When private practices merge with hospital systems, costs go up | Hacker News Reader

When private practices merge with hospital systems, costs go up

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154 pointshhs111 comments

Ah, but deaths…

Go up too. https://hms.harvard.edu/news/deaths-rose-emergency-rooms-aft...

Part of the problem of modern society is that statistical murder of thousands is treated as less of a crime than a normal murder of one person.

I think you mean murder via diffusion of responsibility is good for business. Its like the trolley problem, but instead of one lever thete a chain of them and at least one of them is the final one, any number of them are like tumblers in a lock.

I hate the US healthcare system but I don't support using the word murder in this context. Murder is very very different from trying to help a person but being greedy while doing it.

But it’s not “a person”. It’s millions of them.

I agree it's really sad and fucked up. But the way we deal with murder is long prison sentences and the death penalty. If we introduce horrible incentives for investing in medicine, we won't get compassionate care, we will just eliminate investment in healthcare.

We need really thoughtful incentives and simple policies that let doctors run hospitals. Idk it's hard - I was going to say we should reward them for providing better care but I know the pay for performance system in place also hasn't worked that well.

Single payor system would solve a lot of problems as insurance companies and the economic system/incentives they’ve created in healthcare is the root cause of a lot of the issues. Also, it’s such a large and relatively unnecessary value extraction layer (middleman) that we’d immediately have many more dollars going towards providing care than to running of insurance companies and their owners. Even the hospitals and other providers have to employ armies of people just to understand how to bill things properly in this unnecessarily complex ecosystem. It’s a massive waste of resources in the name of capitalism that does nothing to improve the care provided.

It’s even worse when considering these companies profit more by denying care altogether.

> trying to help a person but being greedy while doing it.

The doctors are trying to help people, the execs are being greedy while doing it. Leadership doesn’t get the benefit of the doubt at this point.

Plenty of docs making the better part of a million dollars.

Buddy, six figures is about 3 short of the amounts we’re talking about here.

Yea, we have to stop villainizing people who are making "a better part of a million dollars." The real villains are the ones making a better part of a billion dollars or more.

Yes, it's much worse.

I think murder is an appropriate term. There is a long history of company leadership making decisions that they know will lead to the death of thousands of people. See tobacco, opiates, leaded gas and many others. And they are not trying to help people while being greedy but they are only greedy without being motivated to help people.

Forgot insurance.

These are two distinct issues.

The study you linked concerns whether the hospital is owned by a nonprofit or by a private equity group.

The question in this study is whether physicians work for their own practice or for the hospital directly, regardless of the ownership of the hospital.

This issue is much more linked than you think, because its a strategy to upcode to have external practice groups.

Your assertion runs counter to the original article, which says that acquiring external practice groups raises prices.

That article isn’t about hospitals acquiring practices, it is about private equity acquiring hospitals. There is sometimes a relation, but not always.

> Part of the problem of modern society is that statistical murder of thousands is treated as less of a crime than a normal murder of one person.

Society is actually quite consistent on that point (unfortunately). The body doing the statistical murder here is the regulator of the hospital system and it is part of the same organisation (the government) that handles the direct murder through the army. People tend to treat horrible missteps in war and medicine about the same.

It might be nice in a moral sense if there was some consistency. It isn't too late to disgrace George Bush and make the rest of his days a living hell, for example. But as political strategies go that seems like a bad idea.

There is no such thing as "statistical murder". No crime was committed here. I don't like health chain consolidation either, but words mean things.

> There is no such thing as "statistical murder".

Sure there is.

Denying categories of potentially life-saving treatments due to provincial laws causing hospitals to value legal considerations over medical decisions is one example.

Perhaps the phrase "statistical manslaughter" is a better description however.

I don’t think you need the statistical:

If you engage in behavior with known and predictable risks, which then kills somebody, it is manslaughter. Like recklessly operating a vehicle or blindly throwing knives.

That sometimes your behavior doesn’t kill people is immaterial — manslaughter is being intentionally risky in your actions which leads to a death.

Or in the case of UnitedHealthcare, felony murder: their felony fraud in issuing false denials for their clients resulted in deaths — and deaths that result from a felony have a special charge.

> If you engage in behavior with known and predictable risks, which then kills somebody, it is manslaughter.

