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Comment by asperous | Hacker News Reader

The disappointing thing to me is all the time spent on this case: lawyers, administrators, jury members, and so on that could be doing something different, hopefully more meaningful to society.

People blame the hospitals but this the game they have to play in order to cover their costs [1]. Just seems like a tremendous waste of resources and social cost.

https://truecostofhealthcare.org/hospital_financial_analysis...

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As long as the public isn't interested in seriously considering alternative systems like Medicare for All, nothing is going to change.

There's a reason that private equity has consumed our healthcare sector: it's incredibly lucrative and inherently disadvantages both the patient and provider through vast amounts of process.

Pretty much every healthcare startup in the US is just trying to figure out how to insert itself into this endless bureaucracy and draw money out of the system while trying to add value in some way.

Value optional.

Thing is, we didn't have socialized medicine in say the 1970s, and I don't remember things being this bad or regulated. What happened?

Maybe just "time" happened? It takes time for the rot to properly develop.

» Thing is, we didn't have socialized medicine in say the 1970s, and I don't remember things being this bad or regulated. What happened?

Or even more simply, we grew up. I was born in the late eighties. I was simply too young to understand that the civil war was not about states' rights. It was about slavery. I thought adults knew everything and as I became an adult I realized I knew nothing.

That or a lot of what was previously swept under the carpet or dog whistled is now out in the open.

Back to the topic though, I agree with you Probably the easiest explanation is healthcare is now a bigger slice of a bigger pie about 20% of a USD 20T GDP iirc. There is simply too much money to be made here. There is only so much investment opportunity that has any good return so smart money will chase anything that resembles guaranteed returns.

Thoughts?

EMTALA was passed under the Reagan administration. This forced hospitals to treat the uninsured, but it provided no funding to pay for those treatments. So the uninsured who don't pay are subsidized by high costs to the insured who do pay. In the 1970's, hospitals would just let the uninsured die in the parking lot / street.

So that's the change.

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

"This forced hospitals to treat the uninsured, but it provided no funding to pay for those treatments. So the uninsured who don't pay are subsidized by high costs to the insured who do pay. "

They are way overcompensating for this. I think it's just a BS excuse like pharmaceuticals having to be outrageously expensive in the US because other countries are negotiating better prices. I have read some studies where they concluded that the losses through uninsured people aren't really that high. They are only high on paper because they account for them with their chargemaster prices which are way higher than what they would get from insured people.

Greed happened. Hospitals consolidated and bought up small practices.

There are a ton of reasons why, but here are a couple of the big ones.

The US is still at the forefront of medical research and technology development in the world. However, many other countries won't pay "market" rates for newer technology developed here at home, so companies often overcharge domestically as a way to recoup revenue they can't collect in other places. Note that American hospitals (particularly newer ones) tend to be obsessed with having state-of-the-art technology, and they're damn sure gonna get paid for that.

Another major factor driving healthcare costs is the increasing barriers to access for millions of people. Lots of folks don't realize this, but the US already has a quasi-socialized healthcare system mandated through Federal law. Basically, it's illegal for hospitals to turn ER patients away that cannot prove ability to pay, so folks without insurance often come to the ER for routine medical treatment because its the only way they can be seen, and they know the hospital isn't going to chase them down for their bill because they can't pay for it anyway. Who winds up eating those extra costs? Folks with insurance. I used to work in an ER and I saw this happen all the time.

Do you have any data proving those points? Both are highly questionable from economic PoV. USA is not doing the majority of research, for sure (e.g.EU does a lot too), and it’s not that expensive. Besides that, drugs and equipment are not the only cost drivers. In other countries those who cannot pay for the insurance get it from the taxpayer money, basically the same redistribution just called differently. This does not explain why in USA costs are much higher than in countries where redistribution is codified in the law.

The data on biotech and pharmaceutical patents per nation is easy to look up and firmly supports the parent posters point- Google is your friend here.

Your second point is a false equivalency as from a private payor perspective the cost of providing care to the indignant is reflected on their localized hospital bill, not on their federal taxes. In struggling rural/inner city hospitals the majority of payors don't cover the cost of the care received (and that includes medicare/medicaid patients), which means hospital bills will be highest in poor regions despite higher rates of federal coverage/subsidy.

