Your heart attack bill: $3,300 in Arkansas, $92,000 in California | Hacker News Reader

Your heart attack bill: $3,300 in Arkansas, $92,000 in California

money.cnn.com

243 pointssinnerswing338 comments

Mildly apropos of this topic, I've had the same surgery (kidney stone removal, sorry for TMI) performed in both California and Arkansas. Random! Fancy my chances of seeing an article like this.

The procedure in AR was much cheaper, involved less invasive and expensive procedures, and was performed every bit as competently, if not more so.

When I look back at the experience, I think a lot of it came down to the sheer amount of redundancy and unnecessary procedure baked into the treatment in CA. I could speculate about the reasons why (fear of litigation being much higher in CA, for instance), though the article does a good job accounting for some of them.

How is this surprising? We've completely taken the free-market out of health care. The only way it will ever be solve is if we re-introduce market forces back into the mix. The other problem is all the government regulations that tie the hands of people that would do the innovating. That's one of the big reasons California is at the extreme. They continually add requirements to medical insurance that increase the cost. The solution is simple, let the free-market, ie us, decide what we want.

That's not the only way. Government based healthcare works very well in a number of European countries.

Generally it just works.

And, as a consequence, our doctors got paid much less and the state-owned insurance companies are still hemorrhaging money.

Where does it work well? A small country with a homogenous population can pull it off but there isn't a single large country where it works. They keep their costs down by rationing coverage with wait-lists. I know a few people from the UK where their family members lived in daily pain and had to wait YEARS for their number to be called. They also limit the availability to the best medications and procedures to keep costs down. Also the quality is also quite poor, hundreds of people in the UK have died of dehydration in the hospital because the staff forgot to give them water.

You realize that every single thing you enumerated could easily be applied to for-profit insurance companies in America, right? Just checking.

>I know a few people from the UK where their family members lived in daily pain and had to wait YEARS for their number to be called.

What about people "the market" doesn't find it profitable to treat? I'd rather be on a waiting list for pain medication than told it costs more than I make in a year.

> there isn't a single large country where it works

The healthcare system in Canada seems to be working a lot better than the one here. Is that large enough?

The population of Canada is approx 35 million, whereas population of the United States is over 300 million. Canada is not a large country population wise.

And presumably, there are nearly 10 times as many taxpayers in the US to fund such a system. Why do the absolute numbers matter? In fact, shouldn't there be better economies of scale in the larger country?

OK, Japan then. 125 million people, universal health coverage, ranked 10th in the world by WHO (the US is ranked 38).

I hate to say it, but:

owned

Why is this always used as an excuse why the US is different? The US has ten times more people, hence 10 time more tax payers. If anything I would expect things to be easier for the US because of its scale.

Canada has significant costs associated with delivering health care service to remote areas because of its low population density. A US public system should be more efficient, not less.

You mean the one where the Supreme Court of Canada agreed that the delays in the treatment of cancer in combination with a ban on private insurance were violating Canadian citizens' rights?

http://en.wikipedia.org/wiki/Chaoulli_v._Quebec_(Attorney_Ge...

Is the bar "works perfectly" or "works better than what we have in the US"?

Wouldn't a free-market system have to ration coverage in some way as well, unless infinite resources were put into medical treatment? The disagreement seems to be over how to ration it, e.g. do you do it based on wait-lists, or do you do it more auction-style, or some hybrid (like France), or something else entirely?

> Wouldn't a free-market system have to ration coverage in some way as well

"Free market" is a rationing system that provides scarce goods/services to those willing and able to pay the most first.

That is certainly not the norm. I lived in the UK for 3 decades, and it's definitely not like that. The level of care is very good, and the vast majority of the population are happy with it.

There are incredibly powerful vested interests in the US who find it useful to convince as many people as possible that socialized medicine is awful and must be avoided at all costs. As a result, there's a huge amount of propaganda floating about, using techniques ranging from cherry-picking (it's bad because of these specific example cases) to outright lies (socialized medicine is why European states are bankrupt). A sadly large number of Americans believe it. Everyone then gets terribly confused when such a person bumps into a European who never noticed that the health care system they used all their life is actually a communist hellhole.

> had to wait YEARS for their number to be called.

