Comment by dghlsakjg | Hacker News Reader

Comment by dghlsakjg | Hacker News Reader

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This would be true if the people that do pay the prices had no influence on your purchasing decision, but the insurers maintain a massive hold on purchase decisions. And in reality, a ton of insured people do pay very directly for their healthcare in deductibles and denied coverage claims.

I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything.

I would love to have had healthcare in America where I was insulated fully from the costs of care. My experience was that it was rare to see a doctor where I wouldn't end p paying at least three figures despite having fantastic insurance.

Meanwhile in Canada, I can recklessly visit three doctors per day for the same issue at no out of pocket cost if I want, and it will still cost my insurer (the province of BC, in my case) less than a single doctor visit 60 miles south of here.

From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying

Many of these things you state as fact do not match my reality.

> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.

That’s basically my plan. I work for a FAANG, and have a low 2k/year max out of pocket for in-network, which is almost everything I encounter. I just book specialists when I want, and I see them as many times as I need. I can do PT 365 times per year, so as long as I don’t go more than once a day (which would be silly), I consume as much as I want. I recently chose to go to the Mayo Clinic — out of state, no referral, and everything is covered. I keep getting estimates from them of $0 since I hit my max out of pocket. The only thing I’ve been denied for is Botox for TMJ which they say is not medically proven (seems to be the opposite, but I understand why they’re wary).

I’ve never had a medication, procedure, or doctor visit denied.

"in-network" is the key phrase here.

You cannot consume as much and whatever type of healthcare. You have to consume from the pre-approved list of doctors that have negotiated rates with your insurer. I also do not believe for a second that if you found a doctor willing to give -for example - daily electrolyte IVs for your post workout recovery, that the insurer would touch that claim. Same thing with cosmetic or elective surgery. Will your insurer cover a facelift? Will they cover Ozempic for vanity reasons? Will they cover the full cost of all name brand drugs after your deductible is spent? And you still have to pay $2k before any of that is in effect.

Mind you, your extreme outlier reality is one that is essentially never experienced by >95% of people, and it still has constraints.

Except I’ve only ever encountered 1 doctor who isn’t in network. I have a 4k max out of pocket for out of network. Even my acupuncturist is in-network.

I’ve never found a doctor who would do anything daily, but if there was a medical need, I’d expect it to be covered.

Where in the world is a facelift covered? No healthcare system covers that. What a silly thing to point out.

If a doctor is willing to rx ozempic I’m sure they’d cover. I already get a glp-1 covered.

Brand name drugs are covered fully.

Yes I have to pay my $500 deductible and co-insurance until I hit my 2k max.

What constraints?

The primary constraint that you are glossing over is that there is a premium that must be paid that most people cannot afford (if they can even access a plan like this outside of a group). Add in the co-insurance, deductibles, uncovered procedures, etc and that becomes a VERY hard constraint on most families. Are you not aware that healthcare affordability is one of the main political arguments for the past few decades?

You must recognize that you are in a position of extreme privilege. Most people simply do not have access to a plan like yours, or cannot casually afford the many thousands of dollars on top of premiums it takes for the insurance to start paying for things. It is not a given that every employed person has 1. a health insurance plan 2. that is paid for in any way by their employer.

Simply put: money is the constraint. You are wealthy enough that you fail to see that spending thousands of dollars is a constraint. Lucky you. That you have never even heard of daily medical treatment tells me that you are also extremely privileged to have never been chronically ill or even known the health needs of someone who is. I can't speak for your insurance policy, but my experience with chronic illness and US insurance companies is that an insurance company that paid for daily treatments without at least making someone jump through many hours of hoops is incredibly rare.

Not only are you uncharitably interpreting my words, you’re making incorrect assumptions across your entire comment here. You’re also shifting from “post workout recovery” (which implies something very non-medically needed) to chronically ill needs, which is either moving goal posts or is just being difficult.

Yes, the US system works great if your are at the social peak, such as working at a FAANG. Thanks for reminding us of the level of class disparity as we struggle to pay our bills or get our children medical care.

When I was a kid, everyone no matter economic level had pretty much the same pediatric doctor group. Now the working class people around me don't really have a pediatrician, but an overworked 'nurse practitioner'.

From the GP: > I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want. Quite the opposite is most people's experience. You have to justify any visit to a specialist before going, you don't get to choose the specialist, many times the insurer will simply deny a payment request for care already received. On many plans, you have to spend 5 figures per year before they will even cover anything.

These do not apply to me. I cannot be the only one. In fact when I was a 2 person startup things weren’t so terribly different from my current situation as well. No need to accuse me of classism when I’m simply refuting the premise with my own data and lived experience.

> From where I sit, the US, which has an unusually high exposure to the real costs of healthcare among peer states, also has the highest cost of healthcare. That sort of goes directly against what you are saying

The US has the highest cost of healthcare primarily because nobody knows what healthcare costs. Even your doctor has no idea -- try asking sometime! I routinely point out to my primary care doctor that the medicine/test/whatever they're recommending is expensive and low-quality, and he looks at me like I'm an alien. Statistically, I am.

You're not wrong that you can get caught in a circle of hell after you get the bill, and that insurers are an opaque barrier to purchase decisions, but that's just saying the same thing a different way -- you have no ability to shop for what should be a commodity service.

> I have never heard of an insurance policy in the US that allows you to consume as much, and whatever type of healthcare that you want.

...and that's one of the few good things about our system, though I agree that the US implementation is maximally stupid. You should have to evaluate the cost and benefit of going to a (rare, expensive) specialist! While I agree that insurance companies suck, it's telling that the debate around this issue has devolved to indignation that someone should be acting to control costs by limiting the freedom to choose expensive things.

