Comment by notepad0x90 | Hacker News Reader

Comment by notepad0x90 | Hacker News Reader

Insurance == Social Disease

There is a healthy concept of insurance where people pay to hedge against potential risk, and that's all fine and good. But one of the most insidious social diseases is mandatory insurance, or industries expecting individuals to insure themselves in any capacity whatsoever.

It is never ok for a business (or government) to offer a service that comes with risks, but then ask their customers/subjects to insure themselves for the risk to the business/government.

If I am charging people $100 for a service, then I ask them to insure themselves and everyone reliably insures themselves (the majority at least), they can still afford to pay my me $100, so why don't i just raise the cost to $100+$10000 where $10000 is the maximum the insurance will pay? You see the problem right, all the insurance achieved is the increase in prices, people still pay the same, you just now have a middle-man economy sucking up all the wealth/value people are generating.

If we could all agree on one thing, I wish it would be this. No more mandatory insurance in any context. Not fire, not flood, not health, not cars. Optional is fine, people who can afford it can hedge against the risk. But a bank shouldn't require fire insurance on mortgaged homes.

Businesses must eat the cost of doing business, in the end the price increase they impose will be less than the price increase of insurance mandates. That, or greed should be a felony (not happening).

For health insurance, it should be a simple subsidy for those who can't pay out of pocket. Some industries must be regulated, even in a capitalist free-market country. Health care, prisons, law enforcement, defense contractors, banks to name a few. Regulated as in centrally price-controlled.

For uninsured people that get sick, house burns down, car accident,etc... the government (for health care) or businesses convert the cost to debt. Same as when someone takes out a mortgage and refuses to pay at some point, or refuses to pay their car notes.

It's like we have had this 50+ year running experiment, it's failing really badly and everyone is coming up with ideas that don't involve scraping the experiment, just modifying it and waiting a bit longer to see if it works out.

> so why don't i just raise the cost to $100+$10000 where $10000 is the maximum the insurance will pay?

Theoretically because you are not the sole provider offering that service and the patient could go elsewhere, or in this case, the insurance company would require the patient to go elsewhere. Obviously, this sucks absolute donkey balls and health care will always involve a healthy dose of "I can't just shop around for where to get help for a heart attack".

In my naive opinion banning discriminatory pricing (no special negotiated insurance pricing), the sale of medical debt, and counting bill forgiveness as tax deductible charity would be a good start. With the absolute technical and capital-intensive marvel that is modern health care I just don't see anyone being able to reasonably get away with no insurance. Maybe there is a mandated co-insurance for all plans that could be covered by HSA accounts that everyone would get access to. That way there is a cost that is transparent to the patient that scales. At that point though I would just go to single payer.

(Rant incoming) Another thing that might need to happen is billing caps based off of certain outcomes. Especially in the emergency medicine realm. If you go to the emergency room and rack up a huge bill for something simple there should be a cap on the amount the hospital can actually recover. All I see is (rightfully) constant bitching and moaning from ER staff that people should be going to primary care or urgent care for issues which are less resource intensive and cheaper. The issue is the ER could provide those same services for just as cheap. Build out those same capabilities in or near the ER. The triage nurse can then send those low priority patients to the facility right down the hall. The issue is hospital admins have no incentive to do that, because as you said, why bill $200 when you can bill a minimum of $2,000 when you have your patient captive.

I also think it is silly we ask people to self-triage. It externalizes a lot of the costs to other parts of society. I can attest to this from the constant Volunteer Fire Department air-raid sirens I hear followed by a "EMS to Well Now Urgent Care for Patient in Distress". I'm sure the volleys love having their evening interrupted when it could have been a simple walk down an aisle.

so long as insurances are the "single payer" the problem will never go away. The single payer should either be individuals or the government (by mandate).

Absolutely agree on the negotiated price bit. That is the root of an awful lot of evil.

I have no problem with the sale of medical debt--what's needed is sanity in the debt collection business. Combined with making one-party record the law of the land--you're automatically free to record telephone calls without notice.

Bill forgiveness as charity? No, that's counting twice. They didn't collect the debt in the first place, there is no profit to be taxed and thus you are deducting $0.

ER: Two problems here.

