Post-apocalyptic life in American health care
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metarationality.com
>rather than deal with faceless automata at health insurance companies
Would this not be replaced with faceless automata in government?
Just look at how the VA is run and complains about it. Looking at that I have exactly zero confidence in the government being able to run things better than the shit show at the insurance companies.
Businesses do need to compete with and overthrow the current middlemen in the medical world. It's just difficult and a very slow process.
The most common failure mode for single-payer is scarcity. You won't be denied, but you'll have to wait many months for an appointment.
> Would this not be replaced with faceless automata in government?
They are controlled by politicians, who are directly responsible to their electorate. Brexit is a good example, using money sent to EU for NHS was one of the more influential ads. Of course, the outcome turned out to be... different.
With the current insurance system, you don't have ANY levers. You can't usually change your insurance company because it's provided by your employer. And even if you want to buy medical insurance yourself via the ACA, you can switch it only once a year. With no way to tell in advance if your new company is going to cover your treatment.
You also can't even sue your insurance company if it denies you the treatment because _all_ insurance companies require binding arbitration. And arbitrators basically always side with the insurance company, because your contract says that the insurance company is always right. That's how UnitedHealthcare can get away with just randomly denying treatment.
Calling out Brexit is an... interesting way to argue here.
If you're proposing my options for heath care are going to be taken away and given to the single option controlled by the electorate who are liable to do things like Brexit... no thank you, I'll take marketplace competition where I can "vote out" the idiots by making a different choice for myself.
People here are like "isn't it awful that personal medical choices are being made by politicians and popular vote" with respect to abortion, gender-affirming care, etc... and those same folks are damn near excited to give away all of their health choices to a government entity.
Do you want your health care options to be dictated by an executive order the first day a new president enters office?
Why? It's an example of directly affecting healthcare via political pressure.
> If you're proposing my options for heath care are going to be taken away and given to the single option controlled by the electorate who are liable to do things like Brexit... no thank you
That's the thing, it can also be fixed by the electorate.
> I'll take marketplace competition where I can "vote out" the idiots by making a different choice for myself.
Except you can't. Go on, read your insurance contract if you don't believe me. You're at the total whim of death panels, who can just tell you to go and die.
In theory it can but in practice it usually isn't, especially for things like this. It's all too easy for some bureaucratic rule to be killing people who have e.g. a particular type of cancer, which makes that 0.5% of people care about it very much, but it takes 51% of people caring about it to change the law.
Meanwhile some other rules are each killing some other 0.5% of people and when you add them all up it's a large-scale disaster but it's also many independent problems. The details matter but the electorate doesn't have the bandwidth to even understand, much less solve everybody's different problems.
You want as much as possible for people to be able to affect their own circumstances rather than relying on the bureaucracy to care about them.
You seem to pretend that people in countries with universal healthcare don't have any agency, but of course they do. Public healthcare doesn't preclude private healthcare. We see this in Western countries that have high-quality universal healthcare, which have successfully managed to strike a balance.
There will of course always be gaps not adequately covered by the public option — new, unproven modalities that aren't offered, or unacceptably long wait lists, or a certain drug being denied that might help improve quality of life over a more conservative drug. In those situations you always have the option to seek alternative private healthcare at higher cost, and you always have the option to get private insurance. So many commenters on HN (presumably American) paint universal healthcare as some kind of draconian Big Brother regime where it's either all or nothing, and the public option will "take away my rights," when nobody has ever proposed such a thing.
In the US, you are under the thumb of private insurance companies whose profit motive is, indisputably, not aligned with patients' healthcare needs. Sure, you can shop around for insurance plans, but realistically, when faced with a health crisis, that's not an option. Which means you have to deal with a system that doesn't care about your health and tries to wriggle itself out of paying anything more than the minimum they're obligated to cover, and that minimum isn't known until the bill arrives. To my mind, having lived under both types of systems, the American scheme is much more restrictive.
Under a universal healthcare scheme, there's no profit motive to cloud the quality of care. There's a cost reduction motive that can affect quality of care, but as the other commenter points out, the democratic model helps balance that. The world over, in places like Scandinavia and the UK, funding of healthcare is a big concern that gathers a lot of public debate and figures heavily in election campaigns; it's not swept under the rug. It's not perfect, but it feels much more of a "we are all in the same boat" kind of environment than the American one where every day we have newspaper articles about huge hospital bills, health bankruptcies, drug epidemics caused by greedy pharma companies, and widening wealth inequality.
The VA system has on average delivers better outcomes than private insurance: https://www.rand.org/news/press/2018/04/26.html
It's the usual "review effect", you only see negatives about the VA, not positives.
That's not all private insurance, just some of it.
That's also talking about the average.
>although there is high variation in quality across individual VA facilities
...
>It's the usual "review effect", you only see negatives about the VA, not positives.
You're saying in rebuttal to a negative review of private insurance, which isn't even what's at issue. Difficulties getting things covered and being buried in beurocratic nonsense isn't really connected to "health outcomes on average".
Your source doesn't make the argument well.
There are other studies with similar results. Comparisons with HMOs is especially illuminating because of the similar models (vertically-integrated organizations).
