorado...

It's a Micro-Economics 101 maxim that all students learn early is that efficient markets depend on as much price transparency as you can muster. When one or more parties have more pricing information than you they have a huge advantage.

Offering discounts to insurance companies and people who bargain is how they do it, but it's still price discrimination. In fact that's how prove discrimination usually works. The more effort you put in, or the more market power you have, the better price you're able to get. That effort is a proxy for your willingness to pay.

"Ability to pay" might have been too narrow a phrasing though. Often as not it's instead essentially "ability to not pay", as with insurance companies using their bargaining power.

Now, will a law requiring prices to be posted prevent them from discounting the price? If only the powerless actually pay the sticker price it becomes a bit meaningless, so maybe? It would depend on the details of the law and its interpretation though, and I won't pretend to be knowledgeable there.

> I believe that they generally charge the max and then, maybe, negotiate the price based on your ability to pay (more likely they put you on a payment plan).

This is exactly how it works. Charge the max given the procedure, circumstance and insurance coverage. Let the consumer fight it out with our massively understaffed customer service department. Then, send it to collections anyway.

Unfortunately hospitals are in the same category as banks that allows them to get away with breaking rules and criminal behavior with a slap on the wrist.

If there ever has been as sector that needs price transparency it's hospital and medical in general. It's really hard to understand that people are putting up with insanity.

There’s one difference, and that’s Medicare/Medicaid. The government could easily decide that they will stop paying hospitals for Medicare/Medicaid patients until this gets implemented. I bet it would happen pretty fast.

There isn’t something quite as direct on banks.

That's not something that could be easily implemented by a new CMS regulation. They lack the statutory authority to make Medicare payments conditional on price transparency compliance. Changing that would require an Act of Congress.

How about starting a non-profit that paid people $X to upload an redacted image of their medical bill?

Or maybe it could be where you get discounts at participating local businesses when you upload.

Kind of like a weird proof of work concept.

How about simply holding non-compliant hospitals accountable with appropriate fines?

I know. Every time I see one of these "mutual aid" solutions, I can only see evidence of the utter betrayal of our government and society.

Just have them pay double the difference to reporter in fines.

I agree with you.

My original thought was to help people better negotiate at the local hospital/health system by knowing what other people pay.

Perhaps like financial and tech firms, paying fines would just get rolled into the ledger as a cost of operating.

This seems like an area where the federal government could take a leaf out of Texas' new found love for citizen-driven lawsuits: allow individuals rather than CMS to sue hospitals for the damages (up to US$2M starting tomorrow).

My guess is that you'd see the hospital IT and pricing infrastructure do a reasonable impression of faster-than-light travel and the information would be available by January 3rd.

Or just say "if the price isn't published in advance it's free".

A post about price transparency wouldn't be complete without the "Surgery Center of Oklahoma"[0]. If one for profit hospital can figure out how to publish prices in advance of surgery (for a lower price), than all hospitals should be able to do so too.

[0] https://surgerycenterok.com/pricing/

non-paywall link - https://archive.is/LQUkO

this seems like something that should actually be able to be handled in bipartisan fashion, you need price transparency for a free market to function properly so Republicans should support because lower costs would stunt demands for universal healthcare.

First off, law/rule is passed. So who is in charge of enforcement.

Second, came into existence 01/2021. That was under Trump and Republicans, so ostensibly they support it.

Third, the only concern I have is being able to ensure that the procedures are the same and also outcome statistics. There are a couple different hip replacement surgeries that you can have. One is trickier to perform but has better outcome and recovery time, if both are listed as hip replacement and customers don't know there are differences then you create a race to the bottom.

The vaccine came from his brilliant scientific mind so there should be no objections there either.

> so Republicans should support because lower costs would stunt demands for universal healthcare.

Oh, my sweat summer child...!

Please don't do this here.

The article is about the Biden administration failing to enforce the rules - how does that make Republicans responsible?

The health care has fully captured both parties. There is nothing you can expect from either party. And certainly not while Biden is in power. He should have embraced Medicare for All which to me seems a viable path to a better system.

It seems he had a limited amount of political capital and he sought to use it on COVID and infrastructure.

> something that should actually be able to be handled in bipartisan fashion

That seems to be making the assumption that any politician is willing to listen to something that the "wrong" side says.

This seems like something that shouldn't be handled by the "free market" at all, because human health is at stake. And because of that, it isn't left to "the free market" in most of europe.

Exactly human health is at stake, so we should let the efficiency of a proper free-market take care of it.

Have you ever received health-care in Europe? I have, Italy. It takes a painfully long time to get an appointment and the quality of care is not close to on par with that received in the US unless you opt for private care anyway.

So your one anecdote outweighs all our other European anecdotes saying the opposite?

I have had excellent service here in Norway and even in these times of COVID I have not had to wait unreasonably long for appointments for things like MRI and my GP seems to have less to do now than in normal times, far fewer respiratory conditions to deal with.

As with any other large system there will be some variation in quality and availability even within the same country as my wife discovered giving birth in two different hospitals in the UK, one merely good enough, the other excellent.

I am European, so yeah, European public health care systems have been taking care of me pretty much all my life, including the months my Mom was pregnant with me.

And I have NEVER had anything to complain about. Neither has my family, or anyone I know. The quality is top notch, and getting an appointment is as easy for me as picking up the phone.

And btw. if anyone is unhappy with what public health care provides, its easy to get private insurance ON TOP OF it. Public health care doesn't replace private insurance, it sets a baseline of quality people receive no matter what.

And speaking of quality: https://www.healthsystemtracker.org/chart-collection/quality...

> Have you ever received health-care in Europe?

Have you ever received health-care in Australia, its pretty good and free.

Maybe it’s time to get a proper publicly funded universal healthcare system. Then these problems would go away. My hypothesis is it could be funded if we increased federal taxes by 100-200 basis points.

I believe a functional universal healthcare system can only be created without interference from the existing insurance companies and healthcare networks, but they have a strong lobbying engine that cultivates both sides of the political spectrum.

If we make a universal healthcare system now, it could be a slight improvement for us, but it can only be written and passed in a way that will funnel an even larger portion of GDP to health insurance companies and hospital networks.

Some healthcare systems post incomplete pricing data or nothing at all, with no penalties yet from the Biden administration.

It's pretty sad that there is basically nobody in DC who wants to improve the healthcare system. Certainly not Biden.

