Hacker News Reader

Comment by rqtwteye | Hacker News Reader

What i don’t get is that the US system is not only super expensive but also totally clunky. As patient you need to track who is in an out of network, nobody can tell you how much something will cost, provider directories by the insurance are often wrong, hospitals constantly make mistakes, insurance denies valid claims, insurance gives you wrong info, ambulance may 5000 or 0, nobody knows, cash prices may be cheaper than going through insurance . It almost feels like as patient you need to program the system in assembly where you need to know every little detail of the system without any documentation. Nothing makes sense but everything costs a lot of money.

At a minimum there should be regulation (I know it’s a bad word now) to make the system easy to use without costly traps.

View on HN

What's not to get? This is what privatization does. It's not for proper care of patients, it's for money to flow upwards to a single individual.

Logically and financially, a single payer system makes way more sense. No marketing costs, no CEO costs, no costs for the entire medical billing industry, no costs for excessive paperwork.

Just care.

When my mom was in hospice last year for a month before she passed, Medicare covered that 100%. It was amazing, it's like, didn't have to worry about being bankrupt after she passed. No paperwork for us to deal with, no surprise bills, etc. just care.

Imagine the world...

To be fair, there are much better models for privatization (eg. Israel has 4 competing HMOs and the poor are given subsidies by the state).

There are many problems with the US healthcare system, not the least of which is the fact that we have something like 18 different ones.

> This is what privatization does.

Yes, this is the same reason it takes 7 weeks and two referrals to have my car serviced, or my floors cleaned. Private industry is terrible at these things.

Exactly, this is clearly not a problem of privatization. In The Netherlands for example the system is privatized but highly regulated and there's no such issues. And like you said there's infinite industries without interference from the state where you clearly know prices and can decide what you want and no shenanigans. The US just fucked up the system somehow but privatization isn't the problem.

I am sure there is a cost savings if insurers were just required to pay. I have to imagine, they put a lot of effort auditing if medical service was in-network/covered by the plan. And more effort in fighting the people over claims. This isn't to say there is not genuine fraud or abuse going on by hospitals/doctors, but you often hear of people just trying to get their treatments covered.

> This is what privatization does.

This is what regulatory capture does. It may be so-called "private" but the government still wants to regulate it up the wazoo, in all the wrong ways. This prevents new businesses from making things better.

> a single payer system makes way more sense.

If the single payer is the very same government then it becomes incentivized to bring the regulation in line to something more sensible. Of course, if the single payer is a separate entity that won't necessarily happen. For example: Amish communities in the US often administer a single payer system, but they haven't been able to fix the situation.

Unless you can identify that the regulatory capture happened as a result of the government's actions as opposed to the business actions, I don't really see how regulatory capture caused this situation. Rather, we made a choice to cripple the affordable care act while keeping all of the provisions that limit the rights of individuals to shop for health insurance, and then we're surprised when the prices spin out of control while the care gets worse.

I don't think regulatory capture is an argument for getting the government out of this business, I think it's an argument for getting the business out of this business.

Thats what regulatory capture does. The enforcement of everyone must buy your product, and you are not allowed to directly shop for who provides your insurance. Insurance is one of the least free markets in the US. Insurance companies are the ones that cry "if only this was more regulated"

"What's not to get? This is what privatization does. It's not for proper care of patients, it's for money to flow upwards to a single individual."

I get that they are maximizing profits. But why does the process have to be so clunky and complex? When I fly somewhere, I buy a ticket with the expectation of getting to my destination without much fuzz. My bags also usually get there without problem.

Translating the health care experience to flying, nobody could tell me how much the flight costs. After the flight I would get invoices from various baggage handlers which the airline would pay for or maybe not based on unknowable criteria. The copilot may be out of network so I would have to pay extra. The pilot may demand upfront payment. And so on.

My point is: Why can't this super expensive system not at least be a smooth experience? Like, you go to a doctor, they enter some data into a website and tell you how much it will cost. This shouldn't be hard to do.