> Difficulties getting things covered and being buried in beurocratic nonsense isn't really connected to "health outcomes on average".
Of fucking course it is! WTF you're even talking about? People absolutely get inferior care because they can't wade through bureaucracy.
But those people don't get counted in the statistics because they failed to navigate the system so the bureaucracy doesn't even know they exist.
It's worse than that. The VA can't be compared to the average insurer because all of their patients are people who could at some point in their adult life satisfy the military's physical fitness requirements, which is not the case for the population at large.
TriCare covers military spouses and children.
Insurance is anti-competitive on top of that. You have a Sophie’s choice of who you want to pay to buy into this crazy system. There’s no transparency in how services are priced or provided. You as a consumer have no insight into how prices are negotiated between the insurer and providers, nor how providers are paid out. Good luck making an informed decision.
Nothing except that it creates a monopoly and a monoculture.
There are many procedures you may not be able to afford out of pocket, so the only way to get them is to choose a provider that covers it. If there is only one provider and they don't cover it, you no longer have that option.
And because nobody else does either, that medical procedure stops being offered because there aren't enough patients to justify it if they all have to pay out of pocket and most can't afford it, even if you were one of the few willing to scrape together the money. Which might not have happened if some insurers had covered it, even if many didn't.
> You have a Sophie’s choice of who you want to pay to buy into this crazy system. There’s no transparency in how services are priced or provided. You as a consumer have no insight into how prices are negotiated between the insurer and providers, nor how providers are paid out.
The existing system is a dumpster fire to be sure. So why not fix it?
Eliminate even the concept of negotiating prices, as if medical pricing is something to be haggled over at a bazaar in Calcutta. Require every provider to publish their price, and then that's their price, and anyone can compare providers.
Which gets rid of the concept of "in network" and all of that nonsense. The insurance pays e.g. 90% of the median price of that procedure within 100 miles of your home, the equivalent of a 10% copay. Then you can choose any provider you want, anywhere you want, and pay their published price. The difference comes out of your own pocket, so you have the incentive to be price sensitive -- but if you want to pay a little more to save yourself an hour drive, you can do that too. And if you pick one that charges less than 90% of the median price you can put the rest in your HSA.
The thing about regulations is that the most important thing they can do is to ensure that markets are competitive. The existing healthcare regulations in the US not only don't do that, they do the opposite. But they don't have to.
Here's a 226 MB csv file from the Mayo Clinic with... lots of prices [2] and a human friendly search tool [3]
It is extraordinarily frustrating trying to discuss these things with people when folks just make things up and have no idea what they're talking about.
1. https://www.cms.gov/priorities/key-initiatives/hospital-pric...
2. https://mcorgstatic.blob.core.windows.net/cms-price/41094460...
3. https://estimator.mayoclinic.org/mychartguestpay/GuestEstima...
Typically no - what treatment is used might be different, but that treatment is needed and will be supplied is not usually up for discussion.
> Would this not be replaced with faceless automata in government?
In 29 years living in a single-payer system I've never needed to do this. The government does not get involved in healthcare, they just fund it.
Single payer is literally a complete solution to the problem you’re mentioning before.
So why is it obfuscation and distraction? Especially when single payer systems in Europe have proven to have better outcomes at a fraction of the cost?
I find the thought process here fascinating. Single Payer, which is actually delivering results in nearly every other developed country is an “obfuscation” and we need to find “actual solutions”. Doing what every other country that doesn’t seem to have the problem in question is not an “actual solution”. No, we must invent one out of thin air or it doesn’t count.
This seems like a Not Invented Here syndrome taken to its extreme.
Rip Van Winkle sleeps in a coma for 80 years, wakes up revived in Swerway
Universal healthcare, where everyone has coverage, is what people usually want.
I'm glad that your boyfriend has a wonderful and caring person like you to lean on.
It's just difficult to parse a writing where the same pronoun is used throughout for multiple different entities. This exact same issue commonly crops up with "he", "she", and "it" as well.
The solution in these instances is to limit usage of the pronoun altogether and just use the noun directly wherever there may be any ambiguity.
For example, don't say, "Julia wrecked Sarah's car; she was pissed!" The "she" here should just be replaced with "Sarah" or "Julia", even if it sounds a little odd to use the same noun twice in short succession.
If Sarah goes by ‘they’, “They was pissed” sounds wrong and most people would actually speak “they were pissed”… but now it is a three way ambiguity: Julia pissed, Sarah pissed, both pissed.
This feels like an example of a bigger failure mode, but I can’t nail it down. Something like ‘groups are resistant to short term change even if it is a clear Pareto improvement’
The history of pronouns for female, male, neuter, and none-of-above tracks with cultural notions. English's pronouns will mosdef evolve to accommodate the new norms. We're merely in a transitional phase.