> “Some hospitals … don’t believe consumers would find [price transparency] useful”

Is saying that consumers are too stupid to understand the benefits of price transparency an adequate defense?

No, the article says exactly why:

> Texas-based Christus Health early this year said on its website it planned to defy the rules because its comprehensive list of prices “will only be useful for our competitors.”

Because publishing prices leads to actual competition.

Price transparency in medical care should have been a thing since the 80s when we deregulated telecomms and aviation. There should be price transparency and WYSIWYG billing, no hidden fees, or bait and switch, etc. No $50 tylenols and such shenanigans.

I’d take it a step further and mandate a single price for everybody. Let insurance cover whatever the actual is going to be for paying in cash and not some voodoo accounting that generates a cash price backwards from the maximum negotiated rates.

Insurance should be to cover unforeseen events. Baking in the cost of trivial things like a “fee flu shot” just acts as a way to obscure the true costs.

Totally agree. Charge the same price for everybody no matter how they are paying.

What would be the difficult-to-foresee challenges this, for practitioners and consumers, would raise?

Let's take it one step further and everyone pays for health insurance out of their taxes according to their means, and the state handles all the billing, negotiation and pricing on their end - and the individual never has to care who's paying and how much. Socialized medicine already covers 40% of Americans between Medicare, Medicaid and the VA. Time to get it to 100%.

The Canada Health Act is a great model. The Feds mandate that the Provinces figure out how to provide everyone a minimum standard of care, and each Province administers a public health insurance program that covers everyone. This would map perfectly to the states.

I'm not sure I would want to go there. "People of means" already pay greater taxes which support government programs. If you think they are not paying enough, raise their taxes, but avoid double taxation.

In other words, I don't think just because I would pay $1000 for a broken arm means I would agree that Bezos should pay $100,000,000 for the same. It would make no sense. It would make sense to close his tax loopholes. Sure.

Sorry for the unintentionally charged and hence confusing language there. I just meant via progressive taxation. Something like the Ontario Health Premium [1] which ranges from $0 per year if your taxable income is $20,000 or less, to $900 per year if your taxable income is more than $200,600.

I agree and also do not want what you outlined! :)

I strongly suspect that a socialized medical program in the US would not actually cost individuals any more than they're paying now - it's just that the cost they're paying is hidden behind employer paid premiums. That's just a private tax.

[1] https://www.ontario.ca/page/health-premium

Ok. Yes, that makes sense.

I think a great way to do this would be for the government to enter the market with a fixed enrollment and a lottery system.

They can run the program for 3 years for 100,000 people and transparently report all their findings and we can see how it went.

> I strongly suspect that a socialized medical program in the US would not actually cost individuals any more than they're paying now

The definition of progressive taxation means this is not the case for anyone making more than 100-150k, given current tax brackets.

Medicare already is 1/3 of the federal budget and I can assure you someone making low 6 figures definitely pays more in tax than 3x $900.

> Medicare already is 1/3 of the federal budget and I can assure you someone making low 6 figures definitely pays more in tax than 3x $900.

Well the first step is redirecting all the premiums paid by employers on behalf of employees into the federal pot. That should net ~$5500 per taxpayer or an additional ~$1.8T per year. That will sort out the bulk of it with no additional cost visible to individuals.

That is not the plan put forth by Medicare for All advocates. There is a strong undertone of income redistribution in progressive proposals for single payer.

I would also expect that if the government was taking that money my health benefits would be at least as good as they are now. And I don't think that will be the case. When I was a kid there was a period where I was on California MediCal and I distinctly remember getting glasses with _super_ thick lenses because all MediCal would pay for was the cheapest frames and lenses.

> That is not the plan put forth by Medicare for All advocates.

I'm almost 100% confident it is. That money is currently being paid on behalf of individuals to insurers. Take the insurers away that money either goes to individuals and gets taxed, or gets sent directly to the feds. Either way it's a no-op.

> There is a strong undertone of income redistribution in progressive proposals for single payer.

Healthcare is the great equalizer. It's not insurance - everyone needs it and everyone will use it. There's not really a strong correlation between more spend and better outcomes past a certain point. Except in the rarest of cases you can't cure cancer with fat stacks. What offering healthcare does is give low income folks the opportunity to found companies without the fear of death. It dramatically reduces the burden on all businesses and especially small businesses by killing a massive cost center.

> I would also expect that if the government was taking that money my health benefits would be at least as good as they are now. And I don't think that will be the case.

Every healthcare system that ranks above America's is single payer or two-tier socialized. MediCal is set up to be punitive to the poors like all Medicaid programs. A Medicare system isn't. There's a reason not a single AARP member is advocating for eliminating Medicare. What getting everyone on the system does is it makes the political class beholden to the needs of the individuals.

I watched Donald Trump in front a group of older folks literally hug a flag and say he'd do whatever it took to keep the Democrats away from their Medicare. That doesn't sound like a system itching to be upturned does it?

Socialized medicine is no more a partisan issue in most countries than a socialized fire department or sidewalks.

> Healthcare is the great equalizer

By income redistribution I mean most progressive proposals aim to heavily tax high earners to fund healthcare for lower income individuals. That money would otherwise be used by those earners to buy their first home, build retirement wealth, etc. Ever heard of HENRYs?

> MediCal is set up to be punitive to the poors like all Medicaid programs. A Medicare system isn't.

Citation is needed here. A lot of good doctors in my area won't take Medicare patients because Medicare reimbursements are too low. We also know from European systems that because everything is triaged based on need that wait times end up being very long if you don't have a life threatening condition. You also need to consider that American doctors make substantially more than European ones. If you compare the pay of specialty doctors in the NHS to ones in the US the difference is something like 5x.

> What getting everyone on the system does is it makes the political class beholden to the needs of the individuals

That is your perspective, and I think it's a naive one. I think it would prevent reforms that drive efficiency. Think of what happens when anyone talks about making Medicare more efficient: they get attacked as anti-elderly and portrayed as wanting to cut benefits. Or the same for military spending. At least the free market (which healthcare is not right now, but it could be) is ruthless about creating efficiency.

> Socialized medicine is no more a partisan issue in most countries than a socialized fire department or sidewalks.

Funny that the UK argues about NHS funding a lot then.

> By income redistribution I mean most progressive proposals aim to heavily tax high earners to fund healthcare for lower income individuals.

As someone who would be on the giving end of that, I'm fine with it, honestly. I won't always be on top.

> We also know from European systems that because everything is triaged based on need that wait times end up being very long if you don't have a life threatening condition.

