Insurers rely on doctors whose judgments have been criticized by courts
propublica.org
propublica.org
Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich.
Why don't you change it? What are the reasons why moving to a single payer system is so bad? Denmark has the same system as the NHS, puts more money into it than the Brits do, and has some of the best health outcomes in the world. If a politician seriously suggested copying them -- with an income tax deducted at source with employee and employer contributions -- what would happen?
https://www.statista.com/statistics/184968/us-health-expendi...
That's 20% of the country that will be less well off if you "fix" healthcare in any meaningful way and the overwhelming majority of them will fight tooth and nail to prevent that from happening.
That is a hell of a minority to overcome when the issue is one of personal economics (i.e one everyone will experience directly, not some abstract social policy thing that people will ignore as long as their lives are good), dare I say basically impossible in a democracy.
(yes I know I'm assuming that the healthcare industry is a cross section of the country, no I don't care if that isn't 100% accurate)
Tough ecosystem to change. But, at the same time, seems to be the one needing change the most.
This observation has value. However, if we hold it exclusively in mind we might lose focus of how prioritizing consumers strongly benefits society.
Health insurers ... don't seem to do that.
Earlier comment: https://news.ycombinator.com/item?id=42435020
It's not "nobody wants this", but "sufficiently many people are sufficiently apathetic to continue this state of affairs".
Who do you think should change it, exactly?
You’re making the classic mistake of assuming the US works like the average European country: a functioning democracy where if something makes sense, politicians will promise it in their manifestos, and then implement it once they get elected.
In reality the US works completely differently and is not a functioning democracy. Making any major reform in any area is, to a first approximation, impossible.
But one of the things that I think is unambiguously better (at least in highly developed Northern and Western Europe) is the quality of democratic institutions and their responsiveness to the people’s will. In the US, it is structurally almost impossible for Congress to legislate meaningfully, so effectively no one is in charge.
A pre-existing condition? You’re not covered.
I saw this as an immigrant to UK from a developing country, who only recently understood what he signed up for
There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland
Congress then set the fine to $0 in legislation passed in 2017, which went into effect in 2019. [2]
[1] https://en.wikipedia.org/wiki/National_Federation_of_Indepen...
Seems like folks across Europe were pretty upset with the number of asylum seekers and the problems that followed their migration into Europe in the last couple of years. Their governments didn’t seem to give much of a shit and that’s led to more right-wing support.
And even if we look only at the wealthier EU member states, "better" depends on which metric you look at. They're generally more cost effective. But the US is better for 5-year survival rates on most types of cancer.
I wholeheartedly agree healthcare in Europe is better, but not everything is better there.
Rich people in Europe have "noblesse oblige". Yes you have to pay for your neighbour who is on welfare and a drug addict. Deal with it.
Welfare -- my 30%+ federal income taxes
Medicare -- my income is taxed for it.
MediCal(California only) - my 10%+ state income taxes.
Uninsured/homeless goes to emergency room and hospital writes it off -- my 30%+ federail income taxes and my 10%+ state income taxes
City spends millions on homeless -- my 10% state income taxes and probably a bit of my property taxes.
On top of it, thousands per year of monthly medical insurance premiums for family of 3, thousands per year of "deductibles" before insurance kicks in.
This cannot be better than just paying high taxes and receiving high benefits for it.
It would be too much credit to call it "financial engineering". Do you know who mostly benefits from these (basically) fraudulent "discounts"?
My belief is that it's the relatively complicated regulation of capacity (federal and state regulations on facilities and providers), which pairs poorly with government programs that increase access to care with direct subsidies.
We should train lots more providers and eliminate barriers to entry (so for instance, if someone wants to open an MRI suite, let them).
The most immediate bottleneck on producing more physicians is lack of federal government funding for residency programs. Every year there are students who graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency program (some do get matched the following year). At one point the AMA lobbied Congress to limit the supply of doctors but some years back they reversed that position. So far Congress hasn't acted.
The other thing we can do to increase the supply of providers is to rely more on physician assistants and nurse practitioners for primary care. There may be some reduction in care quality but it's good enough for routine treatments and patients will just have to accept that. Real physicians should be reserved for more complex cases.
Every efficiency idea is ultimately just used as an excuse to make the system worse and worse. As it stands "real physicians" are already mostly phoning it in, because their attention has been sliced up into 10 minute slivers by "insurance" companies. I'm not saying that NPs or PAs are going to be worse than that (in fact individual NP/PAs can be more engaged than individual MDs!), but it's still galling to be on the receiving end of negative-sum cost optimization - "our next appointment with a doctor is in four months, or you can see a PA next month".
The sweeping reform we need is to drastically introduce actual market dynamics into the industry. This applies regardless of the payer structure - the entire industry needs to be moved from cost-externalizing negative-sum interactions towards cost-internalized positive-sum interactions. Imagine having actual supply and demand for doctors and hospitals funding their own residency programs rather than a set number of government funded residency slots.
There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs. Those can work fairly well for a minority of engaged and intelligent consumers but overall aren't an effective solution to systemic problems.
Classical supply and demand economics don't function very well in healthcare. Demand is effectively infinite: sick people want all the healthcare they can get (even if it doesn't really help them much or causes iatrogenic harm) and they think someone else should pay for it. Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing.
Federal residency payments to hospitals forbids charging for it, and insurance refuses to pay for it. It is enough to cover the salary and cost of the residents.
