Costco now offering virtual medical care for $29 | Hacker News Reader

Costco now offering virtual medical care for $29

cbsnews.com

220 pointslxm228 comments

From the linked blog post by the actual provider:

> Sesame doesn’t accept health insurance (which also keeps prices low). This makes it ideal for Costco Members that prefer to pay cash for their health care, whether it is because they are enrolled in high deductible insurance plans, are uninsured, or simply appreciate the price, quality and convenience of Sesame.

$29 upfront rather than $25 copay + random bill for and additional $125 a month later for a 4 minute appointment sounds pretty good.

The fact that excluding health insurance actually lowers the price makes me wonder what the point of health insurance is anymore.

I've told this story here before. My girlfriend at the time, now wife and I both had pneumonia. Identical symptoms.

We saw the same doctor the same day, back to back. Got prescribed the same antibiotics.

I had "good" health insurance, she had none. My bill AFTER insurance was higher than her bill without insurance.

I'm really not sure the moral but it was frustrating as heck.

> I've told this story here before. My girlfriend at the time, now wife and I both had pneumonia. Identical symptoms.

> We saw the same doctor the same day, back to back. Got prescribed the same antibiotics.

> I had "good" health insurance, she had none. My bill AFTER insurance was higher than her bill without insurance.

> I'm really not sure the moral but it was frustrating as heck.

The moral is that any system which introduces price opacity will gradually increase the price of the product until the price is above what the market will bear.

Look at it this way - at the point of purchase, you are buying a product with absolutely no price information, because "the insurance will take care of it". With no price information to the consumer, there is no price discovery, and without price discovery the supplier will increase prices beyond what the consumer is willing to pay.

If all medical insurances were banned, the cost of medical will not exceed what the market will bear: it can't.

But that's extreme - how about a practical and workable solution: no private dealings between medical insurance suppliers and medical service suppliers.

You have medical insurance? Lovely - you will be forced to submit the claim yourself. When you visit the medical services supplier (doc, hospital, pharmacy, etc) for non-emergency services[1], you will be liable for the bill, and so you will have to lookup what that/those particular code/codes cost/s.

In this way the cost of medical services will actually come down, to what the market will bear.

We've seen the same thing with US tertiary education - free money introduced into the system by the government caused tuition fees to skyrocket, with all the profit captured by the providers. IOW, the price rose to what the market will bear, and since the government was the market in this case, the price rose to what the government was able to pay, which is perhaps 3x to 10x what an unemployed 18 yo is able to pay.

[1] For emergency care, obviously the claim will be submitted to you by the hospital, and you can then forward that claim to the insurance. Even better would be if all emergency procedures have state-backed insurance.

> You have medical insurance? Lovely - you will be forced to submit the claim yourself. When you visit the medical services supplier (doc, hospital, pharmacy, etc) for non-emergency services[1], you will be liable for the bill, and so you will have to lookup what that/those particular code/codes cost/s.

Ah yes. Because I, the lay person, know exactly what all those codes mean and their actual costs.

> IOW, the price rose to what the market will bear, and since the government was the market in this case, the price rose to what the government was able to pay, which is perhaps 3x to 10x what an unemployed 18 yo is able to pay.

Strange how this didn't play out in (most of) Europe.

> Ah yes. Because I, the lay person, know exactly what all those codes mean and their actual costs.

Why would you need to know?

Serious question - how does it help to know what all those codes mean and their actual costs?

All you need to know is $INSURANCEPROVIDER only covers $100 of a bill for $CODE. What do you care what the "actual cost" of $CODE is for $MEDICALPROVIDER?

> Strange how this didn't play out in (most of) Europe.

Because what the government was able to pay was a lot less than what the US government was able to pay, because the US government provided the money (with basically no controls on cost) and then made the student liable for paying it back. This way the state didn't actually care what the purchase price was, they were always going to get it back anyway.

My understanding is that in Europe (e.g. Germany), the tuition was paid for by the state! It's not a loan, the state is not getting that money back, and so there's pressure on the state to limit what it will pay for tuition.

> Why would you need to know?

Who is "you" then in this quote: "You have medical insurance? Lovely - you will be forced to submit the claim yourself. When you visit the medical services supplier (doc, hospital, pharmacy, etc) for non-emergency services[1], you will be liable for the bill, and so you will have to lookup what that/those particular code/codes cost/s."

My point is that you don't need to

> know exactly what all those codes mean and their actual costs.

Why would you need to know? How does it help knowing the actual cost vs what your out-of-pocket expenses?

You get $FOO as the code and $BAR as the cost. That lets the market discover, over time, which providers are charging $BAR+$EXTRA, which insurances only cover $BAR-$uncovered.

You can't have price discovery if the purchaser is not able to determine what the price is at the point of payment. If you have a better proposal for determining what the market will bear, lets hear it.

I'm not sure where you're going with this line of questions, but the impression I get from your comments are "People will find it too confusing to know how much they are are purchasing something for - let them only discover the price of the purchase after they have already bought it".

TBH, it's never a good idea to reveal the purchase price of something only after the purchase is made. There is no justification for it.

> You get $FOO as the code and $BAR as the cost. That lets the market discover, over time, which providers are charging $BAR+$EXTRA, which insurances only cover $BAR-$uncovered.

The problem with this view is that it assumes providers have relatively few SKUs and relatively static pricing, and that providers are relatively static over time. In reality:

- medical providers have an incredibly long list of SKUs, which can have adjustments (e.g. quantity).

- pricing changes frequently

- staff changes frequently. A bill is typically not a provider charging $BAR+$EXTRA, it's more like provider A working at facility B on procedure C has Price 1, but that same provider working at facility D on the same procedure has a different price. And all the prices are affected by the patient's insurance, and the specific contracts that were in place between the provider, the facility, and other parties at the time of service. (I'm simplifying this, in reality pricing is more complex).

It's entirely possible for Provider A to be the cheapest option in town (for a given patient-insurance combination) when a procedure is done at Facility 1, where they work Monday-Wednesday but the most expensive in town for that same patient when a procedure is done at Facility 2, where they work Thursday & Friday. This relationship can change frequently. Worse, this relationship can be subject to the specific service codes that end up being performed (all of these may not be knowable before the service begins).

I want to especially highlight the "over time" aspect as it assumes the relationships between any of these items are relatively static. In truth, it's entirely possible that your insurance carrier has a great deal for a given service this year, but next year has a terrible deal for that service at the same facility (possible because one of the underlying providers has changed). Second, it highlights the opacity in all of this. Even if you had the ability to digest all of the raw data, it's likely the outcome would not be very predictive at all for a given individual who needs to make a purchase today.

> If you have a better proposal for determining what the market will bear, lets hear it.

The market needs a lot more regulation. Think more like electric utilities instead of software.

No need to quote the entire parent message

This is the consequence of the maximum profit margin provisions of the Affordable Care Act[1]. Because of it, insurance companies are now happy to pay more for the same procedures, because it actually increases their profits.

In your case, they managed to negotiate such high prices that your co-pay is higher than the normal cost of the medical procedure. If you are on a Gold plan with a 20% co-pay, you can be sure that the money you paid is what went to the insurance company, while 4 times as much money went to funding healthcare!

You should be really happy about this, because this is a rule created to make sure your insurance funds hospitals, not Wall Street greed!

[1] https://www.washingtonpost.com/news/wonk/wp/2013/07/18/the-o...

There is a book on this “never pay the first bill”

It’s all a big scam.

The pricing of Medicare in the uk is a bit more transparent. If you visit private health care provider they will give upfront the price for self-paying vs insurance. The insurance price is often more than double, e.g. MRI scan via insurance is around £950 vs £450 for self paying. It’s often cheaper to cover your medical bills personally than to pay a for-profit corporation and beg them to authorise every treatment when you need.

