Comment by mlsu | Hacker News Reader

Comment by mlsu | Hacker News Reader

Parent Full thread

I completely agree, but even further: health insurance is itself a silly thing.

Insurance is for:

- costly things

- that happen rarely

- in an unpredictable way

These are characteristics of things that are well suited to insurance. Healthcare -- the type of routine healthcare that makes up the vast majority of spending -- exhibits literally none of these qualities.

Most healthcare expenditure is:

- not costly. An Advil is not costly. 30 mins of some stupid doctor's time is not inherently costly. An MRI is not costly. Medical office space is not costly.

- totally predictable (eye exams, checkups, scheduled visits, hell even big operations like a heart transplant or C-section are rarely done "in the moment." Usually you can see them coming. The hospital can definitely see them coming; they know exactly how long a gastric bypass or a c-section takes, how much equipment and staff they need, etc.

- not rare; most people visit a doctor at least yearly. That's on par with buying xmas gifts!

Only a small fraction of healthcare spending should happen through insurance -- insurance should be for things where you travel in an ambulance to the hospital and that's it.

PCPs should compete individual to individual on quality of service, price, etc.

Hospitals should compete hospital by hospital on quality of care, facilities, scheduling, bedside manner etc.

Rx should be decoupled completely from insurance. Why do I choose Humalog over Novolog? Not for any medical reason! It's because I need to have insurance to buy one or the other. Why do I need insurance to buy a pill? Because I need insurance to see the doc. Why do I need insurance to see a doc? No good f%@#$ reason. Drop it.

Insurance is for when I need surgery NOW for I have no idea what, and I cannot make any kind of choice about it. It should cost $100 a year for a healthy 20yo adult and $400 a year for a healthy 60yo adult.

None of this shit makes sense to have insurance mandated. None of it. I should be able to walk into any doc's office without insurance and pay a flat cash fee, posted on a big bulletin board outside that says $20 per 15 mins. If I don't like it, I should be able to LEAVE and go across the street!

> insurance should be for things where you travel in an ambulance to the hospital and that's it.

There is another major class of things you want to insure against, and it's the big one.

Chronic conditions. You get diagnosed with diabetes. It's costly and it happens rarely in an unpredictable way. You don't know if you're going to get diabetes, or cancer, or something else, so you insure against it instead of being bankrupted by the long-term treatment.

And then the insurance covers your annual checkup for free because they want to catch things early before they progress.

This is a good point, and one that's easily overlooked by the young and healthy.

The expenses for "common" chronic conditions can be MASSIVE. A condition like rheumatoid arthritis can EASILY exceed $30,000/year in medications alone. Add in frequent doctor visits and related medical issues and that runs up even higher. Without some form of insurance (private or socialized), we would be condemning these people to a life of pain and misery (at best) or death.

Yes! I have diabetes. Believe me I am aware of this.

A vial of my humalog approaches $300. A visit to the endo is $500 on the bill.

But there is no reason why these things are so expensive! Other than that I have to have insurance so I have to be "in network" and oh, my insurance helpfully consults with a pharmacy benefits manager to decide which medications are "covered."

At no point do I have any choice in any of this. I'm not talking about choosing to have diabetes or not, I'm talking about choosing treatments for my diabetes. Always, it is a conglomerate like UHC choosing which things I have to buy this month. How convenient for them that they choose how much it costs!

In theory the choice should be in which insurance company you use. One of the biggest mistakes in the US system is having tied that to your employment, and then it's not you choosing anymore.

"Health insurance" is the wrong name for what we're purchasing, but the product itself isn't silly.

"Health maintenance plan" is a more descriptive name for what we're discussing.

Even something as basic as an annual physical is ~$400 (cash price). A doctor visit for illness is $100-$150 before any bloodwork or imaging (which can add another $100+). Those are major expenses for many families. The ability to spread those cost across the year is a good thing.

It's expensive because I can't move doctors, and I and my employer have to buy a stupid financial product to even see a doc. How much of that $400 goes towards the doc anyway? Towards payments on the MRI machine? Towards the office space? No more than $100 all in.

For one billable minute of every doc's time, we are paying 5 billable minutes for various "healthcare administrators" all over the country to move numbers and billing codes around in a labyrinthine spreadsheet. For what?

I don't disagree with any of that. I'd much prefer some form of nationalized/socialized health system (and would not prefer a "cash only" system, because there will be people who can't afford that even at half the current rates).

I mostly agree, but wanted to nit on this point:

> hell even big operations like a heart transplant or C-section are rarely done "in the moment."

Agree on the plannability, but not on the predictability. Once you are on that table, and especially if you are under anesthesia, there are an untold number of ways that procedure can quickly turn into a secondary emergency procedure. It's a miracle of modern medicine that such invasive procedures are perceived as being trivial.

> Only a small fraction of healthcare spending should happen through insurance -- insurance should be for things where you travel in an ambulance to the hospital and that's it.

We already have that. It is called a high deductible health plan.

But health insurance companies do not just sell health insurance, they also sell price negotiation services, so you probably want to use them even before you hit your deductible/out of pocket maximum, otherwise you will end up paying more.

Reply on news.ycombinator.com