You are right that the current state is a free-rider problem. Free rider problems have tons of solutions, in both through markets and public policy. A free rider problem doesn't mean we must throw up our hands and give up. Instead, it suggests the type of solutions which are applicable.
https://www.cms.gov/medicare/payment/prospective-payment-sys...
What solution are you suggesting here exactly? Who should pay for graduate medical education, and how will we incentivize or force them to do it?
If I were to suggest a solution, the first step would be allow all hospitals to bill for work done by residents. IF they can make money on residents the entire problem goes away.
If a resident fixes your broken arm with the same quality as regular doctor, I think the hospital should be charging the payer the same.
From the papers I have seen, unbilled procedures by residents is more than enough to cover their salary.
IF it doesnt get there, we could talk about contractual solutions, but the first step should always be figuring out the true value of their work.
PS, I don't pretend to understand the intricacies of the law you linked, but it does not seem to address the issue on first read. It seems that Medicare will pay an arbitrary premium set by Congress on healthcare services not performed by residents to compensate for the fact that neither Medicare nor private insurance pays for the healthcare services that are provided by residents.
The problem is that employing a resident incurs a lot of overhead. Some of this is paying attendings for training and supervision. There's also a lot of other general overhead expense associated with having another clinician on staff. None of that overhead is directly billable to customers as a separate line item. So, who should pay?
That's why I say that step 1 is determine and bill the actual value of resident work. Lots of papers claim teaching hospitals actually make money on residents before medical education payments (and that doesnt even include the unbilled work I mentioned earlier [1])
If after a true accounting of the value, it still comes up negative due to overhead, then bill the customer! they are the ones that should be paying overhead anyways. There are 101 ways to recoup overhead, especially capital investment.
Your whole argument is just beating down criticism by taking the current broken incentives as if they're set in stone. Yes, we know the incentives of the current system are terrible. In fact that's exactly why the whole system needs to be overhauled with sweeping reforms, rather than waiting for it to get better on its own.
We dont even agree that residents drive up costs. I dont agree that is a given.
If we assume residents are a cost, the solution is still simple. you just attach the cost of training to the physicians salary. Then, whatever hospital they work at will have pay for the training.
Last, the residency program costs are tinny in comparison to overall physician costs. Back of the envelope math shows the 20 billion program is a few percent physician costs, which are themselves only a part of healthcare costs.
I said hospitals. You'd do your residency and then have a commitment to keep working at the hospital for say 3 years (or otherwise repaying the training).
> In game theory terms this is essentially a free rider problem
Yes, this is exactly what I mean by founded on negative sum interactions. Every player is focused on avoiding costs rather than providing value. In a sane market, when a business can't find employees they offer higher wages, overtime, train new employees, etc. That's positive sum that grows the industry, rather than just throwing their hands up and letting the shortages build.
> There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs
I guess if you squint really hard, just subjecting patients to even more unknown charges is some kind of attempt? I'm talking about things like making providers beholden to the basic legal norms of commerce that apply everywhere else. End this nonsense where providers won't answer questions about how much anything costs, but then shake you down after the fact with a volley of fraudulent bills - that foundation is already askew from how every other industry works.
Imagine going to the grocery store, and then receiving bills over the next year from the cashier, shelf stocker, distributor, etc, all claiming that you're also responsible for paying them. Healthy industries work by consolidating costs and making prices legible. The healthcare industry is stuck in a state of doing the exact opposite, but yet has managed to entrench itself with the entitlement of still getting paid.
If providers want to be able to bill patients directly then they need to do the work of forming actual contracts based on fixed price services, estimated work, hourly rates, etc (once again like every other industry). Or if you've got a healthcare plan and go to providers they point you to, the only entity you should ever be receiving bills from is the plan itself.
> Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing.
So just scrap the entire concept of individual agency? Are you a doctor or something?
And lest people jump on me for not just toeing the party line of "single payer" - as I said this is orthogonal to who may be ultimately paying. Furthermore, if we're going to be paying for a base level of care with public funds (which we're already doing for a large part), then we want to be spending that money wisely and not squandering it on a system sick with organizational cancer.
Is there something blocking them now?
Presumably you would still require qualified staff, safe and maintained equipment?
[1] https://www.openhealthpolicy.com/p/medical-residency-slots-c...
Because money is just a tool for allocating resources. And having well trained people with equipment ready to attend to every person in that situation requires a lot of resources.
I’m not justifying our systems inefficiency - let’s just be clear that medical care costs a lot of money.
So the challenging political question is how to manage access and costs (often devolves into rationing) and who should pay for it.
Just to expand upon what you're saying a bit; most people don't view things in such terms which I think is unfortunate. You often see discussions about waiting times in single payer healthcare systems and cost in more free-market systems. The fact of the matter is that if demand is greater than supply you must ration the supply somehow. Prices are one way but not the only way. Waiting lines, by need, randomly, etc... are all valid rationing mechanisms as well.
What I've noticed is that when people don't view this is a resource allocation problem they are able to always see the greener grass somewhere else. They see the lack of treatment of a person or group of persons as a failing of their system where those people would have received treatment in a different system that uses a different rationing mechanism. The issue is that in a different system there would still be people who don't receive treatment, they would just be different people.
By not viewing it as a resource allocation problem I think it gives the appearance that there is a perfect solution and that its just political will halting its implementation.