They could have paid and gone privvate at any time. While wait lists were terrible some time ago they have got a lot better. Since year 2000 wait lists have been consistantly targetted for action by a variety of governments. There are some dodgy actions by some hospitals, but these are called out as dodgy and people take action to prevent it. Patients have maximum wait times listed in national documentation.

> They also limit the availability to the best medications and procedures to keep costs down.

I'm not sure what your point is. Imagine A and B, where A is shown to work effectively and B isn't. Which would you want? In this situation I'm glad that people have a responsibility to evaluate the research to weed out very expensive and inefficient medication and proceedures (and that's really what they're doing. They stop a small number of very expensive and ineffective meds; they don't just allow a small number of cheap meds.)

> Also the quality is also quite poor

How are you measuring quality?

> hundreds of people in the UK have died of dehydration in the hospital because the staff forgot to give them water.

Hundreds sounds too high. Do you have a cite for that please? (Note that the Mirror or the Mail will cause much mirth and laughter and people will then ignore anything else you say.)

While we're talking about deaths from incompetence: Yes, it happens. Yes, it kills distressing many people. It also happens in the US. Medical error is the 3rd biggest cause of death in the US. About 7,000 people die each year in the US because clinicians make a mistake with the medication. About 12,000 people die from unnecessary surgery. About 20,000 die from other errors. Nosocomial (Hospital aquired) infection kills another 80,000 people in the US. About 100,000 people get the right quantity of the right meds, but die from side-effect complications.

There are some things US health care does better. But the UK has better outcomes for some things. We also spend less money on our healthcare than the US.

(http://www.nursingtimes.net/a-comparison-of-british-and-us-m...)

"They could have paid and gone privvate at any time."

Once you have government health care in place, private care costs get so high, only the rich can afford them.

The United States has had this situation for a long time, despite healthcare being almost entirely private.

I'm not so sure that's true. I think prices compare pretty well with the US. Here's one website found pseudorandomly via a web search. (http://www.bmihealthcare.co.uk/paying-for-yourself)

Notice that they offer many surgeries "at a fixed price" and that all costs are known before surgery starts. I'm not sure what happens if there are complications; whether those are covered or not.

(I would have called them to get a quote, but they're not open yet.)

"private care costs get so high, only the rich can afford them"

That is most certainly not the case - private health care is a fairly common perk for senior positions in many companies (I get it and I'm two layers away from a CxO).

Nonsense. It works quite well pretty much everywhere in Europe. Better that in the USA, at any rate.

It works really well in Germany with about one quarter of the population of the states. You pay about 15% of your salary split roughly 50/50 between the employee and the employer and that's basically it. You have to pay some additional money for different things - drugs (10% of the price, maximum 10,- €), hospital stay (10,- € per day, maximum 28 days) and so on. If you are unemployed, the state will pay for you. Finally you are free to opt out and get private health insurance - this may be cheaper when you earn much and are healthy but it may also turn against you.

The price of this is a very large bureaucracy regulating all this and of course costing quite some money that does not go into actual medical treatment.

> The price of this is a very large bureaucracy regulating all this and of course costing quite some money that does not go into actual medical treatment.

I still think it is smaller than the bureaucracy of the insurance companies in the US. I do not know about Germany specifically but the US has perhaps the largest administrative overhead in the world.

People waiting is better than poor people not getting any health care at all.

I gather the NHS (UK) is similar to Medicare, in Australia, where I live.

Under Medicare, highest priority is given to life threatening conditions. For example, if you have a heart attack, you will be treated without delay and to the highest standard. Non-critical cases, such as a knee reconstruction go on a waiting list and it is relatively common for such operations to be postponed multiple times, as higher precedence emergencies arrive at short notice.

Basically, a person who might die will receive care over an uncomfortable person. It can suck if you have a painful, but not life threatening condition, but it is an attempt to give the best overall service within available resources. The public system will treat you if you're not going to die and normally do so well, but in the worst case (that typically makes the news) it can take a long time.

There is always the option of having an operation done privately, and either paying for it yourself, or having insurance to pay for it. Medicare has broad support within Australia.

Where does it work well? A small country with a homogenous population can pull it off but there isn't a single large country where it works.

The Netherlands has a heterogeneous population (I don't see why size matters) with strongly government regulated sector of private insurance companies and hospitals. The net result is that we pay far less per capita than citizens of the US, yet the healthcare system is judged to be much better:

http://www.reuters.nl/article/2010/06/23/us-usa-healthcare-l... http://www.commonwealthfund.org/Publications/Fund-Reports/20...