> firmly supports the parent posters point- Google is your friend here.

Well, you need to change your search engine, because DDG could help you finding this report:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866602/

42% of innovations for 40% of GDP of innovating countries isn’t exactly majority. UK and few other countries are more inventive than USA in relative numbers and the rest of the world - more in absolute numbers.

On second point thanks for clarification. So, if I understood it correctly, it means that this redistribution model is inefficient, because it creates two tier insurance system, with hospitals serving as second tier insurance. This even sounds crazy.

The glory days of the semi-welfare state in the US were indeed the 1950s-to-mid-1970s. A lot of those were regulated monopolies - in the case of health care, Blue Shield was a single, private but regulated insurance company owned by hospitals (some portion of which weren't for-profit). The main way Blue Shield was regulated (and it was definitely regulated) was it allowed to maintain complete control of the health insurance market, so that it operated like "single payer" without officially being "socialized medicine". The elimination of this system indeed brought us to the disaster that we're looking at now.

Boomers are old enough now to fuel the growth of medical profiteering. In the 70's 65+ was 10% of the total population and they spent less time in that age bracket before death. Now they're 16% and living longer.

Public support isn't the question. The public does support Medicare For All[1] but that doesn't matter given the election and decision making process of congress - essentially that it's controlled by forces that profit from the present system.

https://morningconsult.com/2021/03/24/medicare-for-all-publi...

This 100%. You have to flush out the reps who won’t vote for it regardless of constituent support and desire. Determine how many you need to replace, identify the weakest incumbents/most likely races to win, select challengers, fund them, and you hopefully unfuck US healthcare in the end. Maybe you need a few candidates to pull a “reverse Sinema”; run as a Republican, win, and then turncoat and vote for Medicare for All (with the understanding you’re probably only serving one term, but who cares if you get the policy done, 1.8 million voters over the age of 55 die every year, you’re just pulling progress forward with some political sacrifice versus waiting for cohort succession). Politics hacking and social engineering at its core.

If you’re not one to wait, the only other option is moving to a better country.

Public support for Medicare for All is going to look much more interesting in a few years when the Medicare trust funds are running out and they have to cut costs by 15% or more, and it’s clear there’s actually a price tag on the proposal.

And then we'll see the corner we've truly painted ourselves into.

I could imagine a scenario where an angry public demands the government take control of hospital finances.

Not that it's necessarily a good thing, but I could see it panning out that way.

Acting like social security or Medicare funding levels are fact of nature rather than a political football is parroting right wing talking points. The social security trust fund has been raided by congress multiple times and if it or the Medicare gets low, they can put that money back.

More broadly, by having a single payer, a reasonable Medicare For All program would in total save Americans vast amounts of money though of course as a program it would have a cost.

Politicans hiding the cost of things is the fact of nature. No proposal for Medicare for All that has ever been floated has ever seen a realistic price tag attached. The trust fund's depletion is no fact of nature, it is merely an occasion when this will become a little clearer to the public.

When this happens, voters will not like what they are being offered quite as much as they do now, when the costs are some distant abstraction; there will be a whole lot more hesitation and skepticism. And if pointing this out is a "right wing talking point" then go ahead and call me Margaret Thatcher.

Sadly politics today is endless arguments about minutiae rather than actually solving problems. The culture wars exist for a reason. The longer we are at each other’s throats the longer the wealthy can reap the rewards of rent seeking behavior.

"As long as the public isn't interested in seriously considering alternative systems like Medicare for All, nothing is going to change."

I resent the Democrats and Biden for not embracing Medicare For All. This would be the most straightforward path to a halfway sane system.

Even if they did completely embrace it it still wouldn't be happening. There are plenty of current Democratic Party priorities that are dead on arrival in the Senate.

>dead on arrival in the Senate

Democrats fully control every single committee.

You can pretend like they’re the problem and resent them as much as you want but which 10 Republican senators are going to vote with the Democrats? It’s endlessly frustrating when ~48/50 democrats would vote for something and 0/50 Republicans and people either “both sides” it or inexplicably blame the democrats?