This is logic of post-2008 fail-capitalism instead of 1970’s and China’s aspirational, problem solving capitalism.
You don’t address shortages of healthcare, housing or food with an elegant and fair system to decide who starves and dies.
You expand supply to make sure no one has to. You examine supply chain and figure out the bottlenecks.
For example China has started mass producing MRI machines, that’s one way you adress a problem.
No, this is reality. It does not matter if you're working under capitalism, socialism, communism, mercantilism, or some as yet unknown system since economics is the “study of the allocation of scarce resources which have alternative uses.” You cannot deny resource scarcity anymore than you can deny natural selection or gravity. To do so leads to a lot of tragic consequences.
> You don’t address shortages of healthcare, housing or food with an elegant and fair system to decide who starves and dies.
Food is an excellent example to use. In order to guarantee that no one goes hungry, or is well fed, or whatever metric you want to use how much food should be produced? Please find a way for this seemingly simple solution to not devolve into rationing by some mechanism.
> You expand supply to make sure no one has to. You examine supply chain and figure out the bottlenecks.
By expanding supply of healthcare you are taking resources away from somewhere else. Everyone can become a doctor and the nation will have very cheap and plentiful healthcare. Of course no one will be building houses, repairing roads, generating electricity, making MRI machines, refining helium, building the equipment to do the above, or countless other economic activities required for society as we know it to exist. There are limited resources, people, and time. You can’t do everything all at once.
> For example China has started mass producing MRI machines, that’s one way you adress a problem.
How do you know how many MRI machines you need? How do you know if you have too many? What about doctors, nurses, gloves, defibrillators, etc… Prices are actually a mechanism that communicates where more resources need to be allocated and where less are needed. What you’re talking about sounds more like central planning or some subset of it.
This is totally wrong. It takes 5 years to get planning approval in UK, it takes 1 year in France. Tunnelling costs are 3x higher in Uk than in europe. Building a tram takes 3 times less. Lower Thames crossing has been in planning for 15 years and we have spent 300 million on lawyers, more than Norway has spent on building an actual tonnel of comparable size.
If UK has economy of France but infrastructure worse than Poland, maybe we are doing something dumb.
If USA has expensive insulin and poor Bulgaria has cheap insulin and it works just as well, maybe you are doing something dumb.
You can expand supply of housing in UK without damaging other sectors of economy: introduce statutory right to add an extra story on your op if your house. Remove green belt protections, introduce 1 month limit on review of any planning application, after which it is automatically granted if valid objection is not found.
Introduce a single planning portal and standardise software for planning applications across the whole country instead of every Shropshire and Wolverhampton having their own practices. Purchase perpetual license for such software as a country and make it freely available to every citizen.
Introduce favourable mortgages for self-building.
Produce detailed, pre-approved designs for standardised homes and bulk purchase materials or modular components for them.
Organise mass production of high-speed trams and make them available to local government with favourable, pre approved finance terms, so that larger areas of housing are accessible by high speed transport.
All of the above is implemented in different countries around the world, whether it’s France, China or someone else.
References:
https://www.britainremade.co.uk/building_transport_in_britai...
https://www.samdumitriu.com/p/britains-infrastructure-is-too...
The insulin example always drives me nuts. The type of insulin you get in Bulgaria is also cheap in the US. In the US, you can get a months supply of generic off patent insulin at Walmart for $40. You can also get extremely fancy insulins for $1000, and $10,000 insulin pumps.
It’s not a binary decision. Healthcare is a gradient of treatment options and outcomes. The concept you are missing is called economizing which includes substituting services, adjusting time preferences, sharing, expanding network of providers, etc.
> post-2008 fail-capitalism
You mean the one where government agencies were taking the risk of bad mortgages from sellers?
We don’t have anything close to a capitalist market in healthcare or finance.
> Although the period from 1837 to 1864 in the US is often referred to as the Free Banking Era, the term is a misnomer in terms of the definition of "free banking" above. Free Banking in the United States before the Civil War refers to various state banking systems based on what were called "free banking" laws at the time. These laws made it necessary for new entrants to secure charters, each of which was subject to a vote by the state legislature with obvious opportunities for corruption. These general banking laws also restricted banks' activities in important ways.
When my baby was born my wife and I stayed in the hospital for two nights during which we received constant checks and meals. I was ready to go because my baby was healthy and I knew it was expensive.
Is this level of service required medical care? I don’t think so. Many choose to have a medical professional at home to help with a delivery for a day or so.
If it is deemed required, how many nights should be offered? I’m sure people with a bad home environment would stay as long as they could. If we set a hard cap of a few days, that’s also bad because some babies need to be at the hospital and it’s very helpful to have that.
Alternatively imagine if the beds are occupied who don’t really need to be there and then a new baby needs to be born?
Everyone already pays for heavily for it, much more than necessary due to the grift.
These things are conceptually simple and much easier for a bureaucracy to handle than the current dumpster fire. It's actually only impossibly hard for us to solve because entrenched power and corruption mean few politicians are actually particularly interested in making the changes necessary to fix it, and those who are are excluded from the democratic process by gatekeepers.
At least you agree it’s a resource problem and we don’t have infinite healthcare.
The point about rich folks being price insensitive is demonstrably false. One key here is that rich and reckless exists, but is a much rarer breed than rich and careful.