"Also the quality is also quite poor"

If the quality of care is so poor presumably voters here in the UK would be falling over ourselves to get rid of the NHS and replace it with a more efficient and cheaper private system?

The NHS is far from perfect, but in my experience (and I have private health insurane through my employer - which I personally have never used, although my son has) is that the standard of care generally in the NHS is very high - my son was born in an NHS hospital, my wife has been treated for life threatening injuries more than once (e.g. climbing accident) and the standard of care and the attitude of the doctors and nurses was great.

Private health care in the UK is mostly about getting access to non-vital procedures more quickly than others (my son had his tonsils removed) and getting a nicer room.

> They keep their costs down by rationing coverage with wait-lists. I know a few people from the UK where their family members lived in daily pain and had to wait YEARS for their number to be called. They also limit the availability to the best medications and procedures to keep costs down. Also the quality is also quite poor, hundreds of people in the UK have died of dehydration in the hospital because the staff forgot to give them water.

So we don't have these problems in the U.S. under the current "free market" system?

Before you answer, I already know that the answer is "yes we do".

It's really not that simple and I say this as someone who works in health care. Doctors control how many new doctors there will be in any given medical discipline and they do this via accreditation, residencies and fellowships. You can introduce all of the free market forces and relaxed regulations you want but until doctors no longer control the supply of doctors you're wasting your time.

Doctors only have this control because regulation says so. But as long as there are such steep price differences across state borders, it seems that there are, in fact, lower hanging fruit than busting the doctors' monopoly.

Strictly speaking this is not controlled by any regulation You simply aren't going to get the experience necessary to perform certain surgeries with any proficiency without the aide of the gatekeepers. Also the reason for the steep price differences from state to state is partly due to a lack of a supply of doctors with a booming population of people who are seeking more medical care so I would argue decreasing the barrier to entry into the medical field while not decreasing standards should be a part of the plan.

I'm not familiar with the system, but I find it extremely unlikely if >600,000 doctors are able to organise to form a watertight gate without any help from regulation. Surely they control licensing or something?

If you aren't familiar with the system why make the claim that doctors have control because regulation says so?

Because of what your describe in your original post: That scenario is completely implausible, except where enforced by regulation. I don't know what the exact mechanism is, I can just tell that it must be there. It's a game of prisoner's dilemma with 600,000 participants.

Are you saying that I can practice medicine without a relevant degree, or that the supply of the relevant degree is not controlled by the government?

from my personal anecdote - i had appendectomy 2 years ago. total for all bills i received during couple month after discharging was about 28k. Out of these $700 for surgery itself and $900 for anesthesia. There were some other bills where my doctor was involved, like follow up visits, but these did not get over $500 aggregated.

So looks like doctor's cost is not that big of a part of the total bill anyway.

You can't say that all government regulation of healthcare is a bad thing. It literally saves lives.

If healthcare was left as a completely free market I dread to think how many people would die as a result of cut corners and rushed diagnoses.

You can still sue a doctor or hospital for malpractice.

EDIT (answering the responses):

- Overseas you can buy a cheap insurance policy to cover the cost of a lawsuit. The underwriter determines your likelihood of success and charges accordingly.

- You really think regulations stop that from happening now? People still get the wrong limbs operated on and amputated.

If you're still alive, yes. And even then, if you were paralysed from the neck down (for example), would you really be able to enjoy the millions you got in court? Financial compensation for crippling illness always struck me as quite strange.

The point of financial compensation isn't really to compensate the victim (or their family), it's to push the cost of the externality created back onto the provider, giving an incentive to act sensibly.

Lawsuits aren't free.

There are shitloads of lawyers who pick up malpractice lawsuits on contract, saying that they'll do the case for free if they get x% of the winnings.

Just thinking out loud, not making a judgement: I wonder if the overhead from lawyer's fees would turn out to be any less than the overhead from government regulations.

Case law is still law.

Libertarians who think "SUE SUE SUE" is the answer really frustrate me: It's random judges picking the law instead of elected reps

People who think "throw more politicians at the problem" really frustrate me: they are a bunch of random people seeking more power for themselves.

I've always found it a bit strange that libertarians' solution to everything is always "sue!"