The Democrats supposedly stand for health care reform. They don't have a coherent plan and they aren't even trying. The Republicans are pretty hopeless in that area anyway.

>inexplicably blame the democrats?

For several periods during Obama's first term, his party totally controlled the legislative process. The Senate Democrat caucus had a filibuster-proof majority. They could have passed Medicare for All, Single Payer, immigration "reform" -- all of it. Ask yourselves why they did what they did instead.

They had a short period with 60 senators until Ted Kennedy died, so they had to reconcile in the senate what was already passed in the house — they had 59/60 senators who wanted to pass Obamacare with a Medicare public option but Lieberman refused and again, 0/40 Republicans helped in any way. So we got the ACA, a flawed piece of legislation but one specifically chosen to engender bipartisan support since it was largely based on the free market Romney/Heritage plan from MA.

And then what health care proposals did the republicans pass when they had legislative control to make things better? Literally nothing. Vote after vote to repeal the ACA and “a plan” to replace it that’s been 6 months away from being released for the past decade. It’s insane people refuse to admit this out loud.

>0/40 Republicans helped in any way.

Republicans had no access to even read the bill draft. They were limited to voting for the proverbial pig in a poke (remember Pelosi: "You have to pass the bill to see what's in it.")

Which is both a misquote of Pelosi and obviously false because they had been working for months to build a bill that Republicans could support. Enzi, Grassley, Snowe were involved from February onwards and Obama addressed a joint session of congress in September and the final bill wasn't signed until the following March.

Why on earth would you believe people who have lied about every other facet of the bill (Death panels! unconstitutional individual mandate that they used to support!, illegal immigrants!) when it comes to their culpability for failing to improve it.

More specifically, Pelosi's quote about understanding the benefits of the bill after it was signed was in March 2010 on the eve of Obama signing it. The bill he was signing was voted on by the House in October 2009, and the Senate that December.

There are quite a few countries that do not have single-payer and do just fine. According to the book The Healing of America, these include France, Germany, and Japan, all of which get top-ranked results at much lower cost. The key difference is that the government sets the price list for all services.

That would be a big change for the US, but not as big as nationalizing the entire industry.

"doing fine" is a pretty bold claim. I doubt there is a healthcare system without issues. Germany is changing a lot, and not for the better, because the system was not really sustainable as it was.

Well ok, "doing among the best in the world, as of the book's publication." If our standard is perfection then nobody measures up.

Medicare for All can't function well as a single payer system - single payer doesn't work because it kills off the benefit of market-competitive forces; in single payer systems there are gatekeepers who decide what's covered, what's not covered, who might be eligible and what the criteria for them to be eligible is - which all acts as a single point of failure.

I like Andre Yang's proposal - where you allow private insurance but you also have a government offering to compete - both the government option and private options acting as counterweights against the other in terms of competitive forces.

This has the unfortunate failure mode where the well-off, powerful or influential get much better private insurance, which means that no one with means is advocating for the quality of the public option, so it declines or becomes uncompetitive in marketplace bidding.

Private insurance alongside public could work if it followed a strict "school-voucher" model, i.e. it gets the same funding per-head that the public option does and the customers have to show means to self-insure for any coverage shortfalls vs. the public option.

Covering their costs is a bs framework. Hospitals are de facto partnerships run for the benefit of certain insider employees. Their “costs” are whatever the market will bear paid to those same employees.

Ditto for universities.

Universities get away with absurd pricing because the government guarantees the loans. If the govt stopped backing the loans, the tuition costs would plummet and the govt wouldn't need to back them anyway.

People blame the hospitals but this the game they have to play in order to cover their costs...

If you do things that literally ruin people's live, I don't care if you "have to do it" to keep your business going.

As to lawyers, in a society with money and contracts, these exist. What I would hope for would be a statue with in the case of the abusive billing, the victim can sue for ten times the amount of the bill, just for starters.

They don’t have to play this game. For reference, see most other countries who have taken the slightly more enlightened step of a socialised healthcare system.

It's kind of useless to say this an not name at least one such country. Notably, many of the places with "better" healthcare aren't obviously sustainable e.g. France.