I think part of it is that there isn't a great neutral word to take its place. "Partner" is probably the best option overall, but it can mean anything from "person I've been married to for 15 years" to "person with whom I opened an LLC," whereas boy/girlfriend is pretty specific. And the only neutral term of that specificity I've seen proposed is "joyfriend," which I find unbearably silly because I'm not 15 years old :P
Not only that, but doctors also have to fight tooth and nail to get reimbursed by insurance companies (some worse than others... I have doctors who won't even take UHC anymore because the reimbursement rates are too low to break even on practice costs). So we end up with this bizarre arrangement where patients get their wallets drained and doctors have to hunt down their paychecks for services provided... all while the middleman gets richer.
I hope your boyfriend's doing okay. Dealing with a major medical issue like cancer is already hard enough on its own without the added financial nightmare in this country, but at least it sounds like they're in good hands between you and the doctors they're seeing.
The USA spends more GDP on healthcare than any country on earth and the insurance companies are immensely profitable.
Every company involved is making money off the status quo and wants to maintain the current system. when a patient comes along who isn’t desirable and profitable, they’re screwed.
This is all well documented in research about modern USA healthcare and health economics. None of this is an accident and the fact that this situation persists should be a national embarrassment.
But to be fair, you can easily get lost in bureaucracy in public healthcare too, and private health insurance exists in countries with public health too.
The difference is that there is evidence from other countries that a public payer system allows for a better medical system to be built on top of it. There’s no evidence that America’s system of patchwork and arbitrary payments by different vested interests each trying to offload their expense onto some other entity allows for a decent system.
The common goal now in the US healthcare system is profit while a secondary goal is patient care. This causes individual healthcare systems to AVOID, AT ALL COST, interoperability. By forcing administration and bureaucracy challenges they can charge exorbitant rates for those largely unnecessary challenges while claiming patient care as paramount. Unfortunately, this also negatively impacts the patients and their care.
Even Buffet commented that he should have just invested in healthcare earlier on and he would make even more money
That seems immense to me.
From an emotional perspective sure. Their revenue is more than 1 trillion, so while less than 4% lower prices would be nice it wouldn't really fundamentally change anything.
You mean costs can be inflated? Yes, the American healthcare system is extremely inefficient but that doesn't help the shareholders of those insurance companies at all.
That's not necessarily true. If all the for profit insurance companies reduced their profit margins prices wouldn't go down that significantly. I think it's mainly the extreme inefficiency and much higher labor costs.
Which is mooted with single payer. Roughly 1/3rd of costs eliminated. Last time I checked (mid 2000s). Probably more now.
As in doctors, nurses, and other personnel will accept lower salaries because they won't have any choice? I'm not sure that would work in the US.
Also, there are relatively efficient non-single-payer systems in Europe (e.g., IIRC, Switzerland and the Netherlands don't have the equivalents of Medicare/Medicaid). Proper regulation, including price transparency and regulation, would solve most of the main issues and would probably be much easier to achieve than a single-payer system.
A federally imposed universal single-payer system seems to be totally politically infeasible. The best you could hope for is a two-tier system with the government continuing to subsidize for-profit healthcare (including insurance) companies (all extremely expensive treatments covered by the government, but most people who can afford it will continue having private coverage as well).
Wouldn't it be much easier (and possibly more efficient and equitable) to just adopt the Dutch system?
Limiting the US spending per citizen to roughly $2k/year per adult seems impossible in the current climate. It should happen but it won’t. If current health spending trends are to be believed, the number of people using less than 2k/yr in services are less than 20% of the population. There just aren’t enough young people in the US to make up for it, and the feds will never get approval to cover the gap.
The only hope I see for US healthcare is to open government funded hospitals and clinics and offer it as another insurance option. They can compete in the market and hope they have enough funding to eventually convince people that they aren’t going anywhere. This will take a lot of capital to weather the first few years of insanity and shenanigans that we will see from traditional insurance companies. Anything less than competition will be lauded as communism (it will anyway, who am I kidding) but for some poor red states, opening a few clinics in rural areas might actually work for them come time for re-election.
I’m saying all of this as an American living in the Netherlands.
Agreed. This or/and some other variant of the public option.
I've been discussing this with local politicos and orgs. Socializing the notion. Most everyone is receptive once it's explained.
Some day I hope to muster the gumption to do my own lobbying.
Administrative burden (makework) on caregivers would be much reduced.
Instead insurance are allowed to set premiums based on how much they payed last year plus a percentage. So the only way to charge more is to pay out more which sounds insane.
Yes, from the recent report of 2020 [1]:
The health insurance industry continued its tremendous growth trend as it experienced a significant increase in net earnings to $31 billion and an increase in the profit margin to 3.8% in 2020 compared to net earnings of $22 billion and a profit margin of 3% in 2019.
These humongous profit margins of 3.8% can no longer... Wait, what? Three point frickin eight percent? That's what passes for "immensely profitable", really? Maybe there's some other place we should look for greedy capitalists that stole our money than in 3.8% profit margins?
[1] https://content.naic.org/sites/default/files/inline-files/20...
A new regulation was actually proposed by the federal government a year ago to do that: https://www.cms.gov/priorities/key-initiatives/burden-reduct...
There’s also a new program to reduce fragmentation for dementia care in particular: https://www.cms.gov/priorities/innovation/innovation-models/...
Solving the sorts of problems highlighted in the article (from 2017) is well-recognized, by elected officials in 2023, as a priority of their constituents.