> much easier for a bureaucracy to handle
Navigating bureaucracy favors elite groups even more strongly as it requires education in law, politics, and communication skills most lacked by disadvantaged groups.
The biggest problem is if your voice isn’t loud enough you literally have no alternative.
The insurance pleading nightmare is exactly this system. They are a rationing bureaucrat.
The US has unique demographic problems where the bottom quartile of health and well being demand most healthcare resources. So the sales pitch for European style healthcare sounds like “we are going to make everything slightly worse for responsible people and remove higher end options, so we can better cover super users”.
This is not a unique problem. The sickly and elderly always consume much more medical resources than the healthy.
> slightly worse for responsible people
You mean people with money.
And for all the problems the EU countries medical systems have, I've never heard a European say they'd prefer the American system.
The system can't be "just changed" because it's a very complex issue with a lot of entrenched interests. There has to be sufficient political will at the top levels of government that simply doesn't currently exist (in either the Democrats or Republicans).
I suspect because nobody can agree on what the new replacement system should look like.
Basically in all thirst world countries trend is negative unless and experience is frustrating unless you are rich with good private coverage. At least that's my experience.
Fifteen years with the "let's privatize everything!" party will do that, yes.
- the cost of top healthcare will keep going up as new technology is invented
- the amount of care you need keeps going up as the population ages
- GDP can't grow because of various political constraints (Brexit, planning permission, Green Belt, environmental rules, etc)
- Tax revenue can't rise much because it's already ~40% of GDP
- NHS can't grow as a percentage of the budget because of competing commitments (pension triple lock must, in the long run, grow as a percentage of GDP)
I'm sure Labour and Starmer want to fix the NHS, but it's like trying to play chess when you're already mated.
> I suspect because nobody can agree on what the new replacement system should look like.
There is no general “you” with agency. The few people who have the ability to change it have no incentive to do that.
> Multivariate analysis indicates that economic elites and organized groups representing business interests have substantial independent impacts on U.S. government policy, while average citizens and mass-based interest groups have little or no independent influence. The results provide substantial support for theories of Economic-Elite Domination and for theories of Biased Pluralism, but not for theories of Majoritarian Electoral Democracy or Majoritarian Pluralism.
1. https://www.cambridge.org/core/journals/perspectives-on-poli...
It is not. It has been very efficiently designed to strip as many people of their political voice as possible. Our major elections are literally engineered to give insane advantages to whichever party is currently in power
Half the country (or at least, half the voters, which is only like 2/3rd of the country because so many don't vote) believes in rugged individualism and a Just World.
They see single payer as their tax dollars going to paying for someone else's health problems that they caused themselves. In other words, they'll complain about their dollars paying for a smoker's lung cancer treatment or an overeater's diabetic treatment. They think everyone's health problems are their own and don't want to pay for it.
The fact that when they pay for health insurance but don't make claims means their money goes to other people is completely lost on them.
But one thing is clear: it's easy to improve the nutrients that people in the USA take.
Whenever I travel in to USA, in the airports I can't even find a simple salad or any real food, even though I can see lots of pictures of salads, which drives me crazy.
Last year I went through Atlanta airport, I bought a hamburger because they didn't have literally any other food at 10pm, and I thought I would just throw away the buns and eat the salad + maybe the meat (depending of the ingredients). Then I looked at the ingredients and it was like 50 things that I didn't even know what they mean. It didn't smell or taste like food at all, so at the end I found 1 year old nuts in my bag that my mom packed a year earlier, and I ate that.
I'm from Hungary, a country with 4x smaller average salary, and you can be sure that nowhere would the thing that they sold me without shame in the airport would be considered food, do it's clearly not a money problem.
I believe RFK Junior understands how seriously USA food culture is behind compare to the available money and hope he does something about it.
Americans really value choice and access, so they resist anything that hints at “rationing.” As a result, costs keep climbing, and there’s an insane amount of money tied up in administrative overhead.
For anyone looking for a nuanced perspective on this, I highly recommend Peter Attia's interview with Saum Sutaria (McKinsey's formed healthcare lead).
If that doesn't resonate, it's the same as schooling: you can have good and cheap public schools accessible to everyone, and private schools that will cost 5~20x more but provide a significantly different education.
The taste I got of it (introduction bit)
https://youtu.be/QqrpFICtqpQ?si=iqrhOc6lvELGuzvV
A definition of insurance that doesn't seem to understand how randomness can be upon the group instead of the individual. A person in his situation can't be so grossly misunderstanding pooling risk over a population.
I've skipped here and there among the multiple videos to get a better feeling of the whole interview, but to be blunt that perfectly fit into the stereotype of a guy coming from McKinsey.
The idea that American's get better and more immediate healthcare is only true for people with money.
Physicians are largely why the US doesn't have single payer.
They've been funding a massive influence campaign against government health insurance and most cost containment efforts for nearly a century under the guise of "protecting patients" (in reality protecting their pocketbooks).
https://citationsneeded.medium.com/episode-134-the-80-year-p...
A big efficency for NZ is 'pharmac', which is essentially a country-wide medicine subsidizer, and supplier. It's a government entity which figures out how much of a certain drug the entire country will need for say a month, then goes and buys it, in bulk on the international market. Making such a large purchase gives them really good bargining power, and they'll buy generic versions. Not all drugs are pharmac covered, but most are. It means there's not much profit margin for drug supply in the system.