Sorry what? The NHS is free. There is no Medicare. Private health insurance is a luxury, it’s basically a queue jump to see the same doctors often in the same hospital as the NHS offers. Pricing is transparent because they just send you to the NHS for non profitable stuff. And if the test were necessary + urgent you’d get it free in the NHS anyway. In fact the awful incentives it creates mainly just lead to lots of unnecessary tests. That’s why insurance often won’t pay.

The NHS is indeed free, but I was not referring to treatment by the NHS. If you are adult with slipped disc, torn muscle or hernia or other no serious issues then good luck trying to be treated on the NHS. The waiting list is usually two or three years. I was referring to the numerous private hospitals existing in London, where you can see a health specialist within days (it sounds like a luxury in britian, but really is the norm in most countries even heavy sanctioned ones like Cuba and Iran)

seems to me that the moral of the story is that you subsidized the much more expensive treatments of other customers of your insurer whereas your so only paid what she was using.

hedge big losses with small investments, that's the idea behind insurances, isn't it?

You're already paying insurance premiums (and your employer) (out the ass probably) for that purpose.

I like that only 13 years later after a decade of ranting about it - people are finally understanding on their own why the “Affordable Care Act” was such a bullshit scam entirely supported by insurance providers.

It was even sold in a ridiculous way. “We all know health care is broken, so if we just force everyone to sign up, and give them more guaranteed income streams then it will fix itself!!”.

I don’t want to hear about how Obama actually wanted single payer or X. He knew exactly what it was the whole time.

“Medical billing” is an industry probably larger than medical care.

I fully support Costco here, insurance is a scam.

It would have been better had the provider constraints not been struck down by the supreme court.

The entire idea was using the threat of losing access to Medicare $$$ to force acceptance of all ACA plans by providers in order to drive down cost negotiations for individual payers.

Large companies get to leverage large group sizes, and the idea of the ACA was to effectively turn all government aligned plans including Medicare into a single giant "all or nothing" group.

But when the courts struck that down, instead it became the exact opposite, allowing for even more division and sub-grouping across ACA plans, which drives up the end payee costs because there's little to no consequences for providers telling ACA plans to get bent.

The ACA as designed was effectively a compromise, and then the courts reversing the key compromise meant the overall result was a hot pile of crap outside of finally ditching preexisting condition lock-in (which was still a win overall, but a much more minor one).

Could you clarify which part of the ACA you are saying was struck down by the Supreme Court?

The only such parts I know of are the mandatory Medicaid expansion and some stuff related to covering contraception. (And the individual mandate penalty was reduced to zero by Congress in 2017.)

I was not aware of any part of the ACA that required insurers to carry certain plans, apart from the general regulations it introduced on health insurance plans in general.

Perhaps the president/congress shouldn’t try to make unconstitutional compromises.

It’s all interpretation though, isn’t it? Unsurprisingly, the Constitution has very little say on the topic of health insurance. How the content of the document gets applied to modern contexts is a matter of enormous debate, in a lot of contexts “unconstitutional” is a moving target.

It used to be the case that anything that the Constitution didn't allow the government to do was considered not allowed. Too bad now it's the opposite - anything the Constitution doesn't explicitly prohibit it to do, it feels free to. And anything it does prohibit - like regulating speech - it does anyway, in a roundabout way. But at least we got all the problems they promised us to solve this way, actually solved, right?

whether or not something is found constitutional just depends on the prudence of the bench. Segregated schools were found constitutional under the same constitution that later found them not to be. The Supreme Court overrules itself all the time; the march of progress is slow: https://www.grunge.com/895625/the-supreme-court-has-overrule...

Please describe how the Affordable Care Act led to the situation you're responding to.

So why didn't you just say you didn't have insurance.

You didn’t know until much later how much it would cost you after using insurance, and normally you have no way even after the fact to compare to the uninsured price.

(The medical provider also likely won’t be able to provide accurate all-in pricing at the time of service.)

Yeah, this is a stupid system. The free market doesn't work properly when people can't know the price before deciding to buy or refuse the service. Transparency is not an optional perk.

It drives me insane that, when ordering medication from my HMO, it is no longer able to tell me the price of the pills ahead of time. It's worse than "lobster of the day, market rate", at least you can ask the server what the rate is.

I think we're only a few steps away from patients having to place limit orders on medication like they're on ETrade.

Edit: I double-checked and now at least it gives you an "estimated price". But.. what is there to estimate? Why is there a real-time market rate for perfectly generic prescription pills? https://imgur.com/a/grNPBUB

You end up having to place the order and the charge shows up a little while later. It's never 2x or anything of the sort, but it's also bewildering that they can't tell you what it will cost.

As I see it, there is no free market when it comes to healthcare: there is no real choice, only choices that we introduce. What i mean is: when I get hit by a bus, i want to be in the nearest hospital asap and don't have the time nor the consciousness to play the healthcare market game.

It is for the six and seven figure heart surgery/NICU baby/cancer treatment.

Edit: My question is, is Sesame paying the doctors less, or are you actually paying $29 for a Nurse Practicioner/Physician's Assistant?

And technically, that's what health insurance always should have been for.

Allowing insurers to step in the middle of smaller, everyday health transactions by empowering them to negotiate price fundamentally screwed up the system.

There's no reason insurance should be involved in non-catastrophic or routine pharmaceutical purchasing.

The US government does offer a massive carrot for people to choose high deductible health plans, in the form of the most tax advantaged account you can have, a Health Savings Account.

The root problem is most Americans are too poor to afford healthcare at the current prices of doctors/medicines/medical equipment/liability protection/etc, period.

Using an HSA can be a pain in the ass. On multiple occasions I’ve had to go back and forth with the provider and HSA to get an acceptable receipt. I ended up just giving up in one case because it was a small amount and not worth fighting phone reps and automated systems.

Depending on the specifics of your financial situation, age, and healthcare utilization, it can actually be in your best interest to pay more out of pocket and save your HSA money for retirement.

I do not know why that would be difficult, I have never had an issue getting a receipt with patient name, charges, and the amount on it.

Also, the ideal way to use an HSA is to not use it. Every year, transfer the HSA funds to Fidelity, invest in VOO or whatever, and let it ride as long as you can. PDF all the receipts, and then pay yourself with tax free income when you finally need to.

I don't want to google the incorrect information. Can you provide a link that elaborates on this? I have an HSA (~20k right now), don't use it to invest at all, but it is investable within their system, using some preselected mutual funds. I've just been too much of a wimp to risk losing anything.

https://www.bogleheads.org/wiki/Health_savings_account

> Fidelity offers HSAs for employers and, as of November 2018, individuals.[36] Individual HSAs have no account opening or transaction fees.[37] In a favorable review of the Fidelity HSA's features, the The Finance Buff wrote: "No other HSA provider comes close to what Fidelity offers."[38]

I would go to Fidelity.com/toa and start a transfer of assets from your current HSA. If it is an employer sponsored HSA where your employer contributes to it, then leave $25 to avoid it getting closed. But every year, move the remainder to Fidelity and invest the remainder like any other IRA.

> pay yourself with tax free income when you finally need to

My understanding's that direct withdraws are possible after 65, taxed as income. Does your "when you finally need to" mean only withdrawing for healthcare reasons or is there a way to transfer or withdraw without a tax hit, besides for health costs?

Yes, worst case scenario, it performs as an IRA/401k.

But pretty much everyone will incur healthcare costs as they get older, so you should be able to withdraw tax free for those. And all healthcare costs incurred by your family during your lifetime while you had an HSA are eligible for reimbursement.

Quite frankly, I do not know how auditable a 40 year old medical receipt is. Is the IRS' plan to just take everyone's word for it?

Probably yes, until they audit you. I don't think many people who want to defraud IRS do it by faking 40 year old medical receipts.

Medical expenses is a deduction category that can be itemized?

https://www.irs.gov/taxtopics/tc502

Never needed it, so don't know all the rules are, but I'd imagine the IRS gets a lot of fraud through it (since hospitals wouldn't report from their side).