However, neither of the initiatives linked above will systematically address the underlying issues, which are:
1. Conflicting and overlapping objectives between federal, state and local governments, as well as between the different branches of government.
2. Partially privatized administration of government programs, such as Medicare. This inevitably results in further conflicts of objectives, and incentivizes gaming the system.
3. The only real way for the government to learn from failure, and adapt to it, is by creating a mountain of new regulations, which just makes everything more expensive / take longer.
4. Extreme caution, in regulated industries, around sharing information with external parties, due to liability concerns. This drives further consolidation.
If you dismantle the incumbent system and introduce efficiencies that bring US health care spending in line with other developed countries, millions of health insurance workers would be out of their [parasitic] jobs. Which is politically untenable.
The underlying issue is incentive incompatibility. The health insurance industry is a behemoth 10x the size of the automotive industry, for example. You can imagine what kind of lobbying power they have as a result. And they are not interested in anything that destroys their jobs.
Sadly, when you’re discharged to an SNF or rehab, that’s always outside the tribe, and you get the situation described here. Haven’t found a cheat code there yet.
We are also blessed to have a kidney specialist that, as part of this system, has some tenure and traction in this hospital system, and is -- in my opinion -- an incredible doctor and hospitalist who proactively navigates these systems on our behalf. I 100-percent realize that this doctor does not exist everywhere, and we are incredibly fortunate to have him on "our team".
In any setting -- ER/ED, inpatient, outpatient, clinic, urgent care -- when you talk with doctors and nurses, answer their questions, no matter how repetitive. Be kind, and understand that the person you're talking with _now_ has exactly 20 seconds of experience with your case and influence over a very small part of the system.
The phrase that has gotten me farthest is "Hey, I'm a dum dum, but." For example, everyone along the way was ready to tell me why what she had _wasn't_ a seizure, and I wasn't going to argue with them, but what I said instead was "I'm a dum dum, but it really looked like a seizure to me. Her fists clenched, I tried to unclench them but I couldn't. I rolled her onto her side because Seizure Protocol. She said herself she lost control of her muscle movements."
The best thing you can do (like the post author) is be an active, participating advocate for your loved one, the patient: Every. Single. Time.
I don't mean to suggest that "I'm a dum dum" is a bad approach - in fact I think it's great for getting past any cynical defenses that have built up.
But I'll never forget taking my son to the ER and getting to have an actual conversation with a doc. When he was a toddler he would get nasty respiratory infections that had escalated to hospitalizations in the past. When I took him in, he was in reasonably good shape, and initially the doctor just wanted to send us home. But I described his history and said something like "every time he has one of these, we wind up taking him back into the ER at night, where they invariably give him a steroid that clears him right up. Could you just prescribe it to him now, and we'll only use it if it becomes necessary?"
The doc got this big smile and was more than happy to oblige. My guess is that she didn't want to prescribe a steroid for no reason (because they really shouldn't be taken willy nilly), but as soon as I showed her I was, you know, thoughtful and responsible, she was practically falling over herself to help me.
Docs don't want you having to bring your kids to the ER at midnight any more than you do. And for the most part they're in the field for good reasons (especially pediatrics, because you'd have to be insane to do it for the wrong reasons).
If you are able to come across as rational, observant, practical, respectful of their expertise and experience, but also confident that you are the only one seeing the complete picture, 90% of the time this unlocks a much more collaborative interaction. And yes, it’s usually a huge relief to the doctor!
I will say, however, that all government interventions up to this point have made the healthcare and health finance systems of the USA worse and not better as most of these interventions were drafted and paid for by health/finance megacorporations. One example, medicare isn’t means tested in any way and insurance companies will force people to use it despite the insurance policy covering kidney transplants simply because the government offers money for renal failure. Meanwhile, the hospitals don’t even bill for treatment until the patient is on Medicare, because the hospital can charge the government far more money without consequence.
That said, going out of network if you can and going to the places with the cases if you can are the only real current options for beating the odds. I speak from direct experience doing whatever it took to get my wife's cancer treated at MD Anderson. We won, at least for now, but it wasn't cheap.
Reform should happen, but it shouldn’t be based on a bumper sticker, and it should be thoughtful about the vast differences between SF, NYC, West Texas and Southern South Dakota. “Fixing” things for people in major cities while crippling/destroying rural care (more than it already has been) is a bad solution.
Lastly, rural healthcare is in trouble because reimbursements are bad (especially Medicare reimbursements), FFS (fee-for-service) is a failed model, there’s a massive credential shortage, and given those, the credentials that exist would prefer to work in desirable places, not Pine Ridge, SD. If you’re serious about fixing healthcare, you should start by fixing education. State politics, specifically around Medicaid, are, generally, not driving the hospital closures and OB/GYN deserts.
I don't dispute the rest of your arguments about healthcare, but you cannot fix education and/or brain drain without fixing state politics.
Hospitals are not closing because of shitty prenatal laws. They’re closing because reimbursement rates are insufficient, in part, because we’ve allowed too much consolidation, in part, and because there aren’t doctors/nurses who want to live in the sticks and make peanuts.