The system is setup into 'district health boards'. Their job is to manage the health of everyone in a geographic area, and this means both in hospitals, and in primary care (your local doctors office). Because of this, they see the cost of their entire system, and are incentivised to optimise the care overall, as opposed to say a private hospital, and a private doctors office optimising their individual businesses.
One way this manifests, is putting a big focus on getting people to go to primary care, instead of hospitals. Hospitals are the most expensive thing in the system turns out, so they'd much perfer people get to a primary care doctor sooner, before something becomes an issue that requires hospitalization. So they're incentivised to keep doctors visits cheap, and accessible. This comes into play quite a lot with elderly care, they make up a huge amount of primary care visits - but if they don't become hospital visits, that's great.
You mentioned drug use. That's an interesting one as that's a government-wide issue, not just a healthcare issue. It affects poverty, education, emergency housing, the economy as a whole. There's been a big focus on public education, and actually ad campaigns about tabacco and alcahol, trying to make them seem really un-cool. And it's sort of been working, smoking rates are down, I'm not sure about vaping rates though. Meth is a big issue in NZ, but opiate/painkiller abuse is uncommon (compared to the US).
One general point though, is there's not much profit oppertunity for companies in the system. As the majority of money comes from the government, the funding is very standardized. Running a doctors clinic or say a pharmacy is just like running a small business, with the same oppertunities. There just isn't huge 'startup' oppertunities to find a killer product and turn a huge profit. Profit isn't taken at every point of the supply chain in care.
NZ's system has flaws, but overall I'm really pleased with it, and glad that we have it.
In the US, Medicare is doing negotiation for meds for those in the program. There is talk about expanding that bargaining.
The ACA was trying to get people into primary care early. I'm not sure how big of an impact that made. At least in my experience, the primary care is hard to get on short notice in my area - takes 1-4 weeks depending on different things. One big seems to be that the offices Tru to increase throughput and keep their schedule booked solid to make money based on what the insurance will pay per visit (eg maximize visits). I wonder how NZ deals with the availability part if prices are set. I would think the incentive would be similar.
The way it works is patients 'enroll' with a doctors office, and then the clinic gets funding based on that patient population (how many patients, what sort of patients, etc). GPs still set their own fees ontop of that, but it's usually not much (like $20 USD), as they're competitive.
There isn't really an incentive to maximize the number of visits, the goal is to maintain a good patient population, who's satisfied with your services.
The average book size for an individual doctor is about 1000 people (might have gone up a bit by now). But I found that number quite interesting, as it lets you frame the job of a doctor quite differently - their job isn't just to take appointments as they come, their job is to keep about 1k people healthy. It lets you think about how else that problem could be solved.
Bribery is legal.
> The implicit question is – if everyone hates the current system, who perpetuates it? And Ginsberg answers: “Moloch”. It’s powerful not because it’s correct – nobody literally thinks an ancient Carthaginian demon causes everything – but because thinking of the system as an agent throws into relief the degree to which the system isn’t an agent.
Now, weird thing is this doesn't work for the military somehow.
There’s an awful lot of small-government posturing that goes on, but it is not accurate to say our system is the result of a small government approach.
To provide just one concrete example: in the 80s, we had problems with hospitals “dumping” indigent patients. In some cases, they would literally take homeless people who showed up needing medical attention to some random part of town and drop them off on the side of the road.
Naturally, there was public outrage about this. Demands that it stop.
There are, of course, many ways a society could address this problem: a single payer system, a nationwide indigent care fund, etc.
Here’s what we did: as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, the federal government stipulated that any hospital which accepts Medicare/Medicaid[0] and which operates an emergency department must provide “stabilizing care” to anyone who shows up at that emergency department with an "Emergency Medical Condition" before inquiring about the patient’s ability to pay[1].
This law did not stipulate that those hospitals, or the doctors who practice at those hospitals, be reimbursed in any way for providing that stabilizing care, just that they provide it.
Naturally, doctors and hospitals consider this an example of a heavy handed government engaging in cost-shifting. CMS countered with a paper written by one of their economists that what they do here is not technically “cost-shifting” for reasons.
Hospitals now employ staff to get uninsured patients who qualify for Medicaid signed up so they’ll get paid.
(I haven’t seen stats on this in several years, but the last numbers I saw were that around half of US hospitals lose money on an operating basis. They make up the balance in the gift shop, cafeteria, endowment if they are lucky enough to have one, local taxes, or bankruptcy court.)
0 - that’s basically “all hospitals”
1 - the actual rules are more complex, but that’s the gist of it
Haven’t run the numbers but I would suspect the US government is the largest government in human history.
https://worldpopulationreview.com/country-rankings/public-se...
(Wikipedia has a similar page, but not as navigable imo)
I scroll through a lot of European countries before getting to the US at 13.4%.
I think the healthcare (and other) systems suck because they are complex. There are two ways to hid information: lock it up (lack of transparency) OR dilute it amongst noise. The latter is what complex systems of whatever do. Complex systems create opportunity for those with enough resources to locate and exploit eddies of wealth in the system. While those without the time and resources to spend understanding the complex system just decry it because it is too difficult to understand.
I think it's ironically reductive to simplify a complex problem to a general problem of complexity.
I'm not sure what your point is, we appear to agree that the system is corrupted and that there is regulatory capture. My point is that the US government shouldn't be used as an example of a small government in general and for healthcare specifically. Even if I was to agree that the US should adopt an European healthcare system I don't see how to uncorrupt the existing system to enable that to happen. This notion that a government takeover will take the money out of the system and diminish opportunity for greed is fanciful.