> That sometimes your behavior doesn’t kill people is immaterial — manslaughter is being intentionally risky in your actions which leads to a death.

I was thinking more about laws enacted in the last couple of years in various US states which have guaranteed a rise in pregnancy-related deaths[0].

0 - https://news.harvard.edu/gazette/story/2025/04/u-s-pregnancy...

Which laws do you mean?

Abortion bans.

> Or in the case of UnitedHealthcare, felony murder: their felony fraud in issuing false denials for their clients resulted in deaths — and deaths that result from a felony have a special charge.

Sadly, the insurers have a defense to this, and it has largely held up in court:

"We did not deny that person the healthcare that could save their life. We just declined to be the party to pay for it."

no self respecting judge would accept that claim if there was no good faith behind it, such as returning premiums paid so they can pay for it themselves.

Varying degrees of negligence? Drink a lot and drive, your chance of homicide goes up.

Every health system in the world makes decisions that result in deaths that could have been avoided had other decisions been made. I don't like many of the decisions our shambolic health system makes. But none of it is "murder".

I want to highlight your point because you're correct and this is something that a lot of people don't understand about economic systems. We exist in a resource constrained system. There are finite medical workers, finite time, finite medicine, finite medical facilities, finite medical equipment, and just finite resources in general. There will always be shortages and surpluses in such a system as resource allocation is never perfect. If you have a shortage you must ration supply through some mechanism. It can be by prices, by queue, by need, by lot, by status, or countless other mechanisms or combinations of mechanisms but you must ration regardless. This will lead to people dying under certain conditions who may not have died if some other rationing mechanism was used, but if a different rationing mechanism was used then a different set of people would have died. The only thing that can be done is to select the system that allocates resources more efficiently than other systems to minimize this failure mode. This whole idea of "statistical murder" would just lead to the banning of medical care entirely as no system has perfect allocation at all times, although some are certainly worse than others.

Plus I have no idea what the word "statistical" even means in this context...

Our system isn't this resource constrained though. Our system has evolved unintentionally to allocate things this way, but our system does in fact have the resources. In fact, we have so much resources/efficiency/excess we have all kinds of labs/practices doing all kind of optional procedures across the entire country. So many that wait times are really really low for those elective procedures.

Example. I live in a mountain town. Our ER takes hours. I can go to one of the multiple nearby doc in a boxes and get seen in 15 minutes. My town HAS the resources to see those people waiting in the ER. We just don't allocated the resources that way.

My town is a ski town. We have WAY more orthopedic surgeons than we need, but it's extra profitable for them here and living rich in a remote ski town is nice.

My tiny town has multiple beauty skincare facilities with licensed doctors on staff.

It's not a 'we don't have resources' it's a 'we don't prioritize these lives'.

Which is fine. But don't lie to us and say there aren't medical resources.

You also have way more orthopedic surgeons because the AMA lobbied to require primary care physicians to go through the same rigorous residency track as specialists do, where before they could begin practice after a year, and so there's almost no incentive to enter primary care medicine directly anymore; it's the same cost and effort as becoming a cardiologist, but less pay.

An insurer having an auto-deny policy for care claims (procedure/medication/etc) and then fighting a physician’s explanation/reason for their recommendation to the extent the patient expires while this battle plays out, is evil and premeditated and arguably meets the legal criteria of murder in many jurisdictions.

It meets the legal criteria of murder in literally no jurisdiction anywhere.

The same is true for the Holocaust in 1944.

We had to invent new crimes “against humanity” to cover it.

No, that is obviously not also true of the Holocaust. Again: pretzels! It's really easy to look up why we invented new categories of crime for the Holocaust.

It is entirely true. The Holocaust was a sovereign nation committing actions that were legal within its judicial system at the time.