That sounds workable.
"If you choose to live on an obscure island or corner of alaska unreachable by land, should the government be obligated to keep a doctor living and working nearby you?"
To which I'd then imagine the thought process is more sometimes you'll just have to move to a more urban / developed area if you have a really severe disease, or deal with long drives or getting plane flights.
This is a sort of disingenuous way to talk about rural America. Pine Ridge is two hours from Rapid City, not the middle of nowhere, Alaska, and the discussion isn’t about specialty care, but normal primary care, hospital and Ob/Gyn services.
Saying “suck it you stupid rubes, move to a city” is going to make it difficult to get anyone to agree with your version of healthcare reform, assuming it was even going to work.
That was easy.
Medicare-for-all extends a fee for service model that results in poor care, poorer outcomes, massively increases expense, and simultaneously lowers physician reimbursements. Given the increasing doctor shortage, that’s an issue that will be immediately exacerbated. Further, the FFS model incentivizes throughput, not quality of care. Your care won’t get better.
https://journals.lww.com/jcma/Fulltext/2015/10000/Overview_o...
I suspect every reason you will cite is something we could both address as a nation and we will refuse to do so because freedom or some other idiocy. I truly give up. I threw money at family's medical crisis and prevailed. Most can't. More should be able to do so.
Even California is looking to places like Houston to mine ideas for improving their raging homeless problem. If you're not going to steal from the best, why bother doing anything?
I’m not clear why you’re giving up - it’s not an intractable problem. Some folks need to give up on “healthcare only for the rich/cities” and some folks need to stop having strong opinions about a very, very complicated industry they don’t understand at even a surface level (not directed at anyone specifically - it’s a common US problem with healthcare discussions/solutions).
Cost/utilization/availability challenges are fully solvable, if one is committed to a solution and not a message.
So here we are, paralyzed indefinitely, throwing more money at a broken system annually. But also, so many in tech build things from strong opinions about very complicated things, and they are inadequate, but at least they're not doing the same thing over and over and expecting a different result.
I will say this though. I have yet to see private equity do anything besides make an existing problematic situation worse. And if that's what you mean by a difference between America and Hong Kong, yep, I agree.
The difference between HK and the US starts at the fact that one is 1100km^2, and the other is 9.8 million km^2. Solutions that work well in what’s essentially a really dense city don’t, necessarily, work across a massive country with a distributed, diverse population that faces very different, area-specific challenges.
I’ll add, apropos of nothing, that the fastest way to make healthcare in this country better is to fix education costs. If we dramatically increase the number of people in med school/nursing school, and simultaneously dramatically decrease what they owe upon graduation, you will see far more high quality providers enter the system who will be far more able to practice in places that really need them.
Also, it's not like the fact that the private insurance model failed in the US means that it can't work at all. For instance, not all countries in Europe have single payer. In some the health insurance system is privatized to a much higher degree than in the US, no equivalent of Medicaid/Medicare with governments directly subsidizing insurance premiums for low-income individuals.
There are clear problems with the current system, and we paid quite a bit out of pocket to evade substandard care this past year with our insurance company threatening to not cover it at all at every step. We called their bluff by enrolling in clinical trials and they folded. Most can't afford to do so, and some never will, but I wish I lived in a country where more could.
And sure, a more transparent private system could work, in fact, utter transparency should be a requirement from the get-go given what is happening with the public/private mix in Canada. But we have 50 individual states in which to experiment yet good luck with that in the current media/political environment. Not giving either party a break here.
I'm certainly not asserting that. However, first of all, 'Medicare For All' only makes sense if it's mandatory, which means additional taxes. Yes, considering the social, political, and economic reality, the likeliest outcome would be a two-tier system, with those who can afford it getting additional insurance in some way. I'm not sure what's so great about that?
> And sure, a more transparent private system could work, > experiment yet good luck with that in the current media/political environment. Not giving either party a break here
Would passing an extended ACA II with way fewer compromises and more effective regulation than the Obamacare version be really harder than instituting Medicare for All (so either a significant increase in federal income tax or a new tax altogether)?
My marginal rate in California is 53+%. That IMO is ludicrous given the horrendous condition of California and its budgetary planning. But...
I don't think the marginal rates are the real problem here. I think they're just peachy. The problem is we have an effectively ~20 page tax code with 4,980+ pages of bespoke deductions for individuals, corporations, and economic segments. Lose them all and start over with alt-min with far fewer exceptions (if any). I'm already taxed higher than most of the world* including most European Socialist Democracies without any of the perks and returns. It's not about the marginal rates. Which is to say we don't need new taxes, we need fewer loopholes to escape the existing tax rates. And we're not going to get that either. It's way too nuanced and esoteric a platform to gain traction with the sorts that think anyone making $100K in 2023+ is a plutocrat, so once again, I... give... up...
Also, California just loves multiple agencies competing for the same table scraps of tax money, but that's a different thread because all those redundant bureaucrats are getting paid on our dime.
*https://nomadcapitalist.com/finance/countries-with-the-highe...