My original comment was about the neo-conservative ideology, which was either directly in power or heavily influencal in governmental policy in US since Reagan. It's, like anything ideological, mostly symbolic. I think the whole healtchare debate is just one of the symbolic points of this ideology. Ideologies change, and I certainly hope this for US and rest of the world that it changes.
Those agents really just being normal self selecting biology like everywhere else.
Functional illiteracy where people can only understand life through a job and paying bills is a carefully crafted propaganda. America been at the forefront of converting wartime propaganda research into advertising and marketing. A big government military industrial complex is the backbone of the economy. We just look away because wtf else we gonna do?
Against these odds, our current healthcare system is very unpopular [0], and if you put it to a vote, we would probably get a more sane healthcare system, but again, realistically, it's not up to us, unless, over the course of ~6 years we constantly show up to both primary and general elections and vote for representatives who support it, and leave the corporate backed candidates in the dust.
0 - https://news.gallup.com/poll/4708/healthcare-system.aspx
Americans don't want universal healthcare because then "bad" (read: not-white) people will have it. That's it. Giving something to the benefit of everyone is untenable evil because it's "communism". If you weren't lucky enough to be born into a social class that already has socioeconomic benefits, you simply don't ever deserve to have those things.
This country has spent the last half century pillaging the commons and masterfully convincing just enough of the population that it's a good thing, actually.
Why don't we just change things? Because we no longer own the government. Several billionaires own the government. Democratic change is next to impossible because the game has been rigged so well for so long and nobody with any power has any interest in fixing it. The US government no longer exists to serve the needs of the people, it exists solely to funnel the maximum possible amount of money from the working class to the ultra elite
The best way I can describe our healthcare is that it's freakishly complicated, so complicated that pretty much every argument made by any side at any given time is both correct and incorrect.
For your example about single payer, with that scheme costs will likely be much lower but on the flip side, we also would not get immediate access to care (that is you can't attend a doctors appt within 72 hrs of scheduling) and we also would not get access to the latest and greatest drugs and therapies because those are always expensive and SP schemes typically do not cover that.
Now with that said is single payer good or bad? Well it all depends on who you ask. If you ask a 20 something that just visits the doctor once a year for a checkup and maybe calls into urgent care once every few years when the get the flu or food poisoning, that person will be all over the moon about a single payer system.
Now contrast that with someone in their 50's or 60's that has pre-existing conditions, sometimes chronic conditions, and needs constant care and access to the latest drugs. Well for that person single payer is dogshit and won't cover half their needs.
And that is the essence of the problem, two sides with vastly different needs from the healthcare system and a government that has to make one decision that will somehow satisfy both parties, even though that could really never happen. You're either going to pick the 20 year old and screw over grandma or you're gonna pick the grandma and screw the 20 year old.
I am curious, why is this accepted as a "given" of single payer health care? I know it's a a problem in Canada and Britain, but those systems seem to be victims of something between neglect and outright political sabotage.
As a side note, my partner is currently about half way through a two month wait to see her GP in the good old US of A (on United Health Care). I would love to only have to wait a few days.
And HN itself is full of people doing way better financially than the average American with better insurance than the majority of people, so even here many people will have a much better impression of and access to the US healthcare system than the average person in the US actually does.
Also "grandma" is on Medicare, if not completely then as the primary payer (supplement) or at least benefiting from the negotiating/regulations (medicare advantage).
(and just for perspective here, I'm actually not a big proponent of single payer as the main reform. the problem is that discussing any type of reform has been absolutely paralyzed by nonsense talking points to entrench the status quo)
If you're so concerned about not getting the latest and greatest treatment, in the UK private and public health care have started to work progressively more hand in hand. My family are all covered by my private insurance through work. We get consultations online through an app, and they refer us to either and NHS surgery or a private one, depending on which is fastest and has the best health outcomes. That's a privilege not everyone has, but everyone gets the next best thing which is free universal health care covered by all tax payers - corporate and individual.
This "decision" that you seems to think exists isn't one. We get the best of both worlds - a society where the poor don't fight tooth and nail for health care with the risk of becoming forever indebted and subjected to poverty, and the rich get whatever level of service they're willing to pay for.
Personally, I think you're all fed a lot of propoganda by folks that make a lot of money out of the misery of your healthcare system.
Not true today in the US. It took me ~7 days to get an MRI of my hip. And have you tried getting into see an endocrinologist lately?
Apparently the average in her province is about 14 months, about sixty times longer than you experienced.
We seem to have the worst of all options. Not a free/open market. Not a socialized or single payer.
Instead it’s all rent seeking, regulatory capture, and the rich getting richer.
Whereas the disjointed system the US currently "enjoys" STILL has GP rationing -- and worse, whole specialties disappearing or otherwise rejecting a payor because it sucks.
It's bogus that "single payor won't cover people in 60s/70s with chronic needs." That is 100% a policy decision. Versus the entrenched broken system we have now, where often needs are covered despite urgency.
This is a story of the fraud in the health insurance industry, not the racket part of the industry.
Oftentimes by a doctor who cannot or doesn't practice in "the real world" (some physicians employed by insurers go straight to working from them after becoming licensed). Or a nurse (technically with "oversight" by a doctor who might "supervise" the decisions of dozens of nurses or more).