> The drafters of [the Nuremberg Charter] were faced with the problem of how to charge the men at the Nuremberg Trial with committing the Holocaust and other state-sanctioned atrocities committed in Germany and German-allied states by the Nazi regime. As far as German law was concerned the men had committed no crime, but only followed orders. Not following orders however, in Nazi Germany, was a horribly punished crime. The problem in trying the individuals responsible for the German atrocities lay in the fact that, like in World War I, a traditional understanding of war crimes gave no provision for atrocities committed by a state on its own citizens or its allies. Therefore, to solve this problem and close the loophole, Article 6 of the Charter was drafted to include not only traditional war crimes and crimes against peace, but also crimes against humanity…

You're misunderstanding the issue. As far as German law was concerned, ordering the deaths of millions of people wasn't a crime because of uniquely awful German law dehumanizing those people. International law was required, in part, because there was no other way to apply the obvious murder statutes to the case (you'd need to do that under German law, which was warped by the Nazis) and in part because the crimes were themselves more horrible than just murder. It was not because there was some weird bank-shot way in which knowingly operating death camps was alien to ordinary notions of criminal law.

Also: stop comparing things to the Holocaust. Still more pretzel twists. All you have to do is not pursue this dumb rhetorical strategy of depicting policy you don't like as "murder".

> As far as German law was concerned, ordering the deaths of millions of people wasn't a crime because of uniquely awful German law dehumanizing those people.

As far as American law is concerned, causing the deaths of many people isn’t a crime because of uniquely awful regulatory regime dehumanizing those people.

> Also: stop comparing things to the Holocaust.

It illustrates well the point that “just because a killing is lawful doesn’t necessarily mean it shouldn’t be considered murder”.

Because you're intent on framing a policy decision you dislike as "murder" you've found yourself arguing that running a death camp wouldn't be prosecutable without a "crimes against humanity" law, and comparing the administration of health care systems to the Holocaust. This is what I mean by saying you've twisted yourself into a pretzel. You made a bad argument. It's not the end of the world; I do it all the time. Let it go.

> you've found yourself arguing that running a death camp wouldn't be prosecutable without a "crimes against humanity" law

I have cited how we did, indeed, have to do exactly that.

> comparing the administration of health care systems to the Holocaust

Yes. Both involve causing megadeaths in a way existing law is entirely unprepared for.

Arguably was the key word you missed. I don’t think anyone has made this argument before but I personally believe it could be made successfully to a jury.

1) denial of care resulting in death has already has case law for murder, it’s typically geared towards people with a legal responsibility like a grossly negligent parent and does typically get treated as manslaughter but there have been extreme cases where murder was charged. This is where I think an attorney could sway a jury that insurers have a legal obligation to their insured. And particularly where the insurer is objecting to a medical practitioners recommendation/diagnosis/etc.

2) premeditation can be determined because the auto-deny decision has been made and programmed into their business systems.

There are jurisdictions where that’s basically all you need

> Every health system in the world makes decisions that result in deaths that could have been avoided had other decisions been made.

And some of those decisions are, shall we say, justifiable homicide.

Intent and motive makes murder. “I will let these people die so I can be richer” is different than a bureaucrat who gets paid the same either way.

None of them are homicide. Look at the pretzel you've twisted yourself into trying to defend your use of the term "murder".

Look at the pretzel that’s forming from trying to avoid the “decisions to let people die for profit” aren’t homicide.

One twist in your pretzel (or 38, if you want to break it out using the OECD) is that you've essentially indicted every health system in the world for murder.

The US is uniquely and aberrantly expensive amongst the OECD.

Yes! For reasons having very little to do with your argument!

https://nationalhealthspending.org/

Perhaps you could elaborate on what argument that link is supposed to support?

“We spend a lot” and “people make profit off denying and inflating cost of care which results in needless deaths” are not exclusive scenarios.

Point to the spot in that table where private practices began merging with hospital systems and tell me why things were better in the instant before that spot. I took the time to assemble and present the data, you can at least engage with it.

> Point to the spot in that table where private practices began merging with hospital systems and tell me why things were better in the instant before that spot.

That's a strawman. No one asserted they all merged at the same time in a way that this sort of 30,000 foot overview would illustrate, nor that the effects would be instantaneous.

> I took the time to assemble and present the data

I mean, as a bit of feedback on that work, it'd be substantially more useful if the site said whether or not it's at least inflation adjusted. Population adjustment would be handy, too.

I think you want take that up with Medicare; this is just an NHE XLS put up on a web page. I don't know how any of that would change your argument, because you didn't actually make an argument here.

Ford Pintos exploded way to easily. Ford chose not to fix it because it would cost them $11 per car. It was later revealed that Ford presented flawed data and bad math to hide even cheaper options to fix the Pinto.