We don't know that at all. Triaging based on need is a feature, not a bug - and a super easy way to save a ton of money! All of these criticisms were made up by the marketing department at insurers to fleece Americans. That's not hyperbole, and don't take my word for it. Here's an interview with one of the Cigna guys admitting to doing it, and apologizing. [1]

  "Here's the truth. 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"

> You also need to consider that American doctors make substantially more than European ones. If you compare the pay of specialty doctors in the NHS to ones in the US the difference is something like 5x.

Ok, and they shouldn't. I'm sorry. It's not sustainable, it's not affordable. They're taking pay cuts. Nobody is entitled to a certain salary, standard or lifestyle in perpetuity no matter how unsustainable. BMWs for doctors while 10% of Americans are told to die or pick their favorite finger after an accent is unconscionable. America pays more than anyone else anyways, and would still after cuts, where would they go?

However, this is also simply not true for every system. Most similar countries socialize malpractice insurance which is a huge cost for US doctors. US OBGYNs pay up to $200,000 per year in malpractice insurance. In Canada, $40,000CAD. In the UK I think it's 0GBP handled by the CNST. That goes a long way to balancing out pay differentials.

In the US anesthesiologists make 400K USD median, in Canada 335K CAD median.

> Funny that the UK argues about NHS funding a lot then.

They argue about funding and prioritization and all sorts of stuff, sure, but it's not a partisan matter that the NHS should exist and be the status quo. The NHS was literally in the opening ceremonies of the 2012 olympics. 87% of British folks are proud of the NHS. [2]

Canada's Conservatives support single-payer medicine too.

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

[2] https://yougov.co.uk/topics/politics/articles-reports/2018/0...

> As someone who would be on the giving end of that, I'm fine with it, honestly. I won't always be on top.

And I and many others are not. You should recognize that this is a _political_ issue where there is no objectively better outcome. Higher taxation has long run drags on innovation and wealth building. The tradeoff is yes, we don't have universal healthcare. I'm okay with that if it means I have more job opportunities and ability to build my wealth.

> In the US anesthesiologists make 400K USD median, in Canada 335K CAD median

Just because the gap isn't 5x doesn't mean there still isn't a huge gap. $335K CAD is $235K USD. And Canada has comparable CoL to major US cities so you're losing real purchasing power there.

> That's not hyperbole, and don't take my word for it

Take a look for yourself at the data in Table 4 [1] sourced directly from each country's government reporting infrastructure and decide for yourself whether you would accept those wait times. I wouldn't accept a 2 month average wait time for something as simple as cataract removal, that's for sure. The quality of life loss in that time is immense.

> Ok, and they shouldn't. I'm sorry. It's not sustainable, it's not affordable. They're taking pay cuts.

Good luck passing any legislation over the lobbying of the AMA then. You're suggesting fundamentally untenable legislation that will never pass in the US. Aka bikeshedding. This is exactly the reason progressives can't get any legislation passed in Congress.

[1]: https://www.sciencedirect.com/science/article/pii/S016885101...

> And I and many others are not. You should recognize that this is a _political_ issue where there is no objectively better outcome

Luckily the rich are a minority and this is a majority rule system :)

There is 100% an objectively better outcome. Better care for more people, fewer people falling through the cracks is objectively better. There are objective rankings of healthcare system quality.

> Higher taxation has long run drags on innovation and wealth building.

And not dying if a small business owner gets sick has a long run boost to the economy. Individuals being able to take risks without fear of death and pestilence has a long run boost to the economy. A carpenter having all their fingers re-attached instead of just some of them has a long-run boost to the economy. Small and mid-size businesses not having to administer health plans is a boost to the economy.

> I'm okay with that if it means I have more job opportunities and ability to build my wealth.

You'll still have your chance lol.

> I wouldn't accept a 2 month average wait time for something as simple as cataract removal, that's for sure.

Cataracts develops slowly over a period of years. It's explicitly one of the lowest priority surgeries you can get for that reason. It took you 10 years to develop you don't need it out by Monday, late February is fine. (NOTE: In some provinces your data shows you can get it out in 2 days in Canada). It's nuts to think that you should be able to pay more to get your decades old cataract out by Monday so that someone who was in a car accident can get in line lol.

So yeah you absolutely would, and you wouldn't care at all.

Either way, America will almost certainly land on a two-tier system where you can still get your way.

> The quality of life loss in that time is immense. This is exactly the reason progressives can't get any legislation passed in Congress.

It's simply not. Sorry. Data and satisfaction surveys disagree, but also - only for the few who can afford to jump the queue. There's very few of those so they're not really represented in surveys.

> Good luck passing any legislation over the lobbying of the AMA then.

Single payer in Canada passed explicitly against the wishes of the entire North American medical establishment. "The organized medical establishment was not nearly so reticent and mounted a ferocious propaganda campaign fronted by the local College of Physicians and Surgeons with the support of the Canadian Medical Association (CMA), the AMA, the local economic elite and most of the media in the province." [1]

We got it done before, we'll get it done again.

You've been fed a crock. Sorry.

[1] https://canadiandimension.com/articles/view/the-birth-of-med...

> Luckily the rich are a minority and this is a majority rule system

Hmm, is that why the Build Back Better Act got killed in part by House Democrats wanting a SALT cap repeal? "The rich" you're thinking of excludes a large percentage of high earners who live in high CoL areas but are not wealthy. I'll remind you 20% of California earns more than $162k [1]. That's a lot considering the win margin of the general election and most CA state propositions. Enough to tip elections.

> And not dying if a small business owner gets sick has a long run boost to the economy

"Small business owner dying because they got sick without insurance" just doesn't happen. This is a strawman.

> You'll still have your chance lol

Average house price in Frankfurt is 7200 euro/sqm [2]. Tell me again how you can pay for a 200sqm house (=1.4M euro) when European software engineers make less than half of what American engineers make and get taxed more? A new grad at Uber in Europe makes 87k EUR [3]. A new grad in the US at any big name tech company makes more in the range of $180-200k. So your pay is more than double and you get taxed less, meaning you build wealth in the range of 3x as quickly.

[1]: https://www.thecentersquare.com/california/california-househ... [2]: https://www.ft.com/content/3e4f8c40-1dca-447e-a3c4-69911cfc1... [3]: https://blog.pragmaticengineer.com/software-engineering-sala...

> Hmm, is that why the Build Back Better Act got killed in part by House Democrats wanting a SALT cap repeal?