But how would they audit it, if the healthcare provider has retired or deleted their records from 40+ years ago? Are healthcare providers keeping records that long?

I thought the whole point of an HSA was to be used as a tax shelter. I didn't get one because it seemed way too complicated and also I don't make nearly enough money to set aside money in an HSA but that's what I remember when looking up on it a little.

I think you're not supposed to use it actually for healthcare, at least not in your young age.

Who's administering your HSA that you have to provide specially-formatted receipts?!

Every HSA I've had[0], I just reimbursed myself for eligible expenses[1] by transferring from the HSA to my regular bank account. That amount then gets reported on line 15 of form 8889[2] the following April. If it's not an eligible expense, that's between me and the IRS—not the bank at which my HSA is held.

[0]: I highly recommend Fidelity, for anyone reading this and thinking they need a better option.

[1]: https://www.irs.gov/instructions/i8889#en_US_2022_publink379...

[2]: https://www.irs.gov/pub/irs-pdf/f8889.pdf (PDF)

Mine has stopped even asking for a receipt. But more importantly it's a super-IRA that's the best tax reduction around.

The ultimate root of the problem is thinking healthcare works like a bakery: if the bread is too expensive i'll go shopping elsewhere or even choose something else besides bread. This last option is basically off the table in healthcare: you either get healthcare or die. Which in the usa seems to be the options indeed.

For these kinds of relatively low-cost interactions, the HSA is even more of the same problem as health insurance: It's for people who find paperwork to be a fun hobby.

Just tell me how much money I owe you and let me pay. When I find myself at a clinic, I tell them I don't want to use health insurance to pay. They just give me a bill and I give them money.

Would those procedures cost "six and seven figures" if it wasn't for health insurance? To put another way, would the costs be so high if it wasn't for the current health insurance system, where the "consumers" are actually the health insurance companies themselves and patients like you and I have basically no power to choose, well, anything.

Huyterds, they don’t cost that much in Belgium though, US medical prices are out of the roof.

But how much does the Belgium gov pay to subsidize healthcare? (Just because the upfront cost is low to you, it doesn’t mean that’s the actual cost.) Is it still sustainable given the trend of retirees starting to outnumber working adults? Also how bad are the wait times to get socialized medical care?

> how much does the Belgium gov pay to subsidize healthcare?

Belgium spends 11% of GDP on healthcare (https://ec.europa.eu/eurostat/statistics-explained/index.php...)

The US spends 18% of its GDP on healthcare: https://www.cms.gov/data-research/statistics-trends-and-repo....

> Also how bad are the wait times to get socialized medical care?

How bad are the wait times for not getting healthcare at all because your insurance doesn't cover it? Or because the associated costs will bankrupt you?

It's cheaper for Americans to travel to Belgium, and then pay out of pocket for surgical procedures, than it is to get them done in America. And that's including the airfare and hotels too.

The prices have got to be up there. It’s taking up dozens of hours from multiple highly skilled workers at the very least. That with the use of very expensive medication and some very complicated machines adds up.

I don't know if it is insurance or the administration on both the provider and insurer sides. I have a horrible respiratory infection in western Europe, here I'd have likely died or been so overcharged I'd wish I had died. There 17 days in ICU on a ventilator and a few weeks or normal hospital recovery the total bill in 2001 was under $20K, the Euro and Dollar were almost even then so the conversion isn't important. Now if a local had needed that bed more I might have not been as lucky. This is what a well organized society can do, keep everyone under some level of free care so there is less chaos in their ER departments and that they'd have time to treat a foreigner well. If we switched to single payer the estimates are that we'd save money as a nation the first year, even with all the backlog of needed care and any transition costs. The savings would compound as preventive care started preventing more serious outcomes and things like car insurance and liability insurance would come down in cost too.

Yes. They're expensive in the US because our healthcare providers are expensive.

Middlemen can't raise the price that much; you could just go around them if so, either by not using it or by going to another country.

You haven’t been paying attention to what pE is doing. Every day medical services aren’t an international market.

You wouldn't be able to corner the market if it wasn't supply constrained (because it was already cornered by the AMA). The US doesn't accept medical degrees from other countries, has an absurd residential training program designed by a stimulant abuser, there are price floors called "certificates of need" where you can't open a hospital unless your competitors say you can, etc.

NICU baby feels so weird. Why isn't that covered by Medicare or something else? Like why isn't basic health-care for children under whatever age 18 or 16 fully covered by government? At least to certain level.

Because babies and kids do not vote. Why is Medicaid a separate thing than Medicare? Because poorer people are less likely to vote than older people.

The US is composed of very fractured tribes, that people move in and out of throughout their lives. And US politicians are tasked with keeping taxes extremely low, and services very high, and the various tribes do all they can to give disproportionately little relative to how much they benefit.

I imagine your appts/per hour go WAY up when it's a 5 minute voice chat versus occuyping a room in a physical building for an hour, having a nurse take vitals, all that ancillary stuff.

Probably the latter, buf this would frequently be the case now in other providers too. Unless you want to wait for 2 months.

The solution is to have universal catastrophic insurance for all citizens automatically, say $100k or some number. Combine that with tax-deductible health savings accounts and a competitive retail healthcare market, you find a sweet spot between universal and for-profit.

Anyone who thinks the universal model standard in Canada and the UK is actually working has a hole in their head. The solution is a combo.

> a competitive retail healthcare market

What's a "competitive healthcare market" for diabetes? Or cancer? Or childbirth?

> Anyone who thinks the universal model standard in Canada and the UK is actually working has a hole in their head.

The UK has a population of 67 million. There are half a billion patient contacts in any given year. I've yet to hear stories like "I can't afford my insulin" or "we had a child, the bill was 200k and we were also charged for holding the baby"

The horror stories from the UK type system are more like "I had to wait 8 months for treatment" or "my medication wasn't available".

"I had to wait X times for treatment" is a very common complaint in the US on top of "I can't get treatment because my insurance doesn't cover it".

Same for "medication wasn't available": "my insurance doesn't cover the medication required".

The US literally has a video genre of "rationing of insulin to survive".

in uk, good thing is, if you do get to see the doctor, you don't have to pay anything but the tricky thing is "getting some one to see you".

on average, system is good for bottom half but system is pathetic in terms of services after paying such high taxes.

You can definitely have a competitive market for any procedure that can be scheduled. Amazon will often negotiate on behalf of their employees in order to shop around procedures (see Oklahoma Surgery Center).

The difficulty is for sudden situations like heart attacks. For these you need savings accounts and a baseline catastrophic plan.

> You can definitely have a competitive market for any procedure that can be scheduled.

You don't have unlimited fully equipped hospitals and operating rooms. You don't have unlimited heart surgeons. You don't have unlimited MRT scanners or labs doing blood tests.

In healthcare both the supply and the demand are inelastic. Market forces here work only for the most common and the most simple cases like nasal sprays and eye drops.

Hard disagree. The market exists for healthcare. The government may artificially restrict certain aspects of it but the market does respond to signals by building more facilities.

Furthermore a lot of innovation goes to increasing bandwidth of the existing doctors. See tele health.

I think you have a very limited view of what is possible.

I think you have a very rosy view of the market. And you also overestimate the supply and demand in healthcare.

One thing I've noticed about the UK is that I've had to stop reading every British author I've read in my life because they've all died young.

Some of them did manage to release statements about how much they support the NHS before dying. I'd be more impressed if they lived though.

    The United Nations World Population Prospects suggests current life expectancy in Australia in 2022 to be 83.79.

    In fact, Australia enjoys one of the highest life expectancies in the world, ranking 8th out of 60 developed countries. That’s higher than the UK (81.65) and the US (79.05).

[ quote source ] https://www.hcf.com.au/health-agenda/health-care/research-an...