In the modern world people can choose obvious evil choices because it makes them money, but because the damage is spread across the entire world and only slightly makes peoples lives worse it is ignored. Our laws are setup for a world like this. But there needs to be then same sort of legal incentives to keep people in line at this scale. Where if your choice results in one million human years wasted/made worse, society sure a shit is going to punish you hard because it benefits society to not waste one million human years.

While I agree that what you call "statistical murder" needs to be handled differently, I see problems with doing so that need to be solved. Namely, what counts?

Your example of statistical murder is prioritization can be abstracted as profit over life. A first thought might be to condemn any prioritization of anything over life, but this leads to likely unwanted consequences: it is illegal to drive, ever; it is illegal to feed someone food that is not of the optimal health for their particular situation, ever; it is illegal to sell a product, even used, that California has determined a carcinogen. All of these are related to leading causes of death: traffic accidents, low quality food causing obesity and its myriad of consequences, and cancer. We could use improvement in all of these cases, but such absolute bans go too far.

So, how do we determine when it is legitimate to prioritize something over life, or when it's statistical murder?

    So, how do we determine when it is legitimate to prioritize something over life, or when it's statistical murder?

A necessary first step is to hand that decision over to someone who does not personally gain from choosing death. Life-or-death care almost certainly needs to be a government-run, single-payer system.

If giving another kid their cancer meds means one less gold-leaf-covered item in the presidential ballroom, so be it.

> If giving another kid their cancer meds means one less gold-leaf-covered item in the presidential ballroom, so be it

I agree. I want to expand on this and make my question more explicit. In my previous post I tried to give one extreme (where we clearly do not want restrictions on behavior). This is the other extreme (where we clearly do want restrictions on behavior). There must be some line drawn in between in order to enforce either of these extremes (that we clearly want to enforce).

We have that in canada and it does not work that way at all. Single payer turns into a big en(ugh line item that there is political "otivation to limit supply and it all goes to crap just in a different way than it has in america. The solution is way simpler: ensuring there is enough supply that price raising bs fails. That gives you a bunch of different ways to get to the solution that will all work vut they all have ensuring enough supply to limit shenanigans at their base.

> Life-or-death care almost certainly needs to be a government-run, single-payer system.

> If giving another kid their cancer meds means one less gold-leaf-covered item in the presidential ballroom, so be it.

Why do you think a government would choose to cover an additional kid’s cancer medications rather than an additional luxury for government workers? You’re placing a ton of faith in governments.

At least with private companies there is choice (normally). And private companies do not directly wield government power (normally).

Interesting. The cost to save a human life is about $4k. Anyone with $4m then is a statistical murderer. Acting to enrich themselves over saving these 1000 lives. Fascinating. Donations to the Rust Foundation have statistically killed thousands. By setting up the Rust Foundation I wonder how many have been murdered statistically.

It's the beauty of a commercial system, no? Businesses have a duty to make a profit for their shareholders first, second to their clients (keeping their customers happy), and no obligation to the wider society, other than following regulation.

If a private hospital figures out that by jacking prices up by 50% they make more profit, keep their fewer customers happier (not even necessarily more alive!) and treat less people, they are 100% following their mission as a private business.

A European PoV might be that you can counterbalance a private system with a public system, whose goals are explicitly to keep the society healthy and help as many people as possible. The NHS, admittedly not the gold standard for anything good recently, optimises for maximising "quality-adjusted life expectancy improvement" over the whole society.

It's not a metric you could ever replicate with private businesses.

> Businesses have a duty to make a profit for their shareholders first […]

[citation needed]

This idea gets bandied about, but it is only one way of thinking that happened to gain popularity in a certain (recent) time period:

* https://en.wikipedia.org/wiki/Friedman_doctrine

* https://en.wikipedia.org/wiki/Shareholder_primacy

There are others:

* https://en.wikipedia.org/wiki/Stakeholder_theory

There is no legal duty/requirement to do so:

* https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2277141

* https://rpc.cfainstitute.org/research/multimedia/2013/the-sh...

* https://skeptics.stackexchange.com/questions/8146/are-u-s-co...

Also: shareholders are not the owners of company.