This could not be less relevant, but yes, I do think this likely represented the majority position. I think as much as we grumble Manchin represents his people. By the way 70% of Americans support Medicare for All so I'm not really worried about the popularity of the position. [1]

> "Small business owner dying because they got sick without insurance" just doesn't happen. This is a strawman.

18,000 Americans die each year due to insufficient medical coverage. You willing to bet not a single one is a small business owner? [2]

> Average house price in Frankfurt is 7200 euro/sqm [2]. Tell me again how you can pay for a 200sqm house (=1.4M euro) when European software engineers make less than half of what American engineers make and get taxed more?

Speaking of straw men, this is all attributable to the fact the Germans manage to cover 100% of their population for $5,595 per capita, vs America's covering 40% via a socialized program and 60% via private cover for $11,000 per capita?

> A new grad in the US at any big name tech company makes more in the range of $180-200k. So your pay is more than double and you get taxed less, meaning you build wealth in the range of 3x as quickly.

This argument doesn't hold water. You won't get that salary, broadly speaking, unless you live in SF, NY or SEA. There, your cost of living is so high your net take-home pay may well be lower than the German engineer. Certainly not after you adjust for PPP. But of course this has nothing to do with healthcare.

[1] https://www.cnbc.com/2018/08/28/most-americans-now-support-m...

[2] https://policyadvice.net/insurance/insights/how-many-uninsur...

> This could not be less relevant

It shows you that the "rich" you're discounting wield substantial political influence. Manchin wasn't the only one that killed the bill, House democrats also said they'd kill the bill during the merging of Senate/House versions if there wasn't a SALT repeal.

> By the way 70% of Americans support Medicare for All so I'm not really worried about the popularity of the position

Do you know how these surveys work? They literally just ask people how much they support "Medicare for All". They don't present any concrete policy or implications of implementing M4A. That's why "Obamacare" got way less support than "Affordable Care Act" in polls. Please understand the stats you're quoting at the very least.

> 26,000 Americans die each year due to insufficient medical coverage. You willing to bet not a single one is a small business owner?

And hundreds of thousands of people die from benign illnesses like the common cold and the flu each year. What's your point? I bet we can find someone in Germany who died because of wait times too, that doesn't mean we can use that to generalize to everyone.

> Speaking of straw men, this is all attributable to the fact the Germans manage to cover 100% of their population for $5,595 per capita, vs America's covering 40% via a socialized program and 60% via private cover for $11,000 per capita?

This has no relation to the impact of universal healthcare's higher taxes on wealth building. It is a fact that it is harder for working professionals in Europe to build wealth compared to the US.

> This argument doesn't hold water

Cost of living is not so high in NY and SEA. You can rent a luxury apartment in SEA for less than $2000/mo, which is comparable to Frankfurt. Only SF is insane. And German cost of goods is around the same or more than US, so I don't know where you're going with your PPP idea. You need only look at the cost of electronics, gasoline, food, etc. to see they are about the same.

> But of course this has nothing to do with healthcare

Yes it does. Implementing M4A would require heavily taxing high earners. I'm giving you an example of how a high earner would be unable to build wealth under European-like taxation. But it seems like you are unable to understand the idea that high taxes unfairly penalize high earners who came from poor families. I.e. implementing M4A's taxes would penalize economic mobility. Perhaps you came from a family with wealth already.

At this point much of your argument has devolved into Gish gallop, so let's take a step back.

If private cover is so good - so clearly superior - would you advocate for eliminating Medicare and Medicaid? If not, why not? Why is socialized medicine the bees knees once you turn 65 but utterly unworkable if you're younger? Why do 75% of those covered by Medicare think the system is working very well - significantly more than those with private cover - and why would that not extend to everyone?

My argument is simple: Medicare for All entails higher taxes on high earners, which stunts wealth building and economic mobility, especially for high earners who grew up in poverty. This can be easily seen by comparing, for example, salaries of software engineers in Europe and the United States. Medicare and Medicaid are intended to take care of those that _can't work_, but Medicare for All is intended to take care of people that _choose not to work in a higher paying field they dislike_.

> private cover is so good

I would pay for a single payer option if everyone paid a flat fee for insurance that wasn't income based. I'm against the income redistribution part of Medicare for All, for aforementioned reasons.

> Why do 75% of those covered by Medicare think the system is working very well

Once again, polls are incredibly misleading and dependent on the wording used in the survey. You need only look at surveys of Obamacare vs. the ACA to see this effect.

You continually try to engage in asking the same questions by claiming to not understand all the statistics I've given you and I don't believe you're conversing in good faith anymore. Goodbye.

> My argument is simple: Medicare for All entails higher taxes on high earners, which stunts wealth building and economic mobility, especially for high earners who grew up in poverty.

This is an absolutely tiny fraction because most poor people can't afford the healthcare necessary to actually thrive in the economy. Ditto the education. What we need is equality of opportunity, and that requires social services.

> I'm against the income redistribution part of Medicare for All, for aforementioned reasons.

I'm completely uninterested in this. Unless tied to income it's a regressive tax that punishes the poor disproportionately along the axis of marginal utility of money.

> Once again, polls are incredibly misleading and dependent on the wording used in the survey. You need only look at surveys of Obamacare vs. the ACA to see this effect.

This is a different subject and so not relevant. Everyone knows what Medicare is. The only thing most right-wingers know about Obamacare is that Obama created Obamacare. Really it's more like Romneycare for All as it's essentially a Republican policy. There's not a single left-leaning thing about making every individual pay a private company for healthcare. You're not showing a skew in reality, just marketing.

I suspect Americans would feel differently if they knew that Obamacare single handedly dropped the rate of people dying from lack of cover by almost 50% per annum.

> You continually try to engage in asking the same questions by claiming to not understand all the statistics I've given you and I don't believe you're conversing in good faith anymore. Goodbye.

Respectfully disagree. I've successfully refuted every concrete point you've made up to and including whether "the left can pass such a bill" and whether you really need cataract surgery tomorrow.

I wish you the best. Medicare for all is coming. It's just a matter of time.

However, you have failed to answer my core question. Do you think that Medicare should be abolished? Should Medicaid? If so, why? And in what concrete ways do you think that would make America a better place? More efficient? And why is 65 the magic age at which "socialism" finally starts to make sense?

According to your profile, you're not even a U.S. citizen, how can you purport to understand anything in the U.S. when you don't vote here? When you repeatedly post in favor of one political slant as a foreign national that's no different from Russian troll farms getting paid 50 cents a post to spam politics online.