[ raw data source ] https://population.un.org/wpp/

So it appears that both Australia and the UK with National Health services (named differently in AU) have greater life expectancies than the US.

Perhaps it's the authors you read?

Bertrand Russell was 97 when he died.

Medicare isn't the same type of system as the NHS. My understanding is the NHS is actually fairly rare among healthcare systems, but aside from that it has the bad luck to be run by UK politicians.

US's lifespan is not caused by lack of access to healthcare though, that is fentanyl.

> Medicare isn't the same type of system as the NHS.

True, however Australia has a tiered health care system with a very low gap to ensure that practically the entire population has access to healthcare that they can afford in addition to national bulk pharmacy deals to cap generics for the bulk of ailments that require prescription.

For all it's warts the Australian system delivers a kind of healthcare that the US system does not .. widely available affordable treatment for the bulk of medical issues.

US (general mean both sexes) life expectancy sharply dropped as COVID spread, the most that fentanyl can be accused of is the flattening of the general slow increase between 2012 and 2018 .. even that ended and was on the increase until the USofA foot gunned its handling of COVID.

[ Historic USofA ] https://population.un.org/wpp/Graphs/Probabilistic/EX/BothSe...

[ Historic Australia ] https://population.un.org/wpp/Graphs/Probabilistic/EX/BothSe...

> US's lifespan is not caused by lack of access to healthcare though, that is fentanyl.

How do people with substance use disorders stop using substances? They use healthcare, unless they're in the US where they'll using some quasi-religious abstinence-only residential programme.

Tolkien lived to 81. Agatha Christie 86. John La Carre 91. Jackie Collins 77. Ken Follet is 74 and still very active. Anthony Burgess 76. PD James 94.

If you're talking about Douglas Adams, he died of a massive heart attack...in California, where he'd lived for years.

So, in summary, uh wot mate?

Iain Banks (59), Pratchett (66), and I'm not letting them off for Douglas Adams yet.

Though everyone in my family in Glasgow seems to live well into their 90s.

Both Banks and Pratchett died from untreatable illnesses. Feels a bit unfair to blame the NHS.

This is a pretty hot take. The NHS has been run into the ground. That doesn't mean socialised healthcare is not possible. I don't look at broken old car and say "no cars work".

You mean above $100K they pay? Per year or what? Because a $99K/year bill for ongoing treatment is still going to bankrupt people.

Considering the average family cost for insurance is $22.5k

https://www.kff.org/report-section/ehbs-2022-section-1-cost-....

It is quite feasible that redirecting all of that to a tax-free savings account could pay for itself in no time.

That much? Makes the $2600/yr that I pay sound good. I have a high deductible though ($3K). I don't know if putting $23K aside each year and not having any insurance would work for everyone... I think we should just give that money to the gov't and they should cover pretty much everything. With a pool that big I think the economics would work.

It is not as easy as that because supply is heavily constrained. You need a lot more people able and willing to become doctors, nurses, people who change bedpans and clean hospital rooms, so on and so forth. Add in aging populations with fewer proportionate working age people, and the equation does not balance.

That is not something any policy change can fix until far in the future. In the short term, all that is possible is deciding who gets allocated the available healthcare.

> The solution is to have universal catastrophic insurance for all citizens automatically

> It is not as easy as that because supply is heavily constrained

I don't think this argument works when the data shows 90%+ of the population has health insurance.

My assumption is that the many people, if not the majority, still avoid seeking healthcare due to a doctor visit costing a minimum of $250+. You can give everyone the $100k deductible insurance, which is great, but the issue in this thread is that a regular consultation with a doctor costs so much, that a $29 telehealth option (probably with someone less qualified than a doctor) is better.

Nurse practitioners have been allowed by states to handle more and more services. Telehealth primary care has enabled more scaling - I know because I use such a service for my whole family. I’m much, much more confident in the US to handle an influx of immigrants and aging retirees than Canada or the UK with their rigid services.

Yes, one of the ways that the limited resource of doctor time will be allocated is to simply have increasing portions of the population see people less qualified than doctors (perhaps not bad from a systems point of view if it is diagnosing conjunctivitis, but from an individual point of view, you can see where this is going.). You pay more, you get people who have met a higher standard of education/experience, e.g. concierge care and direct primary care practices.

Yes the reality is harsh. But much better than waiting 12 months to get in cancer care and then dying while you wait.

Completely agree. I am fairly conservative in my thinking, and this is a strategy I could get behind.

Clinic visits, including those for acute but straightforwardly treatable illness, just aren't where all the cost is in the system. You insure against chronic illness and major surgery. This is the logic of HDHP plans: it often really is a better deal just to pay cash for routine care, especially when you're (relatively) young and that care is likely to be cheap.

You can see echoes of this in other insurance products. Homeowners insurance, for instance: you insure against your house burning down, but you're probably better off not making a claim for non-catastrophic events, because you'll probably pay more than you would out of pocket, in the long run, when your rates go up.

Obviously, what makes health insurance especially annoying is that there isn't a transparent market for services the way there is for home repairs. Insurers work out special rate sheets with providers and quote bizarro numbers back to you. That sucks! But the underlying logic of insurance not reducing the cost of a pneumonia visit is still sound.

So. Getting a CPAP. DME charges 1.2k$. That's the one that the doctor set me up with. Goes through insurance. I end up having to pay $800 in insurance. Now it requires 1 month of monitoring. Also, $16 for 2 generic filters.

DME is pretty shit about getting back in touch with you unless you force them to via the doctors office.

Dropped them for Cpap.com with a script from the doctor.

What do they charge out of pocket? $800, do the insurance reimbursement yourself. Secondly, they'll call you up 15 minutes after you order and in 2 days later the machine will be on your door step. Filters here are $8 for 6. (Delhi, India was about $5 for 2 in a store with a label stamped from chicago)

Oh, it's a vast field of corruption. Don't look around or into if you want to keep your blood pressure low.

Cause, y'know. It'll cost an arm and a leg to take care of that. With your insurance.

The long form Time article “Bitter Pill” from over a decade ago does a good job of explaining the how and why of the clusterfuck of American healthcare. Sadly and unsurprisingly, not much has changed since then besides slightly more price transparency that hospitals have fought tooth and nail against and hasn’t really moved the needle much in terms of improvement. The only other somewhat significant improvement that I can think of in recent years is the enactment of the surprise billing bill on Jan 1 2022 but I’m not even sure that has done anything meaningful or not since it went into force.

Instead of signing a blank check for my doctor visits, I now get a paper that tells me how much my visit might cost, and that I am only liable for up to $400 more than that. That is progress.

Also, if my wife has a baby at an in network hospital, and the anesthesiologist or whoever is out of network, I know that the healthcare is still going to be considered in network, and so we are still only on the hook for the out of pocket maximum. Also progress.

And if you are away from home, and happen to get into an emergency where you are taken to an out of network facility, you are still only liable for your in network out of pocket maximum, which is progress too.

You're leaving out Medicaid expansion, probably because you earn too much to need to use it.

Good point, but I left out Medicaid expansion in my case because I live in a state who turned it down for political grandstanding purposes. But it is worthwhile to mention because most states did not

It's insurance. Just like car insurance, home insurance, travel insurance, etc. It's not supposed to pay for everything for everyone at all times. It's supposed to pay for the outlier events, the super events where an accident occurs or a tragic health diagnosis.

Health insurance is not health care.

That being said, I'm not arguing whether everyone should be entitled to free/reduced health care - but I am making the point that insurance is just insurance; it's a hedge against an unlikely but costly event.

Thinking of insurance in healthcare like normal insurance is not accurate. They are activly involved in setting coding practices and therefore prices. They are entwined and in many ways ARE health care as far as billing is concerned.

(Currently studying for my CPC exam)

One could argue that they are in complete control simply because the average patient can never pay the amount the provider bills. So the provider HAS to play ball with the insurer, because good luck getting joe blo American to foot the bill (it's impossible in most cases).