I would rather have judges, in a court case where parties get to represent themselves, applying common law, with a jury of my peers deciding the verdict... than random idiots elected by a bunch of other random idiots I don't know make laws without my input.

Judges create case law, over and over. Common law was created that way, and tons more is created that way every day.

I don't know why you assume this is better that popularly chosen law.

Common law is popularly chosen law created by the people. Statutory law (almost entirely with the exception of a few states and their referendums) isn't. Statutory laws applying to 350+ million people are crafted by 435 people.

>Common law is popularly chosen law created by the people

No it's not. It's case law from England. It's created by judges.

Consider this:

You just died because, during treatment for an easily treatable medical problem, a lack of regulation allowed some part of that treatment to have a higher probability of complications.

Now go sue.

That just doesn't make any sense. That's a problem with and without regulation. First of all, some medical procedures have risks. That's just how it works. Second of all, someone could die in a world with a ton of regulations by a problem that could have been "solved" by a regulation. So you're emotional retort applies here too: "Now go elect a new representative to pass a different law."

It makes no sense to die from an unregulated medical procedure?

Let's say it's stitches, and there's no regulation against reusing a stitching needle because in your world the elected body doesn't do that sort of thing. The doctor just washes it off a bit so it's not so gross looking every time.

You're one of the 1-2% that contracts something horrible from the doctor and you're dead within 24 hours.

Now sue.

> It makes no sense to die from an unregulated medical procedure?

What? No. Your argument doesn't make any sense. I then went on to explain why.

> Let's say it's stitches, and there's no regulation against reusing a stitching needle because in your world the elected body doesn't do that sort of thing. The doctor just washes it off a bit so it's not so gross looking every time.

> You're one of the 1-2% that contracts something horrible from the doctor and you're dead within 24 hours.

> Now sue.

This is precisely the same argument as before, but with an example. My criticism still applies. I'll adopt your example so that my criticism is crystal clear:

> Let's say it's stitches, and since law makers didn't setup regulation against reusing a stitching needle because in your world the elected body is incompetent/ignorant/behind. The doctor just washes it off a bit so it's not so gross looking every time.

> You're one of the 1-2% that contracts something horrible from the doctor and you're dead within 24 hours.

> Now elect a different representative to change or add that regulation. Or lobby your existing one.

In either scenario, the end result is "you're dead, so ANY fix is moot."

But they're already elected and already regulating. The counter argument is an argument against regulation, period, let lawsuits and the free market sort it out.

The theory goes, people won't go to doctors that reuse stitching needles vs. the doctor down the street who does.

This is not a theory I subscribe to -- that's the politest thing I can say about it.

> But they're already elected and already regulating.

You missed my point. You can't protect against every kind of malicious behavior. Therefore, whether you have regulation or not, people are going to die from doctors doing stupid/evil things. And your retort still applies: "You're fucked. Oh well." (I'm not saying this justifies freed markets! I'm saying this makes your argument bunk.)

This is the third and last time I'm going to say it: your appeal to emotion applies equally in both state regulated markets and freed markets.

> The theory goes, people won't go to doctors that reuse stitching needles vs. the doctor down the street who does.

That's a red herring to this entire discussion. You were criticizing the idea of "suing" being a bad solution and yet, you've dismissed freed markets for a completely different reason here.

The whole point of suing in this case is restitution. Just because you're dead because of a gross needle doesn't mean someone can't sue the doctor on your behalf. This gives doctors the same kind of incentive to treat you well in a freed market as in a state regulated market. (e.g., They do bad things and they have to pay a price.)

You're trying to discuss two entirely separate issues: 1) pressures on consumers aren't good enough to keep them away from bad people and 2) pressures on doctors aren't good enough to keep them from doing bad things. I recommend refocusing your argument to clarify what exactly it is you're trying to say.

And if you can't manage a polite response, then g'day.

I'm just being impolite to the theory. We've been civil so far.

Let me take on your arguments point for point:

> You can't protect against every kind of malicious behavior. Therefore, whether you have regulation or not, people are going to die from doctors doing stupid/evil things.

So it's 100% or forgetaboutit? I'm going to presume that there's nothing particularly special about healthcare and we can apply this kind of binary logic to everything? Why regulate safe drinking water? Why regulate car safety standards? Why regulate food safety? Why regulate really anything at all since by your logic, we can't make it perfect so to hell with all that. The market will handle it.