There's even a specific court case setting precedent that there is no "fiduciary duty" to screw people over in pursuit of higher profits:

> Burwell v. Hobby Lobby Stores, Inc. - https://www.law.cornell.edu/supremecourt/text/13-354

> While it is certainly true that a central objective of for-profit corporations is to make money, modern corporate law does not require for-profit corporations to pursue profit at the expense of everything else, and many do not do so. For-profit corporations, with ownership approval, support a wide variety of charitable causes, and it is not at all uncommon for such corporations to further humanitarian and other altruistic objectives. Many examples come readily to mind. So long as its owners agree, a for-profit corporation may take costly pollution-control and energy-conservation measures that go beyond what the law requires. A for-profit corporation that operates facilities in other countries may exceed the requirements of local law regarding working conditions and benefits.

Ok fine, companies have a duty to their shareholders to do as they are told, within relevant laws, which usually means maximising profits over some timeframe. Screwing your clients usually hurts long term profits so companies don't always do it.

In what way are shareholders not business owners? They control, via boards, what the company does, and have exclusive access to the profits. These can even be clawed back, in certain situations, if the company then goes bankrupt - i.e. shareholders aren't just paid spectators, they bear responsibility for the business.

So how are they not owners?

> Ok fine, companies have a duty to their shareholders to do as they are told, within relevant laws, which usually means maximising profits over some timeframe.

Nope. First of companies have no duties, as they are not sentient, and thus have no free will to follow order or not.

While the directors of the company often/generally follow shareholder direction, they are not legally bound to: the directors have a contract with the company and so they must do what they think is best for the company.

But if you think it is for "shareholders", then "which" shareholder? The pension fund that wants steady dividend payments for 3 decades? The hedge fund that wants a meteoric rise in share prices in 3 years? The day trader that's trying to cash in on a meme in 3 days? There is no (single) Platonic "shareholder" that a company's directors can aim to be best at: there are a variety of people holding stock. Do a search for "shareholder heterogeneity".

> These can even be clawed back, in certain situations, if the company then goes bankrupt - i.e. shareholders aren't just paid spectators, they bear responsibility for the business.

Using UK law and precedent (just because it was easiest to find quickly):

> Unlike the agency theory, corporate law does not grant shareholders the right to necessarily impose their will on the company. The case of Gramophone & Typewriter Ltd v Stanley [1908] stated that “even a resolution of a numerical majority at a general meeting of the company cannot impose its will upon the directors when the articles have confided to them the control of the company affairs. The directors are not servants to obey directions given by the shareholders as individual; they are not agents appointed by and bound to serve the shareholders as their principals”.

> Shareholders possess a piece of paper entitling them to receive future income, but do not have the right to use any of the assets held by the corporation for their personal use. Companies are legal persons and in that capacity, they can own assets and use them in accordance with the directions given by directors. If any shareholder were to attempt to possess the asset and use it for personal enjoyment, s/he will probably be accused of theft.

[…]

> Shareholders cannot use the assets of a company to satisfy their own debts. In common with other consumers, shareholders can use a company’s assets and services by paying a price, but they generally do not have any special privileges arising from their investment in shares of the company.

* https://www.pqmagazine.com/the-myth-of-shareholder-ownership...

If I own shares in AAPL, I cannot walk into the UFO HQ and start grabbing stuff because I do not own it: I'd be arrested for theft. Further, Tim Cook has a bunch of actual stock in AAPL, but if he tried transfer a bunch of money from AAPL's chequing account to his own account it would be theft/embezzlement: because as a shareholder he does not own it.

It is the corporation itself that has ownership of its own assets. And who owns the corporation? Well just like a natural person [1] ("human"), a legal person [2] ("business") owns itself.

[1] https://en.wikipedia.org/wiki/Natural_person

[2] https://en.wikipedia.org/wiki/Legal_person

Now a natural person can delegate the running of their assets (real estate, portfolio, etc) to other people (grounds keeper, CFP/CFA/CIPM), so can a legal person (President, CFO, etc). But the people hired have a responsibility to the person in question.

Shareholder do not even have the right to demand income/dividends: the directors hired by the corporation have to decide what to do with whatever assets are left over all liabilities are handled, with an eye towards what is best for the corporation.