This isn't quite true. Discounted cash price is often LESS than a given insurance pays. You can see this your self if you download price transparency data for your hospital (assuming they bothered to actually comply)

The parent comment is lamenting this fact.

Costco virtual healthcare is not going to cover your cancer treatment, angioplasty or terminal care. We have to all pay a lot of insurance because a small minority of people (along with the very old) consume a vast majority of our health care spend.

Very true. But for someone in their 20’s-40’s who lives a reasonably healthy lifestyle this is an option for preventative care that they did not have before. We can all lament about why this is an option vs an actual functioning healthcare system but for the people who are alive in this dumpster fire today that don’t otherwise have insurance it’s good that something is available. And even for people who have insurance it’s probably actually financially smarter to purchase cheap “catastrophic death level bazillion dollar cost cancer insurance” and just go here for preventative care on their own dime

It is but the problem is life is unexpected and you’re going to need the insurance if something happens. Personally being in my 30s, I wouldn’t be comfortable having no insurance in America. If I needed surgery for a fall on my hike, without insurance it would bankrupt me. So if I have insurance anyway, I might as well see my primary care physician for a similar copay then go this route. For poor people they are covered through Medicare anyways so they wouldn’t really use this either. This market is for specific one off lab tests and to get referrals.

Catastrophic bills. Insurance doesn't make sense for colds, routine checkuos and other cheap and frequent things. It makes sense where you get a rare disease whose medication costs 50k/yr or more. Unfortunately US system is an unhealthy (no pun) mix of both.

You don’t have insurance in america, you just have corruption. It’s a shakedown tax like when gunmen stop cars in africa.

Nowhere else would you have “insurance” which bankrupts you. How is that insurance? The point is it’s supposed to cover the whole cost for you.

I used to go to a chiropractor, at a time when I had a high-deductible health plan. It was definitely cheaper to tell them I had no insurance. Basically, people without insurance tend to be less wealthy than people with insurance, so providers use this as a way to "price discriminate" and get the most out of both parties. Of course, the fact that insurance probably covers a good chunk of the total cost makes this system even more profitable.

You should be able to turn around and submit a claim yourself to your insurance.

That's true. I don't know about the legality of telling a provider you don't have insurance if you do, though.

It shouldn't matter one bit to the provider. This shouldn't be a triangular relationship at all. Provider should be providing a service for a known price. I should be able to claim to my insurance I've received said service and then they reimburse the thing. Having them negotiate in such a way that I have to pay both for insurance and then pay more for the fucking service after their deduction is some kind of insanity.

I realize it "should" not matter, but in reality this is what I've encountered. And I don't know if it is impermissible to say you do not have insurance in order to get the no-insurance pricing. I simply said that I had a HDHP and they let me pay the cash price.

Like any insurance, the reason you have it is for when something happens that one cannot reasonably anticipate.

It's not the $500 infection that gets you. It's the $60k knee reconstruction or the multi-million dollar cancer treatment.

The existence of multimillion-dollar treatments offends me.

It seems like medical profit motive has driven medical development too long and we could come up with cheaper, more effective treatments if medical research wasn't driven so much by profit motive.

(/someone with a very expensive condition, so don't @ me)

I’ve invested the money I would have spent on health insurance over the past 4 years in stocks. This might not be ideal for older people but if you’re relatively young or healthy it’s an alternative to dealing with the headache of health insurance. Also, touching on what someone mentioned above, the costs are almost always cheaper.

That's how you'd expect it to work, right? Not to say healthcare is a functional market (it's not), but in general, if something is less risky, then it should be more expensive. Insurance companies are less exposed to risk, so they're willing to pay more for healthcare than individuals.

First, I think he meant that the out-of-pocket cost (not including the insurance premiums that are already being paid) were higher than the no-insurance cost.

But even if he meant the total cost, the way insurance reduces risk through diversification is analogous to investment in a less risky index fund vs a more risky single company: beyond some minimal operational overhead, the risk reduction should be free.

I wonder the same thing when some weird GoodRx card is always lower prices on my prescriptions than my insurance.

Goodrx makes money by exploiting the PBM system (which I'm in favor of them doing, to be clear.) If it becomes too popular then something will change in the pharmacy-PBM contracts or the goodrx coupon margin will naturally narrow as they become "the price" and their margins on the rebate sharing narrow as afforded by transaction volume.

Goodrx is great, but it doesn't save money for the majority of insured (for the half of the country on better-than-average plans) and it doesn't bring down costs nearly as much as you'd want for expensive medications. Cycling manufacturer's coupons for expensive medications can match or beat insurance copays when Goodrx won't. (And you'll increasingly find some insurance actually apply a manufacturer's coupon rather than cover directly. I had this happen recently with a 90-day supply of Freestyle Libre 3.)

At my local grocer the pharm techs always seem somewhat baffled when I tell them to remove the insurance and they see my medication price is 50% cheaper. I usually raise my eyebrows as if to say “Really? You don’t see this kind of bullshit on a daily basis?”

Do you try this blindly, to test the cost, or do you somehow know which will be cheaper?

GoodRX app lets you look online for which pharmacies in your area offer discounts with them. So you already know going in that Randalls will charge X with GoodRX and Y with your insurance, Kroger will charge A and B, Walgreens C and D. So yeah you can discover the discrepancy online before you even walk into the store. You simply type your drug and dosage into GoodRx app with your location to get the list and prices. The real hack to get the best prices is to look at larger amounts. I have saved 50% or more on drugs by buying them in 90 day increments instead of 30 day increments (this of course only works with non controlled substances that can be purchased in more than 30 day increments at a time, but that is the vast majority of drugs). There is also no correlation to dosage and prices from what I’ve seen. I was taking 100mg of one drug for awhile, for instance, then I tried to fill 80mg of the same drug at the same place and it was inexplicably double the price

Once in the store you open the GoodRx app and in there is a discount code that the pharm tech at the counter will enter into their billing system that will give you the listed price in the app. Oftentimes I have discovered that the pharmacies keep a list of these types of codes (GoodRx is not the only one, just the one people know about the most due to advertising) and once I show them the app they will try a couple of other codes off their list and sometimes I will get a price that is even marginally cheaper (perhaps 5%) than the GoodRx price I showed them. There’s also huge variation between places. My local grocery chain’s GoodRX price is usually less than half of what Walgreens’ price is and usually at least 25% cheaper than Walmart and Kroger

As to why I have to ask them to remove it, two reasons:

1: most people just assume insurance is always best, when it isn’t.

2: because lol USA healthcare, of course it only makes sense to do this with some of the meds I take and not others. My cholesterol meds are so cheap it doesn’t even matter whether they are insured, and some of my other meds are evergreened to hell and using insurance actually does help by a significant factor, like saving 75% or more. It’s this third class of Expensive But With Actual Competition where this GoodRX stuff comes into play. So half my meds insurance pays for and the other half I pay out of pocket. lol USA healthcare

It depends on the medication.

For generics the discount cards can often make the price lower than the prescription co-pay.

I think it's mostly for saving you from bankruptcy. A cardiac event would destroy most American's savings and potentially cost them their house, without insurace to cover the majority/argue with the hospital

Health insurance is a coupon code you subscribe and pay for every month.

Except coupons actually lower your bill.

The real question is how anyone was ever convinced inserting a parasitic middle man into healthcare would not harm either cost or outcome.

Same as it ever was.

Profit.

In Belgium house dr visit costs me 4 euros as a medium class income… even less to free if I’m poor… The other money is automatically covered by the required insurance which costs not that much either.

Belgium also has a 50% marginal tax bracket starting at 42k.

whoever came up with the idea that this small payments by the patients would solve anything

> From the linked blog post by the actual provider

The linked blog post: https://sesamecare.com/blog/sesame-costco-partnership

You might also be interested in the Oklahoma Surgery Center’s model: https://surgerycenterok.com/surgery-prices/

Especially given the fact that in many insured providers getting a visit in person may take weeks, unless you're going to emergency care.