> I'm completely uninterested in this. Unless tied to income it's a regressive tax that punishes the poor disproportionately along the axis of marginal utility of money.

Nobody asked your opinion. I was simply stating mine.

> However, you have failed to answer my core question

I don't feel a need to prove to you I've answered anything. Like I said, you are conversing in bad faith.

> Medicare for all is coming

Is that why Democrats lost elections in swing states in 2021 by double digit shifts compared to 2020?

> By income redistribution I mean most progressive proposals aim to heavily tax high earners to fund healthcare for lower income individuals. That money would otherwise be used by those earners to buy their first home, build retirement wealth, etc.

This is the most transparently selfish thing I've read in a while. Congratulations.

”Socialized medicine is no more a partisan issue in most countries than a socialized fire department or sidewalks.”

That’s a disingenuous statement since most countries have a mix of public and private care and many folks rely on private insurance and private care. Canada is one where private care is almost non-existent, but the UK, Switzerland, Australia have a significant private segment.

What Medicare for All suggests (and a few Democrats have said it explicitly) is that private insurance would disappear.

So Socialized medicine isn’t a partisan issue in most countries, but neither is private medicine.

A few years ago, in Canada, we were paying $4500 per person - and everyone was covered.

The US was paying $5K public per person and $5K private per person.

Meaning - the US is already paying more per capita in public healthcare spending, than Canada, and for that price in Canada - everyone is covered.

This kind of means, the US could literally give all of its citizens 'Canadian Quality Universal Coverage' and literally save a few dollars in public spending, and wipe out the need for private spending.

So 'cost' and 'profit' are different things.

The US HC system is a giant elephant of inefficiency.

This is not a small thing:

'Healthcare' is a 'Pillar of American Decline'. I don't mean that America is falling apart, but rather, it's having less influence in the world.

50 years ago, you went to the Hospital because you were hurt. Now - it's all about aging people who are elderly who see the doctor 20x a year and it's why costs have skyrocketed. It's also when people are the least productive and less likely to be working with good insurance.

HC is a disaster that makes the US a 'much less attractive place to live' for one's entire life, unless one is rich - whereas that was not the case before.

It really needs to be sorted out.

The Media Left, by highlighting Woke issues, instead of things like outrageous healthcare, has completely lost their minds. MSNBC was calling Elon Musk 'racist and misogynist' for his completely benign comments about this giant tax bill. Instead of looking at inequality issues through economic lenses, they're committed to throwing around gender and racial slander. The HC system is a soft, easy target because there are unlimited stories of people getting huge bills, unfair pricing. But you won't see to many stories, because "Sponsored by Phizer".

> 50 years ago, you went to the Hospital because you were hurt. Now - it's all about aging people who are elderly who see the doctor 20x a year and it's why costs have skyrocketed. It's also when people are the least productive and less likely to be working with good insurance.

Literally 100% of the elderly in the US are already covered by the socialized medicine you seem to be advocating for. It's not optional.

> a socialized medical program in the US would not actually cost individuals any more than they're paying now

But think of all those insurance company employees who would be out of work!

Anyone who's had extensive dealings with the VA would be glad to share why they are not interested in single payer. Making that switch will not remove the incompetence, poor staffing lack of care, lack of accountability, and so forth.

Some sane standards need to be drafted and then enforced, hard and fast, before we start mandating how healthcare is paid for.

And anyone who has dealt with socialized medicine in the OECD will tell you the exact opposite :) Wholesale reform is needed, and that can certainly be part of the package. However, parceling it out is a great way to achieve absolutely nothing as evidenced by the current morass.

Huh? I have experience with “socialized medicine” in Poland, and, in short, it’s shit.

Heh, maybe not the whole OECD but [1] America ranks near the bottom as-is.

[1] https://worldpopulationreview.com/country-rankings/best-heal...

Interesting to look at the population from your link. The United States appears to be doing the best (LPI 2020 ranked 18) out of all the countries with population over 100 million. After Japan (ranked 19) the next closest are China (54) and Indonesia (57). I'm not sure what relevance this might have, I just found it interesting. The CEO rankings show a much different picture.

If I had to guess, one is weighting access to care differently than the other. America's system is good but not top tier if you can get it. It's really bad if you can't.

When you are imagining single payer in the US, are you imagining it being designed and run by the people who created the current system?

People seem to be big fans of Medicare. Of those covered by Medicare 75% say the system is working well, only 22% say it is working poorly. [1]

[1] https://www.kff.org/medicaid/poll-finding/medicare-and-medic...

Thank you for the thoughtful response to my question.

What's really interesting is that 60% of people in general (including those already on it) say Medicare is working well for seniors - but when you drill down only to the people actually covered, that number jumps up to 75%. Same source. Seems like a marketing issue?

> and the individual never has to care who's paying and how much

But then nobody cares about how much the government is paying, and you end up with more and more taxes and inflation.

Taxes are increasing. Government debt and inflation are skyrocketing. Can't we put an end to it?

Also the government can't even build passenger rail without wasting absurd amounts of money and having "unexpected delays" in all projects. Why should we trust it to manage everyone's healthcare?

Because every comparable country that has a government-run healthcare system has somehow ends up with it being ~twice as efficient. I get that there's theory that says a private healthcare system should be better at keeping costs under control, but it's not borne out by the evidence.

"~twice as efficient" is a stretch. They might cost half the price, but they are not necessarily twice as efficient.

Medical treatments and equipments in the US are the best in the world (discounting super small countries). Americans have the highest life expectancy in the world (discounting homicides and transit deaths). Americans can get treatments fast while people in Canada or the UK have to wait for months because the government is rationing treatments.

And we should consider other reasons that explain the costs besides "private system inefficiency": American companies carry the world on medical innovation (so other countries are benefitting from the Free-Rider Problem, and Americans are paying for it). American regulation requires doctors to spend several more years in training than at other countries (in other countries the medical school is usually merged with undergrad). And, finally, Americans just earn more than people in other countries. GDP per capita is 60k in the US, 40k in other developed countries.

> Medical treatments and equipments in the US are the best in the world (discounting super small countries).

Not really. They're fine. In line with OECD. And further, America has a number of blemishes such as among the highest maternal mortality and infant rate in the entire OECD. [1]

  ...the U.S. ranks 33 out of 36 Organization of Economic Cooperation and Development (OECD) nations. In 2018, while infant mortality reached an all-time low in the U.S., at 5.9 infant deaths per 1,000 live births, still more than 21,000 infants died. Compared to countries with a similar GDP, the U.S. infant mortality rate is much higher. France and the U.K., for example, have 3.8 deaths per 1,000 live births.