I'm not sure that's true in general. e.g. at around 300k the effective income tax rate in CA is ~34% (26% + 8.0% state) +5% (SS etc.) = 39%. That's quite low by European standards, if you go down to 150k the total is just 35%.
In Germany for instance you'd already be paying ~42% on 100k
Anyway, that wasn't my point at all, I'm just unsure how politically feasible it would be to accomplish this on the federal level.
> European Socialist Democracies
There is not a single country in Europe left which would describe itself as a "socialist" democracy (thankfully most of them collapsed around ~1990).
Sure, every so often, someone publishes an article about how to balance the federal budget and it always comes down to neither being a republican nor a democrat. And that's why it won't happen. Compromise is dead.
EDIT: Geez, here's one now: https://news.ycombinator.com/item?id=38759502
What you're missing is that the current "system" is so utterly wasteful and inefficient that even if we cover people's shitty lifestyle habits it would still be cheaper than what we have today. Which is basically what TFA's main point is about.
Brilliant essay, with so many fantastic lines.
I am picking this one out because amongst the many perversions of 'the system' is that the crazy healthcare inefficiency is counted as a metric on GDP. Those thousands of wasted hours of wasted hospital activity, ultimately paid for by the tax payer, is counted as economic activity in the national economy.
What percentage of GDP is based on humans navigating broken systems in a 'pre-modern' way? Probably way too much
In short, "Can F1 send you to F2 to be paid by X?" turns on the following:
- Regulations / laws
- Contract with the insured (policy)
- Contract between X and F2
So answering the question definitively requires 3-way parsing of those things. Which is generally a unique 3-tuple for any given patient-provider/facility-insurer combination.
The closest you get to standardization is "We work with X a lot, so generally know how they work."
And as article notes: regulations / laws change years, policies generally remain somewhat stable (post-ACA standardization), and insurer-provider/facility contracts change whenever they're up for renewal.
In short, the system's complexity is what paralyzes it.
Which means simplification is the path forward.
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>> It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.
Also, GOD NO.
Healthcare is complex because it's required to be a 1:1 model of reality. All of reality. Shark bite while riding a train that gets hit by a plane reality.
The reason healthcare is still largely manually done is that it was originally manually done.
It's gotten to where it is by progressive automating... but started at "I start the morning with a stack of paper forms on my desk, and work through them, forwarding them on as needed."
We're not looking at a breakdown of the system, but an incomplete automation. (And part of the current bottleneck is the Cambrian explosion of medical specialists in the last 30 years)
Or, a legalism of a "first do no harm" nature which demands once a qualified professional determines you have cover and it's just an argument about who pays between competing covers, you get no-worse-off service choices immediately until they decide which one has primacy.
Or my favourite: return to an NHS model.
https://www.propublica.org/article/health-insurance-denials-...
The nice thing about it is that it can be done a bit at a time, you don't have to change the entire US at the same time.
No more fee for service, Doctors would go on salary, and without fee for service an entire insurance complication (making sure to pay exactly the right amount for services, no more, no less) evaporates.
The downside: You can only see Doctors inside the HMO network. A second downside is handling emergency out-of-network care (this part would get better as more of them exist, as they would sign sharing agreements with each other).
Note: The capitation part is critical, HMO without capitation is worthless.
That's the goal!!
Very high doctor pay is the number 1 cause of skyrocketing medical expenses.
The model should be coupled with them opening a lower cost university and training 10 times as many medical people as we do today. Along with better supply lowering prices, it also means a Doctor could have normal working hours, so would not need the insanely high salary they need to pay for all the stuff they don't have time to do themselves.
Exactly! I can't think of any other country where doctors routinely make 15-20x minimum wage, and people become doctors predominantly to make a lot of money. In most countries, doctors make very good money, but not 15-20x minimum wage good. In Western Europe, for example, it's more of 5-8x minimum wage.
To answer your question: Ban employers from paying for health insurance as a benefit. If individuals see directly how much it costs, that will put much more pressure on prices. And employees don't have to worry about losing their insurance if they lose their job.
Some other gradual options:
- end the AMA licensure monopoly, making doctors more plentiful lowers prices and increases quality
- reform the FDA approval process to make developing drugs and equipment cheaper
- cover preexisting conditions under Medicaid instead of forcing private insurers to
I see how this would lower prices, but it's not clear how this would increase quality. Naively I would suspect it would, at least initially, lower average quality.
oh lord. the finance industry does not even have a standardized way to transmit prices of securities. there is an enormous amount of inefficiency in the most basic behind the scenes systems..
My only real hope is the generation born after 2010, who all grow up playing video games where you get universal basic income and free healthcare laying around on the street in crates and boxes. And those things both actually work, they are not bug ridden half-finished projects that constantly crash and break. They will hopefully try to implement these things once they gain power.
It's not that they're incentivized to not cover procedures, it's that everyone is incentivized to cover their ass unless regulations are really explicit. Since suing insurance companies is impractical for most people, it's really hard to turn that ass-covering in your favor unless a regulator gets involved.
Even something as basic as sharing notes becomes an ass-covering exercise lest someone use those notes against the doctor in malpractice suit or the data accidentally leaks leading to a HIPAA violation.