That costs less than transportation to many doctors required for insurance approvals.

Pretty good for those with shit insurance.

This is a great option. Even though I do have decent insurance I would consider this just to avoid dealing with insurance at all

I had an urgent care clinic offer me a sling… 5 months later I got a bill for $160. The same sling sells for $4 on Amazon.

They knew my insurance would pay them, and I have to pay my insurance. It’s a scam top to bottom.

fwiw your insurance most likely got billed $160 but that is not what they ended up paying for. that is the negotiation price, which you have less leverage for, but your insurance company has tons.

in a real world scenario, your insurance company probably paid $5

Yeah but they paid $155 in unnecessary labor for the medical billing specialist and the insurance company billing rep to go back and forth for 3 months.

Especially if I just wanted a Viagra perscription, or a Lexapro perscription. Why mess up your insurance?

I have health insurance and a costco membership. I would totally use it if they cap the price at $29.

Anything has to be better than the virtual visit that I had with OneMedical last year.

Story time: I needed a prescription refill and I booked with a nurse practitioner through OneMedical. During my appointment, within the first couple of minutes I told the nurse the prescription that I needed. She then spent ten minutes asking filler questions about my medical history which had nothing to the drugs which I was requesting. Then she sends the prescription to my pharmacy. So far so good. OneMedical then bills me bloody $220 for this visit.

Later on I found out that this nurse practitioner was employed by OneMedical. I figured I would call their office to ask how they can justify these prices. When I call their billing department, they kept hanging up / disconnecting on me. When I reached out to them on their website, they are blaming my insurance company for my large bill.

At no time before I booked my visit was I informed how much I would have to pay despite asking repeatedly. I am all for this costco partnership. Here is hoping that the don't turn into the next OneMedical.

$220 to fill prescription is wild. I'm wondering why there are no tech solutions that solve it for a fraction of what you pay

Please elaborate why said "tech solution" to a societal problem wouldn't end up with the "tech solution" provider undercutting the incumbents by a thin margin and pocketing the most of the difference? I'm not against somebody making money by eating into the fat cats' margins, but this sounds like merely making a different cat fat, without a substantive improvement for patients.

The idea is a prescription requires human judgment to decide this is a wise move. If you take out the credentialed human, you might as well just sell it OTC without a prescription.

If you already have a prescription and just need a refill it doesn't seem reasonable at all (I mean charging $200+ for it, having some human oversight is fine).

Nor did I suggest charging that much was reasonable.

That would be OK with me.

I don't really care that much either way. Just explaining why, as things stand currently, you aren't likely to get a cheap "tech" solution.

I’ve heard it’s due to excessive regulation

If US insists on keeping healthcare private I’d expect soon or later for these money-sucking “health” insurance companies to be replaced by VC-money-sucking tech companies offering a fairly priced subscription for accessing drugs and treatments.

The only obstacle is - and it’s a big one - drugs and health insurance companies crying out to the gov about how tech companies are stealing their lunch and they should broke down.

I'm wishing now for this to happen. At least for now tech companies are pricing things a bit more fairly

For context Telehealth via my workplace, with insurance "discount," costs $50 OOP.

I've said it before, and I'll keep saying it: If the US insists on capitalist healthcare, they need to make two very specific changes to really have close to a free market system -

- Insurance discounts are banned including to Medicare and Medicaid. Everyone pays the same "cash price" (i.e. one price) and then insurance reimburse it to the patient rather than talking with medical providers at all. You get the bill, pay cash, or get insurance reimbursement, but the price is the price. There is nothing limiting your insurance company for providing tools, advice, and technology to find the most cost-effective and beneficial healthcare. But you're both working together on the same "side." The patient is the king-maker, you decide utlimately.

- Employer provided insurance is banned. Everyone, from congress through Walmart cashier buys it on an open exchange creating larger fairer pools that allows people to pick bespoke insurance based on their personal needs and finances. It also forces real competition, not for employer contracts on behalf of their employees, but for individuals and what they want/need/prioritize. It increases social mobility because you can leave one job and go to another without losing your insurance. Making insurance premiums tax-free is an easy problem to solve (we almost have the tools today).

The US either needs to lean out of capitalist healthcare completely (e.g. socialist healthcare, like Canada or multi-EU countries) or they need to lean into it. You cannot do this silly and destructive middle ground wherein people cannot pick their services, providers, or insurance then expect the "market" to be rational.

Having a single charge master (your first bullet point) largely removes the need for non-catastrophic insurance. The whole problem here is price discovery. As people point out, your car insurance doesn't cover day to day maintenance (generally), but it doesn't need to because AAMCO charges a single price for an oil change and that price is public. The reason you need insurance for normal day-to-day medicine is because you have no idea going into a doctor's office how much anything is going to cost, and for that matter the provider doesn't really have any idea either.

The provider could choose to charge by time, but they usually benefit from insurance companies being able to pay them more than their patients, hence them choosing to accept insurance rather than charge by time or something simpler.

Even planned surgery can have an upfront cost:

https://surgerycenterok.com

Reason had an article on the origins of the US system in AMA lobbying: https://reason.com/2020/04/05/how-doctors-broke-health-care/

I always wondered why medical insurance was so tightly integrated into the US. The answer is that it was done on purpose, deliberately, by doctors seeking to prevent existing institutions like unions and mutual aid societies providing healthcare as a commodity.

110% agreed.

Allowing (and requiring!) insurance companies to negotiate their own discounts over-complicates the system and distorts price transparency and signalling.

And group insurance is an ideal that's outlived its utility. It made sense when there were non-trivial actuarial and administrative costs to pricing an individual, but we've got computers now. No reason the pool shouldn't be everyone.

Sean Carroll recently did a podcast with Amy Finkelstein on insurance markets. I think you'd find it interesting. A paradoxical advantage of employer health care is that it prevents people (and insurers) from choosing.

https://www.preposterousuniverse.com/podcast/2023/04/10/232-...

Choosing what? Insurers are already required to accept anyone as their insured.

The only thing that involving employers in the health insurance business via the tax code is it gives them more control over their employees, since it makes people more hesitant to change employers.

If you made one policy that was hostile to the needs of anyone with diabetes and one that caters to people with diabetes, you'd be selecting for a specific population

But that is already illegal, and so has nothing to do with employer chosen and subsidized health plans.

Insurance companies are not legally required to provide the same coverage, rates, deductibles, and benefits as every other insurance company.

Yes, they are required to provide (broadly) the same "coverage" and "benefits". The things that change are network of providers, deductibles, and oop max.

If you have diabetes, no matter which plan you choose from UHC/Elevance/CVS/Cigna/Humana/Centene/Molina/etc, you should be covered for all the same evidenced based care from all insurers. You should also be covered the same for a host of preventative services as required by law:

https://www.healthcare.gov/coverage/preventive-care-benefits...

If you have a high deductible plan and don't meet your deductible, are you really getting coverage? If you had diabetes, which plan would you choose, one that covers insulin supplies 100% or one that only covers the bare minimum, and even only then if you reach your deductible. Oh, and all the good specialists for diabetics just happen to be out of network.

I am not sure what any of this has to do with employers choosing employee's insurance.

>If you have a high deductible plan and don't meet your deductible, are you really getting coverage?

Yes, because you purchased insurance for when costs exceed $x.

>If you had diabetes, which plan would you choose, one that covers insulin supplies 100% or one that only covers the bare minimum, and even only then if you reach your deductible.

If there is evidence to support to use of insulin supplies, then all insurance plans should cover them the same, obviously subject to the plan's deductibles/oop max.

>Oh, and all the good specialists for diabetics just happen to be out of network.

Yes, this is the one variable for insurance plans. Presumably, insurance plans with higher premiums pay providers more, and hence a more expensive insurance plan will have more in network providers.

https://www.macipa.com/wp-content/uploads/Diabetes_Tierchart...