ERs are mandated to stabilize a patient, urgent cares are not. Thus you see people in ERs with situations that could be handled in an urgent care because the urgent care rejects them for unpaid bills. And the ER can't provide those services just as cheap--a big part of what you're paying for in the ER is potential even if it's not actually used. The freestanding radiologist books their machines as solid as can be done without too much friction. The ER needs the same machines but needs them available NOW. I've been in an urgent care over a kidney stone--they had a CAT manned and ready to go at 3am (the only urgent care in town even open at those hours even before you consider the machines--every ER needs those machines 24/7.) CATs don't cost much to run, the main cost is the machine and personnel time (operator and radiologist) and that's incurred whether it's doing anything useful or not. (And then the urgent care punted anyway. Yeah, you're right, stone, we can't deal with it, go over to the ER.)

I will also say that transport isn't always as simple as you make it out to be. Consider that stone I just mentioned--the ER was half a mile away, trivial under normal conditions. Even under those conditions I could have *slowly* walked it--except there was a major street in the way and I most definitely did not want to cross that. Is a taxi going to take the call? No. Call a friend/rideshare/ambulance.

RE medical debt sale - if you have the ability to just sell debt easily instead of having to go through the process of trying to collect it you are not incentivized to charge reasonable prices as you can overcharge and then be perfectly fine collecting much less (but still above your costs) via selling it to a third party. Any debt that is incurred forcibly or as a matter of health of the debtor should not be able to be moved around. The hospital should have some skin in the game.

Bill forgiveness doesn't necessarily target the for-profit hospitals. Not talking about debt discharge. It actually probably isn't even the right term. Essentially what shouldn't be allowed is non-profit hospitals counting discounts for low-income individuals as charity performed by hospital. The value of the charity shouldn't be sticker price but actual cost of services. Maybe that is already the case, but what I hear from randoms suggest that is why some hospitals are happy to "work" with you on your bill. I shouldn't have included "tax-deductible" in there, this is more about maintaining non-profit status.

RE ER. I don't see how keeping the ER and Urgent Care separate matters. In a combined system you would still have two sets of doctors, two sets of CAT scan machines and operators and radiologists, okay maybe not separate but the capacity for both (an appropriately reserved). In the current system you actually have more overhead from having a whole separate billing system, HR, building, landscaping, etc. Yes, the ER still needs to stabilize a patient whether they can pay or not but that becomes *cheaper* when you have a whole other pipeline to send them to. You aren't engaging a highly paid ER doctor and set of ER nurses to prescribe antibiotics to the homeless person that just came in. You can have the RN, or an internal medicine doctor do it instead in the area down the hall. If at any point that homeless person starts to code or the RN/Internal Med doc identifies something concerning, they can get them over to the ER. But again, if you are the hospital why would you do this? You can take in that homeless patient and charge them big money for some antibiotics and hopefully get reimbursed by the government. It's not like the hospital would even lose money on it, you would still charge for the urgent care services, just at the reduced reasonable price it takes to provide them plus a little more. Heck, I'm sure that an urgent care wing incorporated into an ER would beat any standalone urgent care in the business sense, you've generally got a whole waiting room full of prospective customers.. but alas.. you would cannibalize your ER "sales".

And if that cannibalization of ER sales would leave the ER unprofitable, then raise your prices! I don't think any reasonable person would be mad if you charged what it actually costs to provide lifesaving care. Insurance companies would be okay with paying real costs for the fewer cases of legitimate emergencies if they know that the much more common cases of people going to the ER for more minor things would be much cheaper. I would posit that with urgent care support you would need less ER capacity as you wouldn't have it filled up with non-emergent cases.

And yeah, it would be ideal to have them in the same building close together. Retrofitting would be hard or impossible. It would mostly be for new hospitals going forward. It all boils down to designing hospitals to be the most efficient as possible at providing care to patients, not efficiency on generating the most profits.

ER doesn't become cheaper in this case because most of the cost is the potential.

> For health insurance, it should be a simple subsidy for those who can't pay out of pocket. Some industries must be regulated, even in a capitalist free-market country. Health care, prisons, law enforcement, defense contractors, banks to name a few. Regulated as in centrally price-controlled.

Maybe not now, but 10-ish years ago that was the French system. Very poor people get outpatient care that is free at the point of service. Everyone else gets highly regulated private insurance with a strong market component. Emergent/inpatient care is provided by hospitals that aren't part of the insurance system.

There are definitely some trade-offs there, but I wouldn't be opposed to such a system in the US.

States should do their own trade-off calculation maybe, but at the federal level the policy makes sense.

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