> The whole point of suing in this case is restitution.

Good, so somebody can sue on my behalf and bring me back to life? Please point me to a legal doctrine so powerful, a Lazarus Law, so powerful that the dead can be brought back.

> This gives doctors the same kind of incentive to treat you well in a freed market as in a state regulated market.

I recognize that "not getting sued" is a powerful motivator, but that motivator already exists. Regardless of the kind of market environment the care is given in. But relying on that as the only motivator isn't advisable. Lawsuits and regulation seem to be working fairly well. Eliminating regulation seems like a rather rubbish idea from any angle.

Re: what is my argument

Here's the original comment

"I would rather have judges, in a court case where parties get to represent themselves, applying common law, with a jury of my peers deciding the verdict... than random idiots elected by a bunch of other random idiots I don't know make laws without my input."

My argument is that relying only on lengthy, expensive and often untenable (because I'm dead) lawsuits, that involve not just you, a couple of lawyers and a judge, but now involving a jury (let's take a dozen people away from their daily lives because I have problems recognizing the benefits of making rules before people get hurt), as the only means of providing safer case is not the smartest idea I've ever heard.

The lawsuits are for when everything fucks up and you end up in a bad situation after the fact. Regulations are to have a good go at keeping you from ending up in the bad situation to start with. I know, it sounds like madness. But hear me out.

Sometimes, you make rules before you do something to try and keep bad things from happening.

Clear?

> So it's 100% or forgetaboutit?

Sigh. You quoted me out of context. Right after that, I said: "(I'm not saying this justifies freed markets! I'm saying this makes your argument bunk.)"

Neither freed markets nor state regulations are perfect. Which is my point: your particular criticism applies to both equally.

> I recognize that "not getting sued" is a powerful motivator, but that motivator already exists. Regardless of the kind of market environment the care is given in. But relying on that as the only motivator isn't advisable.

You have not shown me how being sued for wrongdoing is any different than being punished by a state sanctioned regulatory body for wrongdoing.

> Lawsuits and regulation seem to be working fairly well.

Depends on what your measure is. In broad strokes, sure. Governments in first world countries tend to work quite well based on our standard of living. But how much juice do you really want to squeeze?

Hint: That this conversation is even occurring suggests there's enough going wrong for people to be unhappy about the status quo.

> Eliminating regulation seems like a rather rubbish idea from any angle.

Adding/changing regulation seems like a rather rubbish idea from any angle.

> My argument is that relying only on lengthy, expensive and often untenable (because I'm dead) lawsuits, that involve not just you, a couple of lawyers and a judge, but now involving a jury (let's take a dozen people away from their daily lives because I have problems recognizing the benefits of making rules before people get hurt), as the only means of providing safer case is not the smartest idea I've ever heard.

I'm completely and utterly baffled to hear that all of those resources are necessary in every case. The threat of all those things happening is enough to make people settle in most of the cases.

> The lawsuits are for when everything fucks up and you end up in a bad situation after the fact. Regulations are to have a good go at keeping you from ending up in the bad situation to start with.

This is equivocation, plain and simple. You've arbitrarily designated lawsuits as "only for really really bad things" and claimed regulations are "preventative." But this is true of both lawsuits and regulations.

Reason to sue: Doctor kills you because of negligence.

Regulation: Don't be negligent.

Same thing. You kill someone because of negligence without state regulations? You get fucked. You kill someone because of negligence with state regulations? You get fucked.

You really think regulations stop that from happening now?

Should we stop sterilising surfaces because it only protects you from infection 98% of the time?

Regulations are far from 100% successful, but yes, I do believe they reduce the number of accidents.

Good, the the incentive moves to kill the patient rather then try to save them from an accidental complication. Dead patients can't sue.

>It literally saves lives.

Authoritarianism does tend to save lives. That doesn't make it a good thing.

>If healthcare was left as a completely free market I dread to think how many people would die as a result of cut corners and rushed diagnoses.

As if that isn't the case in the most heavily bureaucratized healthcare systems today...

The free market doesn't result in "cut corners;" it results in optimal middle grounds between cost-saving and quality of service, tailored to individual market groups.

You can get the free market back in health care once you can convince society in general that it's acceptable to let poor people die of treatable diseases. Until then, it's simply a question of how it'll be heavily regulated, not if.

