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Last year, my daughter caught a stomach bug and for a few days woke up each morning nauseous. We took her to her pediatrician and were surprised to find out that "waking up nauseous" is a Big Deal; it can be a neurological symptom. We were pretty sure that wasn't it (there were... other symptoms... corroborating our "stomach bug" hypothesis) but the doctor was adamant: if she kept waking up and puking, she'd need to get imaged.

She got better and we cleared her to go on vacation with her grandparents, and were just about to get on a plane to go give a talk at Black Hat, when we got a call from our parents in Michigan telling us she was puking again. We called the doctor, who demanded we retrieve her and scheduled a CAT scan.

We are at this point freaked out for a variety of reasons, some of them logistical (trip to conference, driving back/forth to Michigan, &c) but also from the fact that our doctor knew what an epic inconvenience all was and was absolutely clear "daughter needs CAT scan" --- so in the back of our heads there's gnawing "something could really be wrong" (Adia had seizures when she was 4, which, by the way, GUESS WHAT DING DING DING UNINSURABLE ON PRIVATE MARKET NOW, and now 7 years later I still can't even hear she has a headache without taking an inventory of all other possible symptoms.)

So anyways, we want that CAT scan done now now now yesterday now. We get to the hospital for our appointment and: problem with our insurance card. No big deal, we'll just resched--- fuck that, I'm paying cash.

Head scratching ensues, long story short, very large hospital in Chicago doesn't have any price list for a CAT scan at all. Not even an insurance cost to pass on to me, let alone a cash-basis discounted price. Getting imaging done at a top hospital in Chicago without insurance: unheard of. They ended up just making up a price on the spot; $1000.

Wow.

I have on a few occasions floated the idea of making it illegal to insure more than 90% (say) of procedure costs -- there would always be a mandatory 10% copayment. No one I mentioned this to ever seemed to understand the point. I don't know that the proposal is actually workable, but I think you can see where I'm coming from. If patients had to know all the prices because they had to pay some fraction of them, the whole system would look very different.

Making up prices is routine. Got my wisdom teeth extracted. They said there would be a $170 X-ray fee. I already had X-rays done from my regular dentist and brought those in. During the checkout they scratched the $170 X-ray fee and then added at the bottom a $170 consultation fee. I thought pissing off people who are about to knock me out and operate on me is probably not a good idea and didn't say anything.

This is what is happening now, when there are still some people who pay cash. Imagine how complex and impossible to understand this system will become once there would be virtually no people paying cash as there would be public insurers of last resort. No 1/4 cash price lists would exist anywhere - anybody who paid 1/4 price now would pay the full price, provided from the public coffers. Of course, there would also be a need for a huge bureaucracy to check all these payments, argue about them for months, send stacks of papers back and forth, etc. These people would have to be paid, provided with nice benefits and pensions - after all, they work very hard.

On the other hand, you will never have to pay out of pocket for it and probably will never ever made to realize there's a payment in there somewhere. You'll pay out of your taxes and you wouldn't even know how much you paid, so nobody would be up for an unpleasant shock of knowing how much all this costs. 23,800 is not going anywhere - these nice people in the hospital still need to be paid, and they don't deserve the pay cut (if anything, many of them consider themselves underpaid and many of them are right), and these machines and medicines must be paid for too. So it still will be paid for. And it's not getting cheaper - remember no more 1/4 prices for anybody at all? Somebody would have to pay for it, or, more precisely, everybody would pay for it, but won't know how much and where it went. Some think it's better this way.

I have also seen these places. Some of them will tell you the doctor has gone to lunch when you tell them you have individual insurance.

There are "direct access" clinics that can perform lots of blood tests without a doctor's help at a low cost -- $5 to $20 per panel. Fill out a form, draw a couple vials, go home and your results come in the next day.

What's frustrating is that you aren't typically told about these options, and so you end up paying five times as much out of pocket to have the doctor be your gatekeeper. So then you're tempted to say screw the doctors and use the internet to perform your own diagnoses.

It's a shame we have such an antagonistic healthcare system, and I don't see how it can get better as long as the medical industry expects to book profits at a faster rate than the growth of the population.