And now these companies if not using AI directly, will present these providers "notes" along with the claim for review with an AI summary, replete with hallucinations, as bullet points "guiding" them towards the "correct" decision.
The primary difference is that the US system puts the patient in-between the doctor and payer.
Alternative systems usually sort this out by simply denying or allowing the treatment without the patient in the loop
This -somehow the insurance industry does whatever it wants. If I get paid but refuse to provide service, multiple times, I will be a wanted man.
Psychiatric issues, which this Propublica article is about, are already being over-treated even though it may be under-treated in other aspects. Focusing only on these cases of denial may cause under-treatment to go down, but at a cost of much higher over-treatment, which comes out of everyones premiums. I don't think anything wrong with SSRIs or stimulants being used as medication, but clearly something wrong with the way we're prescribing them when despite being the largest consumers of them, Americans suffer more poor mental health outcomes.
https://en.wikipedia.org/wiki/Receiver_operating_characteris...
This is not precisely accurate. The medical loss ratio (80% for individual plans) can also be spent on quality improvement. There is a blurry line between administrative costs and QI initiatives. For example, a plan-provided coordinator could be QI rather than administrative.
This.
You see it anytime you mandate some profit cap or limit as a percentage of revenue. Companies will just manipulate the other variable to get more profits. Or they'll buy other related companies so they can do sneaky internal pricing shenanigans.
Competition focuses on trying to expand the market, rather than screwing a competitor and stealing all their clients.
Just like a person performing better in a job interview isn’t stealing from other applicants who performed worse.
I'm confused. If that's the case, then why would they deny coverage? Wouldn't that be an easy way to overpay?
Heck, they could simply allow everything through and use rising costs as a justification to increase premiums.
This nefarious scheme of course requires insurers to have no competition. After all, if your competitors don't overpay, then they can lower rates and steal your customers.
The truth of the matter is that hospitals and doctors try to maximize their profits through excessive billing and care little about cost efficiency. They don't try this at the same rate with medicare/medicaid both because the government does not generally negotiate - reimbursement schedules are largely fixed and because defrauding the government is a criminal rather than civil offense.
There are some easy fixes here and there. We could, for instance, ban price discrimination by healthcare providers. Every payer would then pay the lowest accepted rate - which is usually medicaid or medicare's. This won't prevent billing for medically unnecessary or inefficient services, but it would eliminate the negotiation problem.
The problem is political. If you save a trillion dollars a year in healthcare costs, the GDP gets lowered by roughly the same amount. Healthcare providers would, of course, fight to prevent any reduction in reimbursements from happening - which they've been extremely effective at historically.
I think we want the opposite when it comes to negotiations and want instance companies to all have to pay out the cash price. The first step to making it possible to not need insurance for most care is making everyone pay the same.
But nonetheless health insurance being affordable only because insurance companies can simply choose to not provide service to their customers and if people stopped forgoing necessary medical care there would be shortages aren't I think the points you think your making.
Doctors and patients have no incentive to control cost and select cheaper and inferior treatments.
They could pay their CEO less.
They could not engage in needless advertising.
They could refrain from paying dividends to shareholders.
The list goes on...
Every health systems has and needs some mechanism to deny potentially lifesaving treatment.
My point is that even when you abolish private insurance, you still have someone in the hot seat saying who dies because that care is too expensive.
[1] https://slatestarcodex.com/2017/02/09/considerations-on-cost...?
The ACA (with this new 80/20 provision) passed in 2010.
Costs have been on a steady upward march (yes, adjusted for inflation) since the 1970s. https://www.healthsystemtracker.org/chart-collection/u-s-spe...
The "Average annual growth rate of GDP per capita and total national health spending per capita, 1970-2023" chart even shows the 2020s as the first decade with lower increases in healthcare spending than corresponding GDP growth.
This theory seems... unlikely as a result. (Cost disease itself is certainly an issue; I merely very much doubt its attribution to this particular provision. Obama didn't have a time machine.)
A most efficient insurance program would be a closed loop.
Any leftover money not spent on care would be used to reduce premiums the following year and/or be saved for higher claim years.
I wonder how that could exist in the US? Perhaps these health sharing ministries are as close as we'll get: https://www.medishare.com/
However, I don't think the problem is truly fixable without Medicare for all or similar single payer scheme. There is just a huge gap in not just bargaining power but just knowledge of the market information between the seller (hospitals and health care providers) and the buyers (sick people) that a free market solution can't even work in theory. Even if you ignore the fact that I can't exactly shop around when I have an emergency any more than I can shop around when my house is on fire. The only viable solution is single payer and the sooner we get there, the better for everyone.
https://www.nbcnews.com/health/health-care/health-care-cost-...
Commercial insurers are already required to rebate premiums if their medical loss ratio is below the limit.
https://www.cms.gov/marketplace/private-health-insurance/med...
I understand regulation plays a good role in that, but I can’t believe that it is the only reason..
Huge feature lists, high standards for correctness, strict regulations, existing long-term contracts.
It's like the space industry before SpaceX. Everyone knows the incumbent is inefficient, but you can't compete without building the whole damn rocket.
I think a substantial part comes from low risk tolerance and opting for high quality low volume care
Providers are not the problem here.
They aren't. Since their profits are capped at 20%, reducing costs means reducing profit as well, so they are actually incentivised to keep costs high.