It's not just the social medicine. It's totally possible to go to a private hospital in other countries and get a reasonable final quote before any procedure is done.

I'd be curious how much money is spent each year on the bureaucracy of healthcare, from employees who do little besides manage health insurance, insurance company employees, billing specialists in medical establishments, etc, etc, etc.

> this the game they have to play in order to cover their costs

Another possibility - cut back on the 20% that goes to executive salaries: https://jamanetwork.com/journals/jama/fullarticle/2785479

Or cut down on these guys:

https://www.beckershospitalreview.com/compensation-issues/18...

> Hospitals over-bill persistently and excessively to the point where hospital billing charges have ceased to have much meaning beyond their ability to shock and frighten people. The

> While Medicare and Medicaid control their costs by tying their payments to the actual cost of medical services, private insurance companies appear to be just paying a fixed percentage of what they’re billed. That alone gives hospitals a strong motivation to inflate their billing charges by more each year independent of their costs.

Medicare isn't that great, too. My wife worked health care and Medicare patients were difficult because of the weird paperwork

Very few medical practices or hospitals can survive solely on patients paying Medicare rates.

This is true. Capitalism is at it's best when it manageably distributes supply and demand forces in a minimal surface, maximizing net utility via the price level and transactions. It's at its worst when those at one side of the transactions (healthcare buyers) are systematically denied information and held hostage via contracts.

The American healthcare system operates on this, and it's such a valuable tactic that it's worth more to waste resources on managing this degree of litigation than just charge reasonable amounts.

In more cases on average, the healthcare providers must be making a net profit via these tactics, otherwise they wouldn't do it. The fact that this tactic is even theoretically profitable means the system is fundamentally broken.

Private medical services are a very profitable business for certain professions that buzz around doctors and nurses. People without knowledge about medicine and whose only interest is a private company's benefit.

Your own link disagrees with your conclusion.

This is the nature of the US society.

It's a shame that the Hippocratic oath didn't contain the sentence "I shall not overcharge my clients or bring them in financial jeopardy".

It isn't doctors who do this. Doctors, by and large, would love to just treat people. And while doctors do make quite a bit compared to other countries [1], the litigious nature of the American patient and the high cost of education make these wages almost a necessity in order to pay off insurance and student loans =[

https://www.investopedia.com/articles/personal-finance/08061...

Doctors are also very self-interested and want to advance their careers.

So if the top surgeons at a hospital want the newest, most expensive toys, and will leave for another hospital unless they get them, it might be that the hospital administrators buy unnecessary machines just to keep their best people around, at the cost of increased bills for everyone.

In this story, the surgeons may not be explicitly greedy, but the system sets them up to cost everyone quite a bit.

How true is that really? What’s the difference in lifetime earnings between a UK and US orthopedic surgeon net of insurance and loan payments?

My sense is that the difference in pay dwarfs the difference in costs.

The AMA is a professional organization for doctors and they have opposed all kinds of changes designed to reduce medical costs because it would hurt their members’ bottom line.

The system is a racket and doctors are in on it.

> The system is a racket and doctors are in on it.

This is a bit much. You're right that the AMA is a big part of the problem, but fewer than 1 in 5 U.S. doctors are paying AMA members. [1] That's down from about 75% in the 1950s.

[1] https://www.physiciansweekly.com/is-the-ama-really-the-voice...

I had no idea they represented under 20% of doctors. I thought it was 3x that. Thanks for the information.

The AMA is a private organization. It doesn’t represent anyone other than it’s leadership. Most doctors aren’t members.

Anyone can create a group and call themselves a “professional organization.”

Anti-abortion groups have their own ob/gyn association.

> and the high cost of education

Why don't they study abroad, e.g. in Europe, where education is more reasonably priced?

I was reading and, evidently (this is internet study, so take it with a grain of salt) it is very difficult to get a residency in an American hospital from a school that isn't in America. While you could do your residency in another country and then retake your tasts, I guess, and become a doctor here, I don't know if you would have to do another term of residency. I couldn't find that answer as easily. Also, studying abroad doesn't end up being that much cheaper if you aren't a citizen, so if you're from America it kind of ends up being a wash, it looks like =[

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