The United States is the most charitable country in the world. On top of that I never said to deny coverage to those that can't afford it. There are other ways. How about the giving them an annual voucher for $X, whatever they don't spend gets rolled over into the next year. Just like a HSA.

People with serious diseases will outspend their voucher, and then many of them will die unnecessarily.

Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind. I've yet to see one, though. Not being allowed to refuse treatment screws up too much.

> Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind.

No such proposal exists. Any proposal that does requires a third party to intervene as either an angel to donate whatever resources are needed or as an agent enforcing policy that one group of people must provide services to another group of people regardless of means.

Both of the aforementioned scenarios do not exist within the realm of market forces because market forces cannot make guarantees.

People will always die because they don't have the resources to fix what ails them. We can only hope to lower the amount of resources to get treatment, and "market forces" are absolutely a legitimate solution to that.

But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely.

"But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely."

We are in agreement. My point is that society is stuck on this (note that I have made no value judgment in these comments myself) and until and unless that changes, market forces are implicitly ruled out.

Actually, the Israeli system does sort-of stop people from dying yet still lets market forces do some magic. It is single payer (gov) through taxes, every person chooses their HMO. The HMOs get paid per member (so they compete for the members) and they are also allowed to offer extra services to their members (which they also compete on). And finally - and I think this is also crucial - the government has a special fund for expensive life saving treatments that the HMOs tap into when needed - so they do not have an incentive to avoid those treatments.

> Give me a proposal that stops poor people from dying of treatable diseases while preserving market forces, and I'll change my mind.

See my comment elsewhere on the swiss model.

People with sufficiently serious diseases will die, period, even if they're the wealthiest people on Earth. I don't see how the inevitability of death caused by disease is a useful argument. If there was some disease that one person had, and that could be cured only by pooling the entire wealth of the Earth, should we forcefully take that wealth to cure that one person?

That would be an interesting hypothetical if anybody sensible had ever suggested anything close to that.

Death isn't preventable, you can only delay it. Should the people pay for someone's heart surgery if their kidneys are on track to fail in a few months anyway?

I don't know, but people in general seem to think the answer is "yes". Until and unless that changes, market forces won't really work in health care.

Life expectancy estimates are often all over the board and wrong. Imagine it's a close relative who is having the heart surgery. Would you actively try to persuade them to not do the surgery to possibly extend their life because their kidneys might fail later, so they might as well die now because they're not worth the money that would go into the surgery?

It's easy to say a Big Mac isn't worth the cost on the menu, it's harder to say that your mom's life isn't worth the cost.

Keep in mind we're talking purely about economics here, as that is what your post is about. We're not talking about quality of life.

Economically speaking, I think it's fine for a person to spend huge amounts of their own money that way if they want. Also, it's fine if they ask around for friends, family, or even total strangers to finance their health. But forcing people to pay (via taxes) for an operation seems outrageous to me.

Not really the point I was making. People will go to great lengths and effectively destroy their own life in the pursuit of saving a loved one. This makes it hard to take seriously the concept that a a free market full of economically rational consumers would exist when it comes to costly medical decisions.

It's easy to say "if you didn't want to be poor, you shouldn't have bought that plasma tv or new smartphone", versus "if you didn't want to be poor you should have let your wife die instead of taking a second mortgage out on your house".

Most people do not have a maximum price on something they consider priceless.

You benefit immensely from society. To expect you to pay some portion of your income to help that society function is not unreasonable, and extensive healthcare is consistently one of the things people in most developed societies see as one of the top priorities for society to spend that money on.

I'd fully support your right to opt out of taxes if you also opt out of each and every benefit society otherwise provides you.

If the government starts paying (at least some) of people's medical bills, there will be a committee somewhere that determines who is deserving of care and who is not.

If the government doesn't, peoples finances decide who is deserving of care and who is not, which more often than not means an insurance company decides.

Personally I'm far more comfortable with a board under democratic control setting rules based on clinical considerations for whether or not someone is suitable for care, than having someone with a profit motive to avoid paying for my care making that decision.

You're more optimistic than I am if you think that a government committee will be democratic, or that such a committee (democratic or not) would base its decisions on clinical considerations, or that people would not be outraged at rational clinical decisions.

In general, I think this kind of decision is highly personal and dependent on circumstance, and cannot possibly be regulated at the federal level.