Or Canadian law:

> In contrast to what you may have previously understood, ownership of a corporation’s share does not represent ownership of the corporation itself. Rather, it represents ownership of certain rights to the corporation, which are granted in consideration for an equity investment or past services. The three basic shareholder rights are: the right to vote, the right to receive dividends, and the right to the corporation’s remaining assets upon dissolution or winding-up.

* https://queenslawclinics.ca/node/81

> There is a basic tension inherent in the regulation of corporations between the role to be played by boards and that to be played by shareholders. Boards have the statutory responsibility to manage the business and affairs of the corporation, and owe an express duty to act in the best interests of the corporation. Shareholders, however, are the ultimate ‘owners’ of the corporation, and have the ability to elect and remove directors. […] For a number of reasons the Canadian regulatory regime has developed a shareholder-centric model, which tends to foster an emphasis on process and shareholder rights, and stands in sharp contrast to the American regime and its nuanced approach to director duties.

* https://digitalcommons.osgoode.yorku.ca/cgi/viewcontent.cgi?...

Not the quotation marks around the word owners. Also:

> Critically, both in British law and theory shareholders are not ‘owners’ of the company they have shares in, and lack many of the rights and powers typically derived from ownership. In 1948, the Court of Appeal ruled that “shareholders are not, in the eyes of the law, part owners of the company”. The House of Lords strongly reaffirmed that ruling in 2003, a judgement the EU’s recent Shareholder Directive echoed. Ownership of capital – in this case, owning shares – is therefore legally and theoretically not the same as ownership of the company.

* https://www.ippr.org/articles/who-owns-a-company

> Corporate reality, though, has proved stubbornly uncooperative. In legal terms, shareholders don’t own the corporation (they own securities that give them a less-than-well-defined claim on its earnings). In law and practice, they don’t have final say over most big corporate decisions (boards of directors do). And although many top managers pledge fealty to shareholders, their actions and their pay packages often bespeak other loyalties.

* https://hbr.org/2012/07/what-good-are-shareholders

* (2) Although they do not own corporations, which are separate legal entities beyond their full control, shareholders play a relevant role in the governance of those corporations. The financial crisis has revealed that shareholders in many cases supported managers' excessive short-term risk taking. Moreover, the current level of “monitoring” and engagement in investee companies by institutional investors and asset managers is often inadequate and too much focused on short-term returns, which leads to suboptimal corporate governance and performance of listed companies.*

* https://www.europarl.europa.eu/doceo/document/TA-8-2015-0257...

* https://blogs.law.ox.ac.uk/business-law-blog/blog/2016/11/mo...

(The post is long because I want a single place for all the references I've managed to find on the subject given how often this idea comes up and has to be debunked.)

I think you may be technically right, but only in the sense that, say, employees do not have to do as they are told by their bosses. Sure, you cannot force an employee to do so something. And yet it's a pretty good description for what actually happens.

> I think you may be technically right […]

What is the law if not a bunch of technicalities.

(It is probably reasonable to talk about shareholder-owners proverbially and as a 'mental shortcut', but it should not be confused for actual reality—especially by those who should know better, like corporate officers.)

Counting in people rather than people-days is problematic, and then you get to qol-people-days. Saying murder is not helpful; see how folks have responded to you.

Australian here.

It's always astounding that no-one in the US mentions the elephant pooping in the living room - that the US spends more tax dollars than Australia and IIRC the UK, and Canada.

Per capita, or as a % of anything reasonable. The US is such bad value that Medicare and Medicaidel, VA, as well as othe government programs cost IIRC more than Canada's system. And Canada has a huge area with poor economies of scale.

Republicans don't want to admit that they're taxing as hard as the French (for healthcare), Democrats don't want to lose the gold plated Medicare system that old people vote for, and literally everyone from nurses to band aid makers to doctors to healthcare CEOs makes more than in other countries.

Maybe I have missed something, but universal single payer healthcare (especially with a hybrid system like Ausralia) seems cheaper than what the US does.

The confusion likely comes from assuming that the U.S. is targeting “cheaper cost of care” as a goal. The target here is “profit for business”. Usually that’s done by businesses withholding wage increases over decades, but occasionally some regulation is canceled or some private capture opportunity is found that jumps profits and prices rapidly. Australian healthcare generates a lower share of private business profit, both per AUD spent on healthcare and per total AUD spent, and so is seen as inferior to the U.S. model by our leaders.