The only area the US really excels is in cancer 5-year survival rates - not because the mortality rate is lower, however, it's about the same as everywhere else. The US just biases towards earlier screenings that do not extend life or reduce mortality.

> Americans have the highest life expectancy in the world (discounting homicides and transit deaths).

Are you sure about that? It doesn't look like that on this chart. [2] Not to mention the US spends dramatically more to achieve that much lower life expectancy than anyone else does.

> Americans can get treatments fast while people in Canada or the UK have to wait for months because the government is rationing treatments.

This is a straight-up lie peddled by the US medical insurance industry. Here's an admission and an apology by a Cigna executive tasked with doing so. [3]

  "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."

They pulled the same thing when Canada instituted single-payer healthcare in 1962. [4]

> American companies carry the world on medical innovation.

Not really. There are as many European as there are American medical companies in the top R&D spenders worldwide. That's before we factor in government expenditures worldwide.

> And, finally, Americans just earn more than people in other countries. GDP per capita is 60k in the US, 40k in other developed countries.

Now imagine what they could do with an extra $5K per person per year - the difference between what the US and Canadian medical systems cost per capita.

[1] https://www.forbes.com/sites/joshuacohen/2021/08/01/us-mater...

[2] https://ourworldindata.org/grapher/life-expectancy-vs-health...

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

[4] https://canadiandimension.com/articles/view/the-birth-of-med...

The infant mortality rate is based on extremely misleading statistics.

In the US, if a baby is born who can be saved but isn't, their death is reported in the neonatal mortality statistics. But in other countries it is more common for babies in these situations to be counted as miscarriages or stillbirths.

In the US, very low birth weight infants are considered to be alive (because, of course, they are), but in Canada, Germany, Australia, and other countries, a premature baby weighting less than 500g is considered to be already dead, even if it is breathing and has a heartbeat. So they don't have to add it to their infant mortality statistics when their healthcare system fails to save its life.

In fact, since the year 2000, of the 52 surviving babies who were born weighting less than 400g, 42 were born and saved in the US.

Sources:

- https://youtu.be/KEHM3EHUTew?list=PLWu1-TbpoIFJZga03X-Wzf1UH...

- https://www.healthsystemtracker.org/chart-collection/infant-...

- https://www.forbes.com/sites/physiciansfoundation/2016/04/12...

The 4th worst maternal mortality rate in the entire OECD too. That would be the mother dying during childbirth. [1] More than double Canada in 2018 and 10X New Zealand. [2] Without getting into your data re: infants (because I do not know enough to do so), I suspect this one's not as easy to hand-wave.

The results of the study carried out in [2] say:

  The U.S. has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports.

American healthcare is acceptable if you can afford it and a death sentence if you can't.

[1] https://www.npr.org/series/543928389/lost-mothers

[2] https://www.commonwealthfund.org/publications/issue-briefs/2...

Unfortunately as one example Medicare Part D price negotiation has been blocked since 2003. When some drugs were moved to Part B, insurance companies were furious because it allowed price negotiation for those.

This is from 2016, so nothing has changed AFAIK. https://www.healthaffairs.org/do/10.1377/forefront.20160919....

Despite this election season’s divisiveness, both major parties’ presidential candidates have embraced the idea of authorizing Medicare Part D to negotiate directly with drug companies to set prescription drug prices. The Medicare Modernization Act of 2003 (MMA), which established Medicare Part D, included a ban on such negotiation.

Apparently both sides of the aisle pander to voters with the idea they'll help with healthcare costs and then don't once safely elected to office.

Your summary doesn’t make much sense.

Part D plans are administered by private insurance, who do negotiate prices.

Part B drugs aren’t negotiated even today. Government has a formula for what they will pay, but there is no negotiation.

Why mandate a single price? Don’t we want prices to be competitive? As a young doctor I may want to bill at a 10% discount?

Medicine is very much standardized, so you want to bill the same per procedure, but for complicated cases you want to allow upcharges.

So a fresh out of residency eye surgeon should get paid the same as a 20 year old doctor who has done 1,000s of the procedures?

The patient should pay the same, no matter who does it. Compensation of healthcare staff is an internal matter and frankly not relevant to the patient.

That's how it works in Germany.

So should every healthcare provider organization throughout the country be required to charge the same price for a given procedure? Many US doctors still run solo practices, so there is no real difference between the company and the "staff". It seems reasonable that doctors with more experience and better skills should charge higher fees.

It seems reasonable that doctors with more experience and better skills should charge higher fees.

That's entirely your opinion. A more experienced doctor shouldn't have problems finding cases that require advanced expertise.

I don't understand, are you being sarcastic? Which is preferable?

The preference would be a higher quality, by virtue of more experience, gets paid more.

Why would I be sarcastic?

So the choice would be between glaucoma surgery according to the standard of care - or glaucoma surgery according to the standard of care.

Now we are getting somewhere! What if all this "choice" did nothing to improve patient outcomes or public health but entirely served to get more money out of your pocket?

Are you saying outcomes aren’t influenced by the skill of the doctor?

Are the outcomes of CS folks impacted by their skill?

To read your sarcasm I'd have to know whether you have in fact gotten surgery by a more experienced doctor. It just depends on so many things. First, you can't be a surgeon for that long, you start losing your "pulso" like stillness of hand at around 50. Then there's the vibe the old doctor and the young doctor give you.

You must use your judgment to interpret it, but let me tell you a trope: the old doctor, sure, he's done this thousands of times, so it's no big deal for him. But he might be complacent, and plus he's been a surgeon for decades, these guys get worshipped by the rest of the hospital, it typically gets to their head. He might have long ago lost sight of needing to help people who lost sight, if he's not a virtuous guy he'll hustle you, 100%. And if he fucks up? 1 divided by 2000 is what percentage error rate, .05%? Assuming it's never happened before.

Whereas the young doctor is probably hungry for his first paycheck after a decade of getting into debt and memorizing stuff, his big chance to stop getting hazed, this won't be his first time really, he'll want to do an amazing job. He has no track record so if he screws up, it won't be automatic to get a second chance, it's high stakes, and he'll have that error hanging over him. He might be nervous though, so you have to keep that in mind. But much better hands, and he'll actually perform the surgery according to the original definition of "perfection" : he'll carry it out all the way through. Won't skip steps to save himself a couple of minutes at the expense of weeks of pain. He doesn't yet know what parts of the surgery he can get away with not doing, he just does the whole thing.