I am optimistic of that because I've lived all my 38 years in countries where all of those are the case for the most part, and where violations leads to lawsuits and heads rolling, resulting in health systems ranked substantially higher than the US, while costing less money per capita (UK and Norway).

In the UK this is handled by NICE: http://www.nice.org.uk/

They conduct appraisals of technology and medicine, and the NHS is required by law to provide treatments that NICE recommends.

The NHS trusts may elect to provide funding for additional treatments, though.

A number of their working groups etc. are open to healthcare professionals, and some are open to patient representatives, carers and lay people. Consultations are open to anyone. On top of that they are accountable to their sponsoring department.

Overall, this system works. You hear people complain about wait times for non-essential treatments, but everyone gets treated.

> You're more optimistic than I am if you think that a government committee will be democratic, or that such a committee (democratic or not) would base its decisions on clinical considerations, or that people would not be outraged at rational clinical decisions.

As opposed to the democratic decision that's already being made in board rooms?

It doesn't have to be democratic because it's not using the public's money.

oh I see, so long as people are killed by private money it's cool.

Oh, so as long as people are "killed" democratically it's cool.

Nobody's killing anybody. People die. It happens. Maybe someday I will have a heart attack. On that day, I'm not going to rob somebody at gunpoint and demand they give me $33k. Equivalently, I'm not going to have the government threaten fellow citizens with jail time and garnished wages if they don't pay their taxes to pay for my treatment. And I'd appreciate it if they'd extend me the same respect.

You know what? You're right. Fuck it. People die. Let's not even bother. Let's cut out the police department, the military...even if you did have the money, why bother? You're just going to die.

Why bother eating right or exercising? Fuck, why not just off ourselves and save all the hassle.

There's absolutely no difference amongst the different kinds of things people can die from, especially ones that are easy to fix and ones that we can't do anything about.

There's absolutely no difference amongst the different kinds of things people can die from, especially ones that are easy to fix and ones that we can't do anything about.

Hey, we actually came back to the point, kinda! There's a lot of things you can die from that fall in between "easy to fix" and "can't do anything about it". Where you draw the "fuck it, people die" line is hugely variable between different people, and it's not something you'll find a shred of consensus on across the 300,000,000 people in the USA. It's better for people to negotiate coverage with individual hospitals (and voluntary charities) than to have standards of care dictated by a central authority.

apparently it's provably not since countries with a strong centrally controlled health care system seem to be providing superior health care vs systems that let people do what you propose

there already is, and always has been

Isn't that just rationing in a different form? If someone has $X to spend on treatment, and the best treatment costs 10*$X, then they will not be able to receive that treatment.

Do we expect that our medical professionals and facilities have the capability of providing the best treatment to everyone all the time? If they do not, how should we decide how to allocate the medical care?

I agree, that's exactly the question. Well, unless we get to a situation where literally every person can receive the best treatment for every ailment, at high-quality facilities with no waiting. If we're not in that situation, then some people can't receive the best treatment for their condition, and the question is who and when.

how should we decide how to allocate the medical care?

Our current method of deciding is to stick our fingers in our ears and pretend it doesn't matter. Anything has to be better than this.

Actually, we are using money to allocate it, which seems pretty reasonable. This will be an even better idea if we can bring costs down substantially.

Hospitals generally won't deny life-saving treatment. But they would deny anything less. Even, paradoxically, providing cheaper preventive care to avoid expensive emergencies later.

>Hospitals generally won't deny life-saving treatment. But they would deny anything less.

That's right, they will let you get sick enough to need intervention, and if you can't pay, they'll try in the meantime to find a gov't program to foot the bill.

Not sure what charity really has to do with it. Americans aren't going to willingly give money to "help the poor" to the extent that medicare does.

I would imagine that the US is also among the greediest countries in the world.

Odd how it can work out that way with percentages.

[edit: grammar]

Charity is an excuse to keep the poor around in order to look good pretending to help them. As a stopgap in the immediate future? They're good things. As a long term strategy? It's intentionally ineffectual.

No charity has, or ever will, end major problems like hunger or poverty.

Also, on a dollar per dollar basis, the government is vastly more efficient than nearly any charity. The Social Security Administration's overhead was 0.8-1.4% (depending on how you count) last year. Find me a private charity that efficient.