> The US has the highest cost of healthcare primarily because nobody knows what healthcare costs.

This requires explaining how places like the UK - where the cost is far more hidden than it is in the US with high-deductible plans being very common - have substantially lower costs.

Well, you're making a a series of logical fallacies (are we talking about the UK, specifically, or an unspecified constellation of "places like" they UK, so that you can avoid the false dichotomy?), but my general rebuttal would be this:

"the existence of magical unicorn places with worse price transparency than the US does not make opaque pricing good."

I'm honestly not sure what you're trying to argue. The US system is good? Price transparency is bad? UK good, US bad?

The US has better than average price transparency, as a huge proportion of us are on high-deductible plans where you directly pay the entire bill until you hit your deductible. Someone on such a plan knows their pediatrician appointment costs $300, because they have to swipe a card (or get a bill for it).

Much of the rest of the developed world doesn't ever even see a dollar amount.

Thus, the "knowing costs drops spending" theory doesn't hold up.

> Much of the rest of the developed world doesn't ever even see a dollar amount.

Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.

Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping". So if you want to call that system price transparency, then all I can do is shrug and walk away.

> Well, as long as you're just making stuff up, I don't see how I can possibly argue with you.

I mean, go visit any Reddit thread discussing an American healthcare explanation of benefits bill. The Americans go "yup, it's expensive here"; the Europeans tend to go "I literally just paid $6 for parking for childbirth".

> Actually, I do: "Paying the bill you get, after the fact" is not at all the same thing as "comparison shopping".

If I get a bill for $300 for a pediatrician appointment, I know what the next one is likely to cost, yes?

Again, people on high-deductible plans know very intimately how much everything is costing them.

> If I get a bill for $300 for a pediatrician appointment, I know what the next one is likely to cost, yes?

No. The next one could be more, it could be less. There could be other fees. You have no idea, because there is no price transparency.

You obviously know this is true, or you wouldn't have used the words "likely to cost". You're just arguing to argue.

I'm not sure why you think there is no price transparency in the US. I know exactly how much I was billed and how much my insurance paid. I generally don't ask ahead of time, because it's going to cost me $20. I get an explanation of benefits for every visit. When I was still below deductible at one appointment they gave me options and how much it would cost. What I don't really get is the option to choose. Limited providers and the network limit my options. From your description you have extraordinary insurance. I have good insurance (according to a staff member commenting on our low deductible). It does not work how you describe. Our insurance servicer (United Healthcare) makes all the decisions. Doctor prescribed x, it gets denied. We've had denials on meds they have been covering for years. I wish we could shop around. It's just not realistic.

> I'm not sure why you think there is no price transparency in the US. I know exactly how much I was billed and how much my insurance paid.

Go to the grocery store. There are no prices posted, you just take your cart to the register, and the cashier charges you $20, then sends you a bill in the mail for a random amount -- trust us, we'll figure it out! Oh, that can of tomatoes really was $50. Sorry. At least you know for next time, right? (Unless the price changes.)

Do you see the problem now? Would you really call this system price transparency?

You're very fixated on knowing the cost beforehand.

Americans know intimately that doctors visits are going to hit them in the pocketbook. Far more than someone from a single-payer system does, where there's a good chance they will never receive a bill with a dollar amount on it.

Yet, we're the big outlier on medical costs. Knowing "this is gonna cost me, ooof" does not seem to have any impact on the costliness of the system.

It's not just specialists that are expensive, though. The ER is expensive. You cannot price compare during a medical crisis.

It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.

This isn't cosmetic surgery comparison shopping. This is "this Doctor has experience with my rare neurological condition, has published papers on it, and has shown success in designing care plans for people like me."

> It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.

Except...you absolutely should, and it isn't weird at all. If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it? [1]

Maybe you would, maybe you wouldn't, but the choice exists, and someone is making it.

[1] You can make it more complex and human, of course: most medical interventions not only cost money, but also carry serious risks. Maybe you would choose to spend an enormous amount of money, but would you also choose to take a treatment that will leave you deathly ill for the remainder of your life in exchange for 1 extra day?

Then be honest in society. Last time the proponents of the current system talked, they implied changing anything would result in 'death panels' that would do what you are saying. So which is it? The current system results in death panels, or prevents them? Because this is a total change from what was sold to the American public.

"Death panels" is an unfortunate name, but they exist in all systems. The current system in my country and your country has them. Any future system in either our countries will have them. It does not matter if the system is public or private.

They are simply not avoidable unless you have literally (literally literally, not figuratively literally) an unlimited budget. No country or system has unlimited resources.

The thing is in the USA we were specifically told by our politicians if we change from the current system we will have death panels. And that we have to stay on our current system so that we can avoid death panels.

> If I tell you that experimental treatment X for rare illness Y will cost you an enormous amount of money, and carries a low chance of benefit, would you buy it?

This isn't theoretical. People do exactly this. https://www.newsweek.com/doctor-sold-fake-miracle-cures-near...

> It's also weird to think that someone with a rare, degenerative illness should have to evaluate whether their quality or length of life is "worth" the money that a specific specialist will cost.

But all countries do that cost-benefit analysis all the time.

Not every procedure or medication will be administered to the patient, even when those procedures and medications have been approved for use in a particular country.

My out of pocket pre-insurance costs in Portugal are so low that I sometimes forget I still need to file for reimbursement with my private insurance provider. My copays on certain plans in the US were higher than this.

There's no way the cost difference (often literally 10x+) in private healthcare with the US can be explained by anything other than "US prices are actually total bullshit".

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