I don't get it as well, though I think the situation is classical regulatory capture. In other words, the wrong regulation.

I like the style the Czech/German system is doing healthcare. It is public but kinda private. You pay to the government, but you decide where to go so the hospitals/doctors compete for your money. It is very different than the centrally planned Danish or English based where there's basically some person in top that decides everything.

It has NOTHING to do with regulatory capture.

The US is polarized with the republicans not wanting any socialized health care because they don't want to care for people not like them. You can't organize and correctly run a health care systems when half you politicians actively sabotage and burn it down.

> not wanting any socialized health care because they don't want to care for people not like them because they don't want to care for people not like them.

Categorically, older individuals tend to vote more conservative and more republican. This doesn't make sense to me at all.

What makes more sense is that they argue against the socialization of any industry that funds their campaigns.

Democrats seem to take a more middle ground. ie Obamacare socialized low cost solutions and pushed costs uphill toward people who need more expensive care.

Do you really think politicians are motivated by "not wanting to care for people not like them"

That's such an insane assumption to make.

Do you live in the US? There were supporters of a certain party complaining that the president wasn't hurting the right people fast enough..

That is your perception, I'd bet if you asked those people they would disagree with your synopsis

And also where the industry that's supposed to be regulated is reverse-dominating the regulatory agencies. Maybe par for the course in other industries too, but they have powerful lobbying groups like American Hospital Association.

I am Czech. I do not have dentist or GP, they are overloaded, none are taking new patients! I have to pay private treatments out of my own pocket! Alternative is to spend like 30 hours calling and calling, and then wait 3 months for an appointment at dentist!

I am forced to pay about 500 euro on mandatory public health insurance (tax) every month!

The same is true in my city in the US, though. My dermatologist schedules 6+ months out for new patients; cardiac/neuro is 3-9 months depending on the urgency. Most of the primary care practitioners in the area are full up; I see regular posts on the local subreddit looking for anyone, anyone taking someone.

> As patient you need to track who is in an out of network

It's not even which facility, but which staff member! My mother had a pair of surgeries at the same facility, but the first anesthesiologist was in network and the second one was out of network. Both worked for the same place, but the second one was a contracted employee and so they bill differently then the direct hired ones.

It was a major mess and ended up costing us an extra 10k or so.

I am currently fighting a 4k bill. For some super glue and gauze and 'oh it shouldn't be more than 150 that you are paying today'.

They literally just charged me the max they possibly could to my insurance. The insurance just said 'oh well' and paid part of it. Now I am in collections over 1/3rd of the amount I can easily pay.

The provider will not even tell me what procedures got it up to 4k. How the hell did that pass the insurance sniff test.

These jackasses are just sending out bills and hoping someone will pay it. Your credit screwed over. Oh well. They already got paid.

My mother ended up with a collapsed lung. The doctor caused. Then they charged her for it. My mom had a nurse hand my mom her own purse and my mom fished out a bottle Tylenol. 400 bucks.

No one knows what is going on or how things are being charged. At this point it is obviously on poupous. This is not health care. It is racket designed to steal money from people who are sick.

Seriously. If it wasn't for Kaiser making this somewhat sane (even though maybe their care isn't as good as "the best" specialists), I would probably be a nervous wreck, trying to juggle stuff for my family..

Not helpful to you now, of course, but this billing practice is now illegal:

https://www.cms.gov/nosurprises/ending-surprise-medical-bill...

(Signed by Trump during the 2020 lame duck!)

> As patient you need to track who is in an out of network

It's worse than that, there are also "tiers" within a network, even for different physicians under the same health group. We were actually debating moving our kids to a different doc (but in the same office!) because of this.

The whole system is madness.

Never experienced what you describe. My pediatric practice is the largest in the state and has like 10 doctors and 10 NPs. We can see whoever we want.

Maybe the health care conglomerates in my city are decent but I’ve never ever tried to book any appointment and been told they are out of network. Never had a hospital experience where some random doctor was out of network but everyone else is.