I stand corrected! Apparently ACA does not require coverage for all evidenced based medication, but rather coverage for at least 1 medicine in the class of medication?

https://www.verywellhealth.com/what-is-covered-under-obamaca...

> Individual and small group plans must cover prescription drugs, and their formularies (covered drug lists) must include at least one drug in every United States Pharmacopeia (USP) category and class—or more, if the state's benchmark plan includes more.16

Here in Israel, healthcare is free. There is nothing like the comfort of knowing that no matter what, you will be taken care of. You can't buy that for 29$...

I read that Israel has 4 non-profit healthcare providers, and it’s considered one of the most efficient healthcare systems in the world.

I was in Tel-Aviv last year. What a nice city.

Yes. I am not an expert but from what I understand, the reason is because governments are inefficient and cough (sometimes get corrupt). Therefor the government funds the healthcare insurance companies to take care of the citizens. They do profit from other aspects so that always clashes with the non-profit side. As usual, everything in Israel is a mishmash of interests but it works for the most part. For example, they provide additional insurance (like the premiums I mentioned in the previous post) and pseudo care like acupuncture, horse riding etc... That is also subsidized if a doctor prescribe it. For example, horse riding for autisim or ADHD etc...

Not to mention the they document everything digitally and I mean everything. That gave Israel the advantage to be the first to get the immunization in COVID since Israel made a deal to provide that health digital histories for the pharmaceutical companies for further research. That was a calculated risk, but seems like it payed off...

How long do you have to wait to see a doctor? Also, are they any good?

Times are depending on priority and payments. I.e. If you don't pay anything then you are seen in either FIFO or depending how serious it is. Your family doctor also has a say on priorities. If you pay about 15$ a month then you can have 3 appointments a year with every private doctor you want. Also, you have priorities in private surgeries. If you don't have premium insurance and you want a private doctor then it can cost about 150$ for 1 appointment. So everyone practically pays the 15$.

Plus, children up to 18 don't have to pay the premium they automatically insured in premium. Children have full dental free care up to 18 years. No problems with appointments if you have priority (like immediate pain or something).

The specialized doctors (heart brain etc...) are all encouraged to do a post doctoral for a year in Canada or US so they are pretty good.

I wish Americans looked up their own country, too

--- start quote ---

The 2022 survey indicates that it now takes an average of 26 days to schedule a new patient physician appointment in 15 of the largest cities in the United States, up from 24.1 days in 2017 and up from 21 days in 2004.

Major cities, like those included in the survey, have some of the highest ratios of physicians per capita in the country, yet the survey indicates physician appointment wait times are increasing.

Family medicine is the only specialty in which average appointment wait times were down relative to 2017, according to the survey. The average wait time for a family medicine appointme

https://www.wsha.org/articles/new-survey-physician-appointme... is 20.6 days for all cities, down from 29.3 days in 2017, a 30 percent decrease.

--- end quote ---

You can typically get an appointment with your GP within a day or two; their role is basically triage for the rest of the health system. Access to specialists is tiered; a referral from a GP gets you access to earlier appointments, without a referral you could wait for months. So people with chronic conditions who know that they need to set up appointments on a regular basis set up those appointments months ahead of time (instead of setting a personal reminder on their phones then trying to get an appointment in the next day or two), while slots are kept open for people who get referrals for more acute cases. An appointment for a specialist after securing a referral can be anywhere from same-day to a couple weeks or so. Some people pay for private insurance because the thought of waiting a couple weeks to see a specialist is unthinkable for them.

I have a parent who needed cancer treatment in the US (in a major urban center), even with insurance, trying to get an appointment with oncologists, radiologists, etc. could take more than a month, trying to get surgery scheduled was a multi-month affair. Especially for cancer treatment, where time is of the essence (who knows when the tumor will continue to metastisize?), the process was frustratingly slow. The Israeli process is far faster.

As far as quality... look, most doctors in the system aren't going to be Dr. Gregory House. But no complaints. By and large, the ones I have encountered will listen, are attentive, are not immediately dismissive of attempts to self-diagnose, and do a good job. Israeli law also recognizes the right to a second opinion and doctors encourage patients to secure one if they so desire.

There are huge variations between different urban centers in the US. I live in a major center in the US South, I got an oncologist appointment in 2 weeks, a CT scan in 2 days and surgery also scheduled in 2 weeks.

I can't imagine it'd be worse than wait times in the US. For many things it now takes months to get an appointment. Oh and the day of your appointment the doctor's kid will be sick, have fun waiting another 2 months. That's the reality I live in.

I don’t know if you can use an argument about waiting times if most of your country can’t go at all due to the cost. I’m sure anywhere could have no waiting times if you take away the patients.

Nowhere near "most of our country" (in the US) can't go at all due to the cost.

> I don’t know if you can use an argument about waiting times if most of your country can’t go at all due to the cost.

This is a crazy comment. Man asked 2 simple follow up questions. Did not “use an argument”. Also, what do you presume his/her country to be such that most can’t go due to the cost? I don’t remember them stating a place of origin.

Free? You don't pay taxes whatsoever? That's odd.

That is a matter of debate, I don't have a good answer for you. I see the US at one extreme of saying: you are responsible for your health in all ways. In Israel it is like, we give you the option to be more healthy but we'll catch you if you fall. There are many many progressive taxation rules. Basically if you earn a lot you pay more. It is one of the most (if not the most) heavily taxed country in the world. Mostly because of arms budgets. In Israel we view the survival of every person as important because we are relatively few. I am guessing when you have 100s of millions of people this is less important for survival as a whole. Good or bad, you decide what works for you.

> we'll catch you if you fall

In American English (not sure about the rest of the world), these programs are literally known as "social safety nets", as in nets that might catch falling aerial performers. Just interesting to see the language used. It'd be nice if they were respected in America.

Good. Amazon has something similar. Not sure if the Costco one can be used for kids (i know Amazon doesn't) . I have to pay 150 dollars just to see a pediatrician to check if my kid has an ear infection.

in colombia, for $49, you can have a real doctor come to your home

In Australia it can cost $0, including home visits after hours. The actual cost is between 2% and 3.5% of your taxable income. A person on the average Australian salary of A$90,000/year would pay $A1800/year. For that you get doctors and hospitals (part of a national scheme called Medicare).

An interesting comparison between countries is here:

https://www.commonwealthfund.org/international-health-policy...

That "can" is doing a lot of heavy lifting, less and less GPs are bulk-billed. We're still better out-of-sight than the US, but under the last govt we started sliding towards privatisation.

Bulk billing for GP visits seems to be getting rarer though, I looked on Healthengine and there's way less GPs doing bulk billing in my capital city. My last GP visit was ~$50 after medicare.

It always amazes me how some places worked out socialised health care and other places really, really didn't.

You would expect developed nations to all land within a few percentile of each other on major issues but for whatever reason the gap is enormous here.

It can cost you $0. There is a difference in what you wrote.

That's not even what they said. The very next sentence detailed the personal cost of Medicare.

These kinds of comparisons are confusing.

A friend had a grandfather in mexico that had prostate problems. He was 85+ years old, and the doctor convinced him to have surgery. He had some weird problems with the anesthesia, but they bundled him in a car and sent him home. to die. The doctor was still paid up front.

In the US, it would be very hard to convince a doctor to do surgery on an 80+ year old patient. They would have watched over him until he was completely stable. All kinds of other differences.

Also I think in other countries you can't get some operations at any cost, like heart bypass surgeries, while in the US you can pay for it if you have the money.

I think there needs to be more nuanced comparisons.

> In the US, it would be very hard to convince a doctor to do surgery on an 80+ year old patient.

Not sure about the US, but this doen't seem to be true in the UK.