On the other hand, if the old doctor is humble and the young doctor is arrogant, it could be the other way around. You need to judge the vibe.

Price transparency is a thing. NY (and I think other states by now) have ruled that surprise billing was never enforceable.

Given “no hospitals have been penalized as of late December, according to the Centers for Medicare and Medicaid Services, which is responsible for enforcing the rules,” this comes close to dereliction of duty by CMMS. That said, that hospital’s spokesperson said they will be in compliance by the New Year, so maybe this is just a work in progress.

The price transparency rules became effective on January 1st 2021. A change like this will always take time for everybody to implement. But, I agree. If CMMS doesn't penalize non-compliance hospitals will drag their feet indefinitely.

It's disingenuous, patronizing and offensively cynical, but it's no defense. It reminds me of people naming bills the opposite of what they are meant to do. The "Patriot Act" was touted to among other things "defend freedom" and then enabled a surveillance state. That kind of thing. The hospitals will have to be sued into compliance by the Attorney General's office if it's important enough to Mr. Garland.

Wonder if individuals can sue once they get their bills, on the grounds that they didn't realize that would be the price, and this was caused by the hospital's failure to comply with the law.

No the federal law which requires price transparency didn't create any private right for individuals to sue on that basis. In principle that seems like a good idea but it would take a new law.

How so? If there is no price transparency, couldn’t they sue them for violation?

That's too bad. I don't pretend to know anything about the law but it feels like this is one of those places where either thousands or tens of thousands of arbitration claims or a class action lawsuit would be effective.

Waiting for the "Freedom to Fly" act to drop any day now, which should prevent someone from flying without a pharma endorsement. It's like a perverse kind of poetry.

---

People in here acting like it wouldn't be called that lol...

Your freedom to spread infectious diseases ends where my lungs begin.

Quite a cynical take, but I understand this talking point after hearing it for the past 20 years. Many people would consider themselves freer if they were living under possible surveillance in a safe society, versus in a surveillance-free society with the constant fear of random terrorist attacks.

What you say may be true, but that’s not a dichotomy we’re presented with.

There is room in the middle between those two extremes. Law enforcement had serious interagency rivalries, the intelligence community wasn't able to say when another WTC attack would happen after the previous one, and even after that one nobody was living in the fear of random terrorist attacks, even though we had plenty of domestic ones.

My personal opinion is when confronted with their failure to accurately predict and prevent the 9/11 attack, law enforcement and intelligence both said well just give us all the money and unleash us. Our society is less safe now not because we decided to throw money at the problem, but because we decided to retaliate with force, which never deescalates the situation without a total victory.

So now we have less freedom thanks to the surveillance state, absurd debt levels, and no progress in fully dismantling the terrorist network.

It's an euphemism for "we don't want to make it obvious how much we overcharge".

Fine them - nothing is going to change until the fines are larger than the competitive impact

The fine is only $110,000 a year. They make more doing nothing.

does anyone know if they are forced to list complete procedures? example: hernia will cost $4200

or will they be able to list dozens of other charges that may or may not be added to the procedure?

Hospitals are unbelievably corrupt and it’s truly despicable.

The worst bit is that this is often learned during trying times in ones life, when stress makes it easier to overlook.

I had a hospital call me recently and inform me that the cash price for an upcoming procedure would be much lower than the price they would bill the insurance company. Since I wasn't going to meet my deductible this year, they suggested I accepted the cash price to save money.

I asked them if the insurance price was the price billed to the insurance company or the negotiated price that actually gets paid. They could not give me a straight answer. I had them stay on the line while I added my insurance company to the call. The agent at the hospital communicated the necessary information to the insurance company (there's a ton of stuff that effects the price, down to which radiologist happens to be scheduled that day). And of course, the negotiated price for the insurance company was lower than the cash price the hospital was offering.

I really don't think this attempt at getting me to pay the cash price was some accidental mix up. I think someone at the business side has figured out not only can they convince people to pay a higher rate, but that then they don't need to deal with billing the insurance. A double savings. I wonder what percentage of people they successfully scam with these calls.

To anyone outside the US reading this who is really confused, I'll see if I can start a GoFundMe to explain the US healthcare system to foreigners

This specific con really ought to be illegal and it's becoming incredibly common to the point that I see it every time I'm at any medical facility now.

The exact statement you described is used: "Oh you won't hit your deductible yet so pay this lower cash price" and you are spot-on that it's a sly way for the facility to get more for the procedure by hoping the patient doesn't understand negotiated billing. And it works... almost every time I've seen it offered it's accepted.

Not to even mention the secondary effect that this causes the patient to not make progress towards burning their deductible so if they have more medical events that year they'll basically pay that amount AGAIN.

This month, a family member was scheduled to receive a (fairly involved) CT scan (at an in-state state university hospital) on a date that just happened to fall into a "COBRA dead interval" (the first month of COBRA-funded health insurance eligibility has a 'pay later' clause; retroactive coverage for the first month does not spring into existence until some weeks after payment for that month's coverage is made, which might well be after that first month had already passed); in attempting to explore options, I learned from the provider (hospital) rep that if we elected to have the CT performed as originally scheduled (therefore in the absence of verified insurance coverage), we would be required to pay the "self pay" amount ($444[1]) at the time of the procedure; if we chose instead to delay the same procedure until insurance coverage was confirmed restored, the amount to be billed (to insurance) would be $3700.

Since this conversation occurred within the "COBRA dead interval", there was no feasible way to ask the soon-to-be-restored insurance provider how much they would be able to discount and/or adjust the $3700 price of this same procedure downward... based on past history, I'm not confident that an insurance company would pre-commit to a set of discounts and/or adjustments for a procedure price (i.e. the final price we'd be required to pay out of pocket if below our deductible) prior to a (post-service-delivery) claim being filed and processed. Catch-22? Or "we can't know what's in the [legislation] until we pass it"?

edit: add [1] the "self-pay" amount would constitute payment in full.

How long did this whole process take, and what was the result? Did you get to pay the negotiated amount?