There's been regulatory action on this in the last few years, but the really insidious scenario here was in-network facilities employing out-of-network staff in ERs and ORs, where several different providers are involved.

https://www.nytimes.com/2022/06/30/well/live/surprise-medica...

> These bills arise because even if you visit an in-network provider, you can still be treated by an out-of-network physician who works there, said Karen Pollitz, the co-director of the Kaiser Family Foundation’s Program on Patient and Consumer Protections. “The doctors who work in hospitals generally don’t work for the hospitals,” she said. “They bill independently, and they can decide which networks they participate in.”

Things like a major operation where the hospital, surgeon, nurses etc. were in-network, but the anesthesiologist - who you may never have even encountered while conscious - was not.

https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-sur...

> In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Mr. Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill.

> Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.

> “The idea of having an assistant in the O.R. has become an opportunity to make up for surgical fees that have been slashed,” said Dr. Abeel A. Mangi, a professor of cardiac surgery at Yale, who said the practice had become commonplace. “There’s now a whole cadre of people out there who do not have meaningful appointments as attending surgeons, so they do assistant work.” In Mr. Drier’s case, each surgeon billed for each step of the procedure. Dr. Tindel billed $74,000 for removing two disks and an additional $50,000 for placing the hardware that stabilized Mr. Drier’s spine. Dr. Mu billed $67,000 and $50,000 for those tasks. If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon’s fee. With current Medicare rates, that would have been about $800, less than 1 percent of what Dr. Mu was paid.

The US system combines everything bad about bureaucratic socialized medicine with everything bad about private health care.

Data/information asymmetry is a feature.

The side of the transaction who has better visibility+analysis, the more likely they are to win on the transactions.

Where you’re going wrong is thinking that it’s intended to work for patients at all.

If you look at it as a pump that’s intended to provide the worst possible care with the most friction it can tolerate and at the highest parasitic cost I’m certain you’ll find it makes perfect sense.

Part of the issue is that regulation in this space is extremely difficult, as UHC is a for-profit corporation and thus is incentivized inherently against the societal goal of providing healthcare. Even if there is regulation to force UHC to spend 90-95% of the money given to it on healthcare, this incentivizes UHC to make healthcare expensive so the 5-10% portion it can keep can also grow. Not to say that governments shouldn't still try to make it more fair, but to say that UHC has a duty to its shareholders to find as many loopholes as possible to refuse to pay out healthcare.

Does it make a little more sense when you remember that "health care" and "health insurance" are industry segment names in the US, not literally descriptions for what those segments are centered on? Both of them are for-profit industries that focus on converting maladies, and the absence of maladies, into money, respectively. That's their prime focus. And you can be cynical about that and go "So, what, it's in their interest to get people sick and then keep them sick? That's insane!"

And yes.

Yes it is.

The US system is 99% for its own benefit, especially $profit. Patient experience is not a meaningful metric.

Costing money is the point. Confusion is the point. It’s built to extract as much money as possible.

Insurance companies are parasites. They extract $200 billion from the system in order to tell you that you can't get treatment. It's supposed to function as a risk pool and instead it functions as a tax--which is utterly dystopian, because it's a tax that goes to a private system that you can't even find a way to opt into if you have the wrong employer. It's so messed up.

“As patient you need to track who is in an out of networK”

I just specify my insurance provider/plan in zocdoc and generates a list of doctors who are in network and their calendar of availability. I think this was a bigger hassle 10 years ago, yes.

Oh, a sweet summer child.

That's only for the initial GP visits and maybe for simple tests. Once you get into specialized treatment, it's a whole another world.

For example, if you are admitted to an in-network hospital, an infectious disease specialist can be out-of-network, and you will have to pay for them.

I am currently fighting a bill for a yearly physical, which should be covered 100%, because my doctor is in network and covered, but "the facility" (aka his office) is billed as a separate entity. Insanity.

Did you receive your physical at a hospital?