"The number of people aged 75 years or more undergoing surgery increased from 544,998 (14·9 per cent of that age group) in 1999 to 1,012,517 (22·9 per cent) in 2015. By 2030, it is estimated that one-fifth of the 75 years and older age category will undergo surgery each year (1·49 (95 per cent c.i. 1·43 to 1·55) million people), at a cost of €3·2 (3·1 to 3·5) billion."

From https://pubmed.ncbi.nlm.nih.gov/31115918/

The average medical degree costs $220K and requires a decade of education. This has natural consequences.

https://educationdata.org/average-cost-of-medical-school

And that $220K is just for medical school, a 4-year degree before entry could be an extra $100K on top (even assuming many state schools with inter-state students).

For other things Community Collage may suffice, but Medical Schools are extremely competitive with spots being artificially restricted while the population continues to grow, so it is very unlikely that a Community Collage applicants even with good scores would be accepted.

PS - Medical residence also often get paid a low enough salary and their loans kick in, that it can be a financial struggle without family support. There is a reason why many come from wealthy families.

The $220k also does not account for the opportunity cost of income for a person smart enough to become a doctor in the first place. Had that person gone into software development or finance, they might have easily earned $400k+ over 4 years, and with a better quality of life to boot. And that does not account for the slavery during residency.

I would estimate a doctor has to earn at least $1M if not $2M extra during their working years to offset giving up their alternative life in the prime of their life.

I mean, they do. Being a doctor is the one profession where you're guaranteed to be rich, especially if you specialize at all. Even software development is no guarantee of riches - there are a lot of software developers making the same (or not much more than) accountants.

Any medical doctors out there? I've read that most doctors are $500K in the hole when they're all finished with school.

My wife is a medical doctor, (although she got a degree in computer science before switching to medicine), but she's in Finland where education is free, so no debt was required for her.

(Yes of course it isn't free, it's paid for by taxes. Taxes get quite high for high-earners such as doctors. So it all evens out.)

It’s the same answer to the question: Is it true most college graduates are $100k in the hole? It highly depends on the context of the individual, but OP is right: 4-year college then 4 years medical school, and then after that years of fellowship.

The shocking part isn’t how much they pay, it’s also the opportunity cost of how long they make little to no money. When determining hourly wage, most physicians in training (e.g. residents, fellows) make minimum wage.

It’s a decade of training or more where income is severely deferred. There isn’t even a guarantee of an astronomical salary because some specialties do not pay well.

Only if they're careless. Also, there are many options for internship and residency that qualify for PSLF, so in the end the total amount may not matter (to them), because it ends up forgiven after 8 +2 years in a non profit or govt hospital.

I don't believe this. The astronomical prices aren't just covering the doctors education, it's the insurance companies and middle men.

A big part of it is the liability insurance. Being able to sue and collect from healthcare providers for millions of dollars has a cost.

One of the pernicious undercurrents affecting costs throughout all of US society, where I think the pendulum has swung way too far.

Also, malpractice insurance is expensive, so patients are also paying for that...

In Yemen just $4. I don’t think it’s worth comparing countries.

Everyday we are one step closer to realizing Idiocracy

1. Crocs are a regular shoe

2. US President was involved in professional wrestling

3. Costco for everything

Say what you will but in Idiocracy people had healthcare.

And by the likes of Dr. Lexus no less!

People talking about this supplanting standard health insurance plans: how does this change the calculus at all? We have health insurance primarily for “disastrous” health costs from very large health needs. This thing doesn’t sound like it provides child delivery or cancer care.

I'm glad to see this. There is a huge need for something like this, so much so people routinely ask health-related questions in online forums which routinely have poor policies for how to handle such questions.

Frequently, someone claiming to a medical professional tries to bully everyone into accepting their answer as the only acceptable answer. Weird online social dynamics exacerbate the problem.

If you aren't verifying medical credentials, anyone can claim any expertise, whether framing real credentials in the most impressive fashion they can spin doctor it without lying or outright lying.

It's a broken system. Hopefully, services like this where you pay a small fee and you know it's an actual medical professional will serve to start filling in some of those gaps.

Everytime I experience the Indian medical system, I feel how unorganised, inefficient and corrupt the whole ecosystem is.

But then everytime I see posts like these on the US medical system (and UK, Israel etc.), it gets me to think how awesome the Indian medical system is.

I dont know much about the US medical system, but I always wonder why just banning all medical insurance be a better system than what is there currently. For those who can't afford, just setup one govt. funded hospital in every district. What am I missing ?

The Indian medical system is extremely bad for the doctors and nurses practicing within, which is why India sees a massive brain drain of medical professionals.

Government funded hospitals are a hit or miss. I get better healthcare service in the rural hospital of my mom's hometown, than in the city where they're living. Of course, at least for the large part, the system does not rely much on insurance backends, but for expensive procedures, you better hope you have insurance.

That being said, unlike the US, every Indian government has still prioritized healthcare regulation on the cost side.

> What am I missing ?

Corporate greed.

Well, it's probably pretty good. I believe I trust Costco to provide a quality service more than I trust most doctor's offices.

Too bad Costco (Costco employees) is not providing the service. It a different company called Sesame, and I do not typically lend Costco's reputation to vendors they endorse.

Reading this thread in the doctor's office in Australia, where I am getting face to face treatment without paying a cent, and feeling extremely lucky.

“Welcome to Costco. I love you.”

https://m.youtube.com/watch?v=sdNmOOq6T8Y

Idiocracy called it. Costco law school soon.

When I read the heading then I was of the view that it is about how high the prices of Telehealth is but it was other way. Is it just me or anyone else also feels that the prices are pretty high? Does the article talks about Specialist or General Practitioners?

  Disclaimer: I work as a Software Engineer for a Telehealth company

It can be kind of high in other contexts too in my experience. I've been using a place called adhdonline for my medication and the zoom meetings (every 3 months after the first month) are $169, no insurance accepted, and my insurance won't reimburse it either. It was a lifesaver being able to find this place since doing the whole procedure of getting medication in-person seemed too daunting, thanks to the adhd. I could find an in person place now that my insurance wouldn't discriminate against but this service is too convenient.

i still don’t get why people don’t sign up for kaiser if they have no health care.

I'm currently between opportunities and could qualify for food stamps. I don't get them because I come down with a intense depression every time I interact with the safety net.

No one cares, you must obligate them. This FACT is constantly shoved in your face throughout the entire process. Automatic rejection when you first apply (you must appeal), Means testing, Constant reapplying to extend benefits.

The people running food banks are way nice though. Seamless sign up, no run around, no hassle, just friendly help and compassion. Unfortunately these types of people don't make life worth it, like spitting in a ocean.

Probably because it's only available in 7 states

For one they are only in a couple states....

It's also often cheaper to pay cash for meds vs insurance+copay.

Welcome to Costco I love you.

Virtual Imaginary health care for 29,99. How very late stage capitalism.

Ah, doc-in-a-box is back.

CVS had something like that about a decade ago. I went to one once on a weekend. I got treated and was given a printout full of plausible medical jargon. When my real GP saw it, she said "according to this you're taking a drug only given to pregnant women".

Were you recently unfrozen from cryo? Clinics in pharmacies, like CVS and Walgreens, staffed by NPs or PAs have been a thing for a while now and have done heroic stuff during the pandemic. For the majority of common complaints the care delivered by an NP or PA is on par with that of an MD and much cheaper and more accessible to most people.

For example, I work at a major medical center of some repute, and it takes months to get any kind of appointment there, while I can usually get in same day at the pharmacy clinic. In fact, they are so good, my employer has bought up a bunch and slapped their name on them.

> hen my real GP saw it, she said "according to this you're taking a drug only given to pregnant women".

A drug only being given to pregnant women can mean (1) a drug that works but may have been superceded by a new drug that's not tested in pregnant women, but otherwise works for everyone just as well or (2) a drug specifically meant to treat a condition in pregnancy, which I believe is what you're attempting to insinuate without cause.

Reply on news.ycombinator.com