It's unfortunate that the author of this article in question manages to take away the wrong impression.
> It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.
> Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?
The thing they miss is that healthcare companies are already making trillions of dollars. They make trillions because the system they designed is working as intended. You look at other countries and how their healthcare systems work and you will see a vast difference in functionality and efficiency. Because they know healthcare being a for-profit driven industry with weak government controls leads to the shitshow we have in America.
You can't boil healthcare down to a single reason.
At minimum, there are supply (providers and facilities) and demand (insurers and patients) sides, each of which have their issues and solutions.
There is no magic bullet that any country has found to solve the problem, other than -- have enough providers and facilities for patient demand and find a way to make it worth their while.
Everyone wants top quality health care, everyone wants tests, everyone wants scans, everyone wants to cover their fucking ass. Take multiple X-Rays when there is no good reason to, to prevent lawsuits. the guy who lied about taking Heroin gets a full lab workup for no good reason.
USA has top tier health care. It's simply not economical to give it to everyone who demands it, and Insurance companies are not dumb and believe everything that gets submitted.
I've always thought that this is something basic that we need to address as part of any health care reform.
We can't afford to give everyone unlimited health care, so how do we determine the limits?
I assume that a lot of socialized health care systems end up using waiting lists, perhaps based on the patient's age, treatment cost, and probability of a positive outcome, with the option of going outside the system and paying for more/quicker care, for those who can afford it.
One person I discussed this with assumed that there was plenty of money to give everyone care as good as billionaires get. I don't assume that's true. Has it worked out that way anywhere else?
It’s not necessarily a good thing to want unlimited healthcare for all. Proper use of a scarce resource doesn’t necessarily mean it’s about rationing it with waiting lists and selective treatment. You can probably get quite far by first not overtreating a lot of people.
I get your point - yes doctors have a lot of tools at their disposal, and yes using those tools comes at a cost, but wouldn't you want to use those tools if you were in that position?
X-rays are not exactly cutting edge- if a fracture is suspected they are fundamental. Bloodwork etc are key diagnostic indicators. Sure people lie ("Everybody Lies" - House [1]) tests are helpful to understand those lies.
It absolutely can be economical to give everyone the best possible health care - especially at the primary diagnostic stage. That being true, yes, every part of the system is independently determined to maximise their profit. From the X-ray operator to the blood-test-maker.
It's worth remembering that these common tools, that have been around for decades, are still more expensive (by a lot) in the US than elsewhere. Yes, health insurance makes massive profit. But so does precisely everyone else involved at any level.
So if it is "not economic" perhaps its more any issue of "greed" than math.
[1] House is an old TV show about computer support, using medicine as a metaphor.
There is a government mandated interface and it’s found at http://www.x12.org in the form of the 837, 835, 276/277, and 271/272 among some others. There are also paper equivalents in the CMS1500 and CMS1450.
These are truly one of the main culprits of the problem because of how old, woefully inadequate, and rigid they are but cannot be easily changed as the speech between these two entities are highly regulated via these specs.
Health insurance companies are rent-seekers. They provide absolutely no value. They are simply designed to siphon money to shareholders at the expense of people dyijng due to denied or insufficient coverage. They are literally merchants of death.
Did you know that lobbyists managed to sneak in a provision to the ACA (aka "Obamacare") that prohibited physician-owned hospitals? That's still in effect. That's what we get with this ridiculous system.
Even non-profit hospitals engage in similar behaviour to for-profit institutions because their executive are overpaid [1] and are incentivized not to spend money on healthcare and instead engage in fundraising and increasing funds under administration, a little like how elite colleges do.
Also unlike every other developed country the US government is prohibited by law from negotiating drug prices with one exception: in the Obama era the VA was allowed to negotiate prices and thus pays a lot less than, say, Medicare. It's even more ironic that most novel drugs are the result of Federal research dollars. The only research most pharamaceutical companies engage in is patent extension.
Last year, the IRA was passed that will allow in a few years the government to negotiate prices on a handful (8?) medicines and even that faces stiff opposition in Congress.
This system needs to be scrapped.
[1]: https://revcycleintelligence.com/news/how-nonprofit-hospital...
It’s just that a big chunk of that pool of money goes to middle men, some of who lobby heavily to law makers and media company to tell a story that we have the best healthcare.
US only works because we have other sectors of economy that generate a huge amount of wealth that even with such huge inefficiencies in healthcare, things move on.
US spends more every year on healthcare but its citizens’ life expectancy is decreasing. Post pandemic the trend is reversing.
https://www.healthsystemtracker.org/chart-collection/u-s-lif...
Some folks have figured out how to suck money and soul at a grand scale.
The biopsy was indeterminate, and instead of immediately sending it out for a second opinion or molecular testing they decided to wait until I could see my specialist before giving me the options. I immediately told them to go for the second opinion and to check about insurance approval for molecular testing.
They had no idea how to bill me for molecular testing because the pathologist for some reason never suggested it in their report (which I later learned from another peer specialist at another hospital that molecular testing would have been written on the report for insurance approval purposes).
My insurance adamantly insisted that it would be covered, and then turned around and told my hospital that I would have to pay nearly six thousand dollars out of pocket.