> their claims process is so arduous that providers demand higher rates to deal with the high rate of denials and ever changing minutiae.
I think this is also the case
much higher profit margins
Even better, insurance companies can wag their fingers at the doctors and all of Ayn's acolytes will chime in about how for-profit care is here to save humanity from the evils of doctors. All the while the for-profit insurance companies are laughing to the bank because they're disincentivized from negotiating more reasonable prices. There's a reason Medicare pays conversion factors that are about a third to a half of what for-profit insurance companies are willing to pay.
Even better, insurance companies have a captive audience. While the federal mandate to redirect your money to for-profit insurance was struck down, five states (and DC) have their own individual mandates.
Why would they turn productivity improvements into lower costs, when they could instead turn them into higher profits? Big health insurers such as UHC practice "intercompany eliminations", as it's known; they own those providers you mention and use increasing charges there to get around the limits on how much of the insurance premiums they can keep for themselves. It's in their interests for the charges to go up, especially on anything that's actually cheap. Productivity improvements is just more profit to launder through the providers they own for the purpose of laundering those premiums.
> In interviews with ProPublica, federal judges criticized a system that fails to address problems that arise in court case after court case. They faulted the Employee Retirement Income Security Act, which governs many insurance claims in court, for not allowing for punitive damages, the sort that can rise into the millions of dollars and deter companies from bad conduct.
> To one federal judge, who like others spoke about cases on condition of anonymity, doctors and the insurance companies they work for essentially get off scot-free. “They might have to pay 10 claims,” the judge said, “but if they can avoid paying a thousand claims, then why would they change anything?”
Only thing I have seen work: full sending 3 bullets into a healthcare industry CEO. The subsequent public indifference was quite eye opening. Didn’t matter if you identified as Liberal, Democrat, Progressive, Conservative, Republican - it was a unified response across the nation. Conservative talking heads getting ripped apart by own audience for being “out of touch.” Democratic leaders (Tim Walz for example) getting ripped a new one for fake sympathy.
We are well beyond “policy changes”, especially as we go into this next administration.
RICO charges need to hit, and stick.
> Having the weight of an MD behind a decision can be powerful, but lawyers and judges who’ve handled these sorts of cases say it can be misleading. Although doctors ultimately determine whether to cut off insurance coverage for a particular treatment, those decisions are generally not considered the practice of medicine and therefore cannot be challenged in a malpractice lawsuit. The doctors advising insurance companies can’t be individually sued on medical grounds, even if something goes wrong after the denial. As a result, their names are cited in lawsuits filed against the insurers, but they are not defendants in suits brought by people denied insurance.
Odd indeed. Is it some semantic thing? Denying care is the purest form of not practicing medicine?
For example when I had an injury I had to do 6 weeks of physical therapy (without improvement) before they would authorize an MRI scan and then surgery.
The legal system could just as easily have seen that the determination of which procedures are "medically necessary" is indeed part of medicine itself. It's a miracle of delusion and corruption that it went the other way.
But that doesn't mean applying the same "malpractice" framework to the people deciding what's covered under the program is necessarily the right approach either.
We're going to apply that to some insurance job function operating outside standard medical practice how exactly?
Sure, but being paid by someone to make the final call if the patient should or should not receive their treatment team’s desired procedures should.
A doctor at an insurance company isn't deciding the "final call" on anything. The patient can pay for it without insurance, insurance company management could say "ignore the doctor and pay for it", the patient's medical team could say "You can't afford the procedure and insurance won't pay for it, that's okay we'll do it for free!"
It's not that I'm arguing against some way of holding insurance companies accountable, I just don't think what doctors are doing there is practicing medicine.
I don't think I can accept that people knowing or almost certainly knowing the outcome of their actions and taking those actions regardless should not responsible for the outcome under our legal system.
It's like taking legal advice from me: I'm not your lawyer (or even a lawyer) and I'm probably wrong. But it was your decision to take it.
Well done, Propublica. Keep it coming!
Doctor.
Do health insurance companies have to follow similar requirements? If so, individual cases of insurances denying insurance would be bad, but would indicate that the overall system is still working reasonably well.
Unfortunately unintended consequences have resulted in that meaning it benefits health insurance companies to increase the cost of care so their 20% share is more.
No one is looking at absolute raw numbers, investors/owners usually only own small slices, so they care about what percentage return they get.
Why can't the insurers have an app where the patient (or the provider) can type in the procedure codes they are planning to use and then the insurer returns the co-pay, co-insurance and other cost based on the plan the person is in? The insurer must have these systems already internally so why not mandate to give access to the calculations to patient? I had several occasions where I tried to figure out how much something would cost and the answer was "we can only tell you after the procedure was done".
This seems to be totally doable to me.
https://youtube.com/playlist?list=PLpMVXO0TkGpdvjujyXuvMBNy6...
Yet I had multiple doctors tell me and did things to me other doctors told me should be considered medical malpractice.
When I went to try to sue I found there's literally one judge who could deal with it but they refuse to even try to deal with my case in the court system.
Then the doctors try to shame me for dealing with my issues without taking the meds which the Doctors themselves told me would make my situation worse.
Instead I get a ride through Charlie's Chocolate factory showing me how America works.
...ok? Is ProPublica seriously trying to assert that they should be barred after a single decision ("one or more" includes "one") has been criticized ("criticized or overturned" includes "criticized but upheld")?