Our government largely works for the billionaires who make money off this system. This is a problem. Keep this in the back of your mind until the next primary election you can vote in & tell your current representatives that you want a healthcare system that works for you.

This! Agreed! I wish more people understood this reality before they shout, “but you have to wait in Canada and the UK… socialism evil”, “higher taxes”, and “no other country has the same freedoms America has”.

A way to understand it is to look at it at a higher level. Republicans, in modern US terms, want to privatize or remove any spending where the government gives things away to people for "free." And sorry to be pedantic, but free's in quotes because what the government gives away for free is of course funded with taxpayer dollars or government-issued debt, both of which almost all Republicans have traditionally been vehemently against (yes, I'm ready for comments about how Republicans don't care about debt as long as it funds their priorities; you're right of course but it's not all Republicans saying that).

The belief, and this is very apparent at the moment with all the stories about DOGE and the Trump admin, is that the government wastes money and the private sector can do it better. In cases where there's no return on investment to be had, Republicans would want that "free," government-provided service/product to be cut entirely (again, see recent DOGE actions). Btw, when I say ROI, in the eyes of Republicans, the more nebulous the ROI the more likely they are to say "kill it" because this really is about dollars and cents (with some culture war issues thrown in, but that's a very small part of the larger dollars and cents issue that almost all Republicans care about).

And to put a finer point on it, the Republican Party believes a significant percentage of the US population doesn't work hard enough (or at all) and that therefore those people don't deserve to get anything for free (i.e., I don't want to pay taxes or have the government issue debt for the sake of people who haven't earned it). That's why you'll have a hard time arguing that very wealthy people shouldn't take advantage of the government because in the eyes of Republicans those people have, literally, earned whatever they get, including "free" things from the government (this mostly takes the form of pro-business regulations/subsidies).

More specific to single-payer health care, if the US offered it, Republicans believe it would take away an incentive for people to work because for working-age people that's how you traditionally get health insurance. To repeat from above, no work = nothing free. That is a feature of the system in the eyes of Republicans, not a bug.

For those wanting to understand more, ask ChatGPT/Google/etc. for Republican proposals for how to manage Social Security, Health Care in general, Medicare specifically (see "Medicare Advantage"), Medicaid, food stamps, Social Security Disability, etc.). If you really want to understand it fully read it straight from the Republicans' own websites. Visit the Heritage Foundation, or Americans for Tax Reform). Every one of these topics is discussed in detail. Particularly relevant at the moment given this administration is doing much more to make all of this a reality. Prior Republican admins did some of it as well, of course, but not as aggressively as this one.

I say this on a lot of my (mostly long-winded posts--sorry!): I'm attempting to be factual here. If you're reading a politically-biased angle please reply and say so, and if you can tell me which words in particular are triggering you, I'd genuinely like to know because my intent is to communicate the rough facts on the ground.

edit: changed one incorrect word

> Republicans, in modern US terms, want to privatize or remove any spending where the government gives things away to people for "free."

A private health system can work. There's nothing inherently bad about it. A private system with some subsidies for poor people can work fine.

The problem is that in our health system, the incentives are misaligned. There is no market for insurance policies outside the ACA, most people have no power to choose their insurance provider.

One easy fix is to prohibit employer-sponsored insurance entirely. At most, allow employers to provide vouchers that can be used only for healthcare purchase.

Not that you accused me of this, but I didn’t say it couldn’t work. Was just pointing out that Republicans would prefer to privatize (almost) everything to provide some background for the parent.

To give my personal opinion, if given only choices on the poles (fully private vs single-payer), I’d vote for single-payer. And I’d actually do it because I think the ROI would be enormous, though difficult to quantify. I do think it’s tricky (at best) to have health care fully private because the profit motivation can be cut throat. Maybe you’re right though it could be private but with heavy regulation (sort of sounds like what we have today though for working-age people). And you didn’t say regulate it but I’d have a hard time agreeing private could work without regulation.

Reply on news.ycombinator.com