Seen in that light, the increased prices are a universal winner for us: profits go up -> inflation goes up -> GDP goes up. Wages do not go up, and so as a whole we’ve surpassed 25% of all households unable to afford a one-bedroom home. Economists are taught to only model inflation in terms of price level: inflation = profit increases + wage increases, with no way to model their separate impacts. So our policies are economically sound, as long as one disregards the growing poverty.

Despair is, as Demotivators reminds us, highly profitable :-(™

It's basically about racism and control. One of the key reasons the US didn't get universal healthcare in the Social Security Act of 1935(!) was because FDR relied on Southern Democrats who thought it was a threat to segregation. That culture is still very much alive.

Conservatives in the US see the world as a power hierarchy and their most important job is to uphold it, like they are princes next in line to be King. See how hard they fight China and cut social services to funnel money up to billionaires. They will literally die for it.

Their inheritable privilege dies forever if they don’t fight to uphold it, and the one rule of all landed gentry is never to jeopardize the family’s privileges, under penalty of disinheritance and expulsion.

Yeah. This tribal territorial zero-sum perspective is the original form of politics. It doesn't work so well in a modern knowledge-based multicultural world, but the DNA hasn't caught up yet.

The primary reason that this happens is that medical billing and patient management systems are so complicated that it's cheaper for private practices to outsource this to a hospital that already has a contract with Epic or similar extractive vendors.

If the US had a simpler billing/insurance system (or these extractive middlemen were removed entirely), this wouldn't be happening to the same extent.

Everybody needs healthcare. It’s a clear win for society if private actors can’t make it more inefficient by parasitizing a profit. The answer is single payer on the dime of the rentier capitalists. That’s how you reinvest in your society, not crypto and secret police.

Everybody also needs food. Should the government also pay for everyone's food?

Why not? Flour and rice and potatoes are cheap, why shouldn't a basic level of nutrition be available?

In the richest country that has ever existed? The one that sends 1/3 of food into the dump? (https://refed.org/downloads/refed-2025-us-food-waste-report....)

Yes, obviously yes. If someone can’t pay for food, we clearly have enough to go around.

Well now you're shifting the goal posts. There's an enormous difference between having the government buy food for a few poor people (which I support) versus being the single payer for food for everyone.

Not really.

There's agricultural subsidies that help farmers to nominally ensure that the US doesn't need to import foodstuffs. That practically guarantees that food is available, but it isn't "single payer" in terms of obtaining that food.

That "single payer" for obtaining food is food stamps. You have to be poor, to very poor, to qualify. But you get stamps, you bring to your grocery store, and you get free essentials, paying with food stamps. The market then redeems the food stamps to the government to get paid. And, guess who prices these essential products? Well let's just say that the government is generally rather stingy about it, but markets that sell these essential items are practically required to accept food stamps, even if only to keep products moving so they don't rot on the shelves.

Food stamps are also agricultural subsidies.

When I was on food stamps there was a long tail where I qualified for a few dollars worth. Always seemed odd.

My understating is the dynamic have changed over time. But for much of its history it was as much about “what are farmers having trouble selling” as it was about “who needs food.”

How much would it cost? I could stomach a pretty big tax increase if it meant no children in my home country would ever go to sleep starving again. That seems like a social good to me.

Why not? What would you want for yourself or your children if you found yourselves destitute and without other people to fall back on? Would you be comfortable with them starving?

Let’s get back to the original point, which is that the motive for profit in healthcare is at odds with the stated goal that everyone should have healthcare by right. Trying to make it about something else is a distraction.

We do. We subsidize agriculture, and virtually everybody gets at least a subsistence level of food. Beyond that level, it's easy to let people decide what they're willing to pay for, because it's based on what they want, and not what they need. Wants are easier for individuals to figure out than needs. Health care is a need.

Guess why there are farm subsidies?

Farmers vote?

They also get the same dick sucking level of praise as firefighters even though they are selling a product to us

Given that we're well into a post-scarcity society by now? That's the only sensible thing unless we're choosing gratuitous cruelty.