I was on the phone about 40 minutes. The rate in the end was the negotiated rate from the insurance company. The amount of time and effort involved in finding out how much something will truly cost certainly seems like an intentional feature

Meanwhile in Canada I have had multiple trips to my doctor, multiple tests, x-rays, ct-scan, blood work, and probably a couple others I am forgetting and my bill has been zero dollars. There is no such thing as a bill. I guess I pay taxes but that is it. As a non American it is so hard to see this and understand how it is allowed to happen. You guys must have to choose between doctors or financial uncertainty and I can't understand how a country as good as USA has allowed this to happen for so long.

As a Canadian my mom waited 16 months for a hip transplant. She could barely get around her house, but she was deemed “lower priority”.

While my coworker in the Bay Area got her a choice of surgery slots less than a month out.

There are trade offs.

In the US, the waits are short because few can afford to be in them.

In the US there are about 400K hip replacements performed every year. That's a lot more than a "few". The vast majority of Americans have some form of insurance which covers joint replacement surgery if they meet the medical necessity criteria.

In both Canada and the UK there is also private systems available that you can decide to avail yourself off, which like the US system will charge you into bankruptcy but will give you the immediacy you desire, then you get to have a choice, wait or debt.

At least here in quebec, the private system is not allowed to provide a lot of services and cannot provide much more than basic consultation, cosmetic surgery or treatments that are more or less arbitrarily allowed by the public insurance system. Tons of people went to the state when the public system basically stopped treating anything they didn't deem to be essential for almost a year back in 2020. I know tons of US hospitals did the same, but some didn't so you at least had a choice.

Here, once the government decided that your disease, surgery or therapy wasn't "essential" you couldn't do anything at all because the private system can't do most them either. Both of my parents are nurses & according to them at one point their hospitals were almost entirely empty, but because of that arbitrary you still couldn't access most non-urgent care which was very frustrating for them.

This is such an essential point, and at very least people should be suing the government over this.

That said, knowing our courts, they'll just say 'stuff it' and that's that.

Chaoulli v Quebec (AG) [2005] 1 S.C.R. 791, 2005 SCC 35, was a decision by the Supreme Court of Canada of which the Court ruled that the Quebec Health Insurance Act and the Hospital Insurance Act prohibiting private medical insurance in the face of long wait times violated the Quebec Charter of Human Rights and Freedoms.

https://en.m.wikipedia.org/wiki/Chaoulli_v_Quebec_(AG)

The private systems in Canada don't offer hip replacements, they offer a narrow range of services.

Also, 80% of Canadians live a 1 hour drive to the US border.

The 'fallback' to the Canadian system - is the US system.

I don't think either systems are ideal, we need somewhat more private service in Canada, and the US needs socialized coverage of some level along with private.

The big giant social issue that nobody wants to talk about, is that the 'pyramid' in the US is so much bigger than in Canada for so many reasons. The US upper middle class are much richer than in Canada. And the poor are really poor. There are 1M undocumented workers in each of Cali and Texas - if you put them on the books, it stretches the disparity even further.

This makes it harder to impose a 'one size fits all' system.

That said - all basic HC services should be minimally covered through the state.

The number of people putting up 'Go Fund Mes' is nutty.

People are also legitimately wary of governments ability to effectively provide for services, which is a legit concern. The government can be just as corrupt and inefficient ans the private sector, and it's not nearly as easily displaced.

Finally - I would like to see the 'Walmart' of Healthcare come along and do damage to the big providers. Walmart works on a cost basis and their pricing is based around reducing cost, then adding a very small markup - which is different than other businesses. If I was President I would probably beg Walmart to literally start providing basic services.

Incorrect about Canada. Doctors are prohibited from practicing in both the public and private hospitals. There is almost no private surgery - people just go to the US.

That's just stupid. It just makes sense to have a fast lane for paying patients because that shortens the queues to the public surgeries as well.

That works pretty well in Finland. One of my parents needed a cataract surgery this year, all cased and diagnosed by doctors in public healthcare. The actual surgery would've been maybe six months from now. Private clinic -- three weeks. My parents didn't even go shopping for another clinic, waiting three weeks was no problem. It also cost much less than they anticipated, a quick routine operation not worth the wait.

Are you implying that a negative trade off is that you're not prioritized according to wealth?

No, I’m implying that spending you more money can get you care faster.

Even Medicaid or Medicare patients in the US don’t wait 16 months for hip transplants.

Are you not prioritized according to wealth if you can pay to skip the queue? Or as in the US, to require payment to even be in the queue.

There's a lot of reasons behind it I think as a complete history/politics deletant; damage from cold war anticommunism, side effect of post world war 2 success, and the general story the US and it's citizens tell about themselves as individualistic.

The US came out of WW2 immensely wealthy (overall of course not everyone was allowed to participate in the boom) which buried a lot of the impetus that pushed other European countries to create their national health systems.

Then we were fighting against communism which took so many forms of social programs into the area of forbidden ideology that could spell the doom of the US and the rest of the world.

And then there's just the individualistic streak that seems to have been endemic to the US since it's founding. Religiously as well as economically there's a lot of focus on individual effort and rewards.

The thing to understand about the US healthcare system is that it's all based around corruption and waste (where waste to you is profit to someone else). The inefficiency is the point. It's a racket.

There are many known better systems and obvious improvements, where "improvement" means you get the same quality of care for less money. But then you get the same quality of care and the providers make less money.

Even if you're going to have a market-based system, things like price transparency would make it more efficient. Which is why they fight it so hard.

If all we did was replace the existing insurance system with single payer, it would solve nothing, because all the same lobbyists would just make sure that the government continues to overpay them. Single payer advocates like to point out that Medicare pays a bit less than private insurance in the US, but Medicare pays a lot more than single payer systems do in other countries. And if it was the only payer in the US then the lobbying pressure to increase what it pays them would be even higher.

Regardless of who is doing the paying, the problem that actually needs to be solved is the corruption.

> There is no such thing as a bill.

There are plenty of private healthcare services in Canada. Ever been to the dentist?

American healthcare is fantastic for the wealthy. Get what you want when you want with almost no wait. We also get treatments you can't get in Canada, if you have enough money.

The wealthy in the US have some of the best health outcomes in the world. It's only when you average with the middle class and the poor that our average outcomes drop.

The system stays the way it does because it's great for the people with power -- the wealthy.

American healthcare is actually pretty good for the middle class too.

https://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-...

” She later learned that, not only is Ibrance not covered in B.C., but the test that detected the return of her cancer isn't done anywhere in Canada.

"I always thought, it's crazy that my backup to save my life is another country," said McDonald.

"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."”

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