The second opinion took three weeks, which concurred with the original pathology report and finally put the magic words "recommend molecular testing" on paper which got insurance to approve it. But rather than push it through, my specialist decided to play phone tag with me for a couple more days to make sure I was okay with the fifty dollar copay.
This entire process, from start to finish, took six and a half weeks to learn that the biopsy sample was benign and nothing to worry about. Now imagine if this were a serious thing and that I needed to have surgery as soon as possible. A six and a half week feedback loop to begin scheduling surgery (every surgeon for this issue in my area was booked at least five weeks out) may as well be a death sentence.
I've come to the conclusion that in this country, even if you are extremely proactive and aggressive about advocating for your own health, it's still not enough. You have to supplement this with something proactive like a full body examination in a foreign country (i.e. Japan's Ningen Dock system), otherwise you risk dying from the apathy and bureaucracy of the American medical system.
> at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.
The money wasn't wasted -- the broken communication and intricate rule sets delay things for as long as possible, meanwhile the patient is charged, and someone is making a profit.
> On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.”
And here it is: when there was a credible threat that the money would stop flowing, the system acquiesced, insurmountable bureaucratic problems lifted.
> Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best.
Here lies an opportunity to rip the spine out of the entire scam. Steal the rule books, leverage a LLM with RAG or other information retrieval architecture, and get answers in minutes, not days. Offer this as a service to (relatively) seamlessly slice through the obscure-by-design bureaucracies -- only of course to be hindered by the entrenched players and the politicians they have lobbied, who will fight tooth and nail to maintain the status quo.
Most medical interventions, even ones that are serious like hip replacements, can be scheduled. It’s annoying while you are waiting, but it’s the rare case where emergency medical attention must be applied immediately.
All hospital systems should be deregulated - no more “certificates of need” and monopolist hospitals that can veto additional competition. If any entrepreneur wants to open a facility with licensed medical doctors, they should be able to service any and all ailments.
Finally, there will only be 2 official options for payment - retail and single payer. Single payer will kick in whenever bills go above $X, call it $50k. Retail will be out of pocket for anything lower, and people will shop for their own solutions. They can always buy additional insurance, and fund tax advantaged health savings account, but the single payer will not kick in until a catastrophic amount is reached.
The nightmare of medicine stems from the desire of doctors to be paid what they are worth, and the desire of government to cover everyone for “free” but never having enough money. We need to unshackle the market to let doctors get what they are worth, but drastically increase competition and the entrepreneurial animal instincts to destroy the bureaucratic mess that has bogged everything down.
I do think your bar for catastrophic is far too high and should probably be ~$10k cumulative spent in any span of time less than 12 months because $49k is ruinous to almost every American.
There are complicating factors here:
We culturally, societally, and philosophically don’t really know how to make decisions about end-of-life care, and death in general.
We also lack an agreed upon moral framework for how to care for people with diminished cognitive capacity (the extreme being permanent vegetative state).
It's a thing, even if ignored. We're paying big premiums for that to insurance companies as part of our wages and taxes.
I wonder if other countries do significantly better?
[1] https://www.saturdayeveningpost.com/2013/03/how-doctors-die/
Or is something else making a difference?
How does the Netherlands handle end-of-life care? I see in 2013 that 3.4% of all deaths in the Netherlands were people who chose euthenasia [2]. Maybe that saves their system a lot of money? Maybe they look at end-of-life differently?
In the Netherlands how do they make decisions about who gets possible life saving treatments versus who does not? does anybody who wants state of the art chemo get it, even if they are 80+ years old?
[0] https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locat...
[1] https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locat...
[2] https://vivredignite.org/en/2014/09/recent-euthanasia-number...
Biggest surprise for me was that the best aspect of the healthcare system has been Medicare. Consistently helpful and all the communications were clearly designed with seniors in mind.
Very other aspect is characterized by innatention of obvious corporate motivations.
The problem is that most people don't have that kind of money and the system as a whole is designed to take advantage of regular folks by not providing the care they need (regular care, not the best care).
Does it sound plausible?
I'm sorry but this sounds like someone invoking "they'll write it off" without knowing how write offs work. In that scenario your revenue will be 2/3rds of the list price. Taxes payable is dependent on your profit, not your revenue. Profit is revenue minus costs. Inflating the list price doesn't change anything in this equation, and thus won't affect your taxes payable.
Stories I hear about Europe is that it’s affordable, but still slow and bureaucratic. You hear about some people even coming to the US (gasp!) to get expedited treatment.
Asia seems to be both affordable and also fast and efficient.
There is no one single root cause to fix here. The entire system needs to be uprooted - entire companies and shareholders will need to get wiped out. Unfortunately, ain't happening in ultra capitalist America.
For other countries, there is still hope.
Like health care and anything, you get what you pay for.
Given the insanity of it, and US being capitalist in nature, may be the best way to fix all of these isn't more regulation, but to deregulate the market so they could compete?
And on the topic, I am wondering if anyone knows a good site that compares the Medical System around the world?
So basically if you are poor you just… suffer
knowing back channels, having the 'village' mindset is much better