We are in no such thing.

The world as a whole is poor.

Because a small number are very rich.

They do already. Heard of SNAP?

Buying food for your family is a quintessential market transaction that works great with the government at arm's length. Healthcare.. less so. I'd rather deal with the DMV than a private insurer.

Universal income you say?

My country will pay for your food if you can't afford any, yep. I'm glad to pay taxes to cover it, because extreme poverty isn't great for a society.

Remember kids, social security keeps society secure against poor people with nothing left to lose!

I guess it depends on our priorities as a society, doesn’t it?

You don't need single payer. There are plenty of examples of working health systems in developed countries that don't rely on single payer. You just need some regulations that ensure that the system works mainly for patients and not for shareholders.

The US has reached an almost comical level of insanity and blatant inefficiencies but somehow there is no political will to address anything. Even the current fight over the ACA subsidies is basically about throwing even more money into the fire without addressing any structural issues.

Yes, this.

If you’re interested in solving this, check out Camber. They’re building what is essentially Stripe for small clinics.

Higher collections rate + faster time to money = clinics can focus on providing care. Very cool problem!

https://www.camber.health/about

I think that is hands down, the worst website i've visited in my life. No hyperbole.

> doctors are rather good at providing care across corporate boundaries

I’ve found that to not be universally true. I say that as someone with eight different health systems in MyChart and who has been treated by two additional hospitals who don’t use MyChart in the past year.

Some systems are very competent about sharing across borders and good at it. I’m lucky my primary hospital is one of those. Others are god awful at it and take multiple calls to get them to even fax records.

Ironically, there are two nationwide networks for sharing patient data - CareEverywhere and Carequality. They even have a bridge between the two, so in effect it's one large network.

But that's all predicated on the provider's EHR being able to talk to it, or at least talk to an interface engine that can be configured to talk to it. And money. It costs money.

Every modern EHR supports those nationwide networks. Many provider organizations have been too lazy to set it up or train their users.

Oh, you say that, but...

"Standards are anything but". I used to work for a company that wrote healthcare software, from EHRs to claims benefit management.

And our software was riddled with little transformers, because vendor A's implementation of HL7 behaved differently to vendor B's, and C's.

That's a different problem. The national networks have standardized APIs. Obviously the content returned will have some variations depending on the original source.

Local regional hospitals and air ambulance companies are being bought up by private equity. And, surprise surprise, privately-owned regional hospitals are cutting critical care specialty services and so air ambulance life flights have increased 900%. I expect mortality has increased too logically because of delays in care.

The Air-Ambulance Vultures (2022) https://archive.ph/2TYGj

Air ambulances, backed by private equity firms, leave patients with $45,000 bills (2018) https://www.latimes.com/business/la-fi-air-ambulance-cost-20...

Not for nothing though, and not defending PE... or insurers (UHC denying air ambulance for serious MVA trauma due to "lack of pre-auth")... but most air ambulance companies have fairly cheap "membership":

Airlift NW has a $60/year membership for families that will bill your insurance, and consider what they get from insurance as payment-in-full (https://www.uwmedicine.org/airliftnw/membership). Many also have reciprocal programs in other areas.

Most of the private practices in my town have been bought out by the local hospital system as the older partners are unable to find anyone to become junior partners as the overhead costs have doubled since Covid. The only way to meet overhead is to have the hospital buy the practice as they can charge 2x to 10x for the same visits. It is a backdoor way to socialized medicine.

It takes the great minds at yale to figure these things out

Data vs. feels

Nobody has ever said private is less wastefull than public?

Moot. When private equity and conglomerates get involved, operational concerns like waste and quality of service no longer matter. The only thing that matters is making money.

It's also worth pointing out precisely who owns these hospital systems.

Most hospitals in the US are nonprofits

"Nonprofit" is extremely misleading. Most nonprofit hospitals are as greedy as for profit hospitals. The money just doesn't go to shareholders but to executives and their friends who have businesses the hospital hires.

Costs go up on paper because now they need to charge people more while pretending they are starving. Costs in all other industries go down with mergers.

Less competition usually means higher prices and inferior service.

Imagine if every restaurant went to being owned by McDonald’s, and the reason we’re told for it is “credit card payment systems are so complicated!”

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