Make a Wish Foundation crows about spending 76% of funds on programs. If the SSA were as efficient as Make a Wish Foundation, it would have an overhead of an additional $185 billion a year (i.e. approximately equal to all federal payroll expenditures).

The bulk of charitable spending is on programs and fundraising, usually in that order. The SSA doesn't have to worry about fundraising, hence the disparity in admin expenses.

What a ridiculous statement. Most of the charities' overhead is money spent on fundraising. The SSA doesn't have to fund raise since it's illegal to not pay into it.

What's ridiculous? That seems like a compelling argument to forego fundraising in favor of taxes.

overhead is not the best measure of charity, QALYs saved is. If one charity has 50% overhead but saves 10 times the QALYs as one with 0% overhead you want the one with the overhead.

Thank you.

The government probably has a worse QALY because it runs Medicare, but that's not the government's fault -- anyone who runs the medical care program for old people is going to have horrible numbers there.

(You are more likely to die if you are on Medicare than if you are uninsured. This isn't because Medicare is killing you, it's because old people are on Medicare.)

In addition, we'd have to examine marginal-QALY versus average-QALY. Depending on the question one or the other could be more important.

Americans freak out whenever anyone tries to do QALY measurements, so we don't know just how good (or bad) our various programs are, public or private.

Why would you assume or imagine when you have the single biggest source of information in the world at your fingertips?

From http://www.charitynavigator.org/index.cfm?bay=content.view&#... we learn that:

- Total giving to charitable organizations was $298.42 billion in 2011 (about 2% of GDP). This is an increase of 4% from 2010.

- Giving by individuals (which includes bequests and family foundations) is critically important as it represents nearly 9 out of every 10 dollars donated.

- 32% of all donations, or $95.88 billion, went to religious organizations (down 1.7%). Much of these contributions can be attributed to people giving to their local place of worship. The next largest sector was education with $38.87 billion (up 4%).

- Donations were up to health charities (2.7%), to public benefit charities (4%), to arts, culture, humanities charities (4.1%), to International charities (7.6%), to human services charities (2.5%), to environmental and animal charities (4.6%).

For comparisons to Europe, check out: http://www.american.com/archive/2008/march-april-magazine-co...

- Per capita, Americans give 3.5x than the French, 7x Germans, 14x Italians.

- Americans are 15% more likely to volunteer than the Dutch, 21% more than the Swiss, 32% more likely than the Germans.

The pattern holds true across many demographics (education, age, income).

So if the $298.42 billion donated world wide, almost half ($135 billion) went to fairly self-serving purposes (e.g. me donating to my alma mater to improve the stature of the school).

I don't think data really helps you get to an answer. I can only go by my experience living in America.

My observations are that Americans definitely look out for themselves. People tend to give (as you stated) in ways that directly or indirectly benefit themselves.

These are broad generalizations but having lived here for 30 years I'd not consider our society to be generous by any stretch of the imagination.

All I can say is, I am glad I don't live where you do or hang around the people you do. Having lived here all my life I cannot count the number of people who bend over backwards to help others. I watch people with half my income give money to church, charity, and the like.

Now, in the techy world I work in, I can find a wealth of self centered pretentious types who are more concerned about how their seen that what they see.

I was thinking he had pretty bad selection bias. If I applied the same to my day yesterday, you'd assume every software developer was a sharp female game hacker with a little too much caffeine in her system. ;)

First, those numbers were US exclusively as that was the situation you referred to.

Second, while many of the donations were to religious organizations, many food banks, shelters, etc are run by the same institutions. Assuming those categories are mutually exclusive is risky at best.

>Not sure what charity really has to do with it. Americans aren't going to willingly give money to "help the poor" to the extent that medicare does.

"Medicaid" is the program you're looking for, not Medicare. Anyway, Americans did willing give money to "help the poor" get medical treatment. There were various organizations that operated charity hospitals (Shriners and the Catholic Church come to mind) where you paid what you could pay, and Americans donated generously to keep those hospitals running. It was normal for doctors to put in some amount of unpaid time in charity clinics because that was considered the right thing to do.

But the government crowded all that out, and since it's been a few generations people don't remember.

>I would imagine that the US is also among the greediest countries in the world.

This isn't even close to being right.

Most of that "charity" is for religious brainwashing. Sending kids on thousand dollar flights to work on a cinder block indoctrination center and also get a beach vacation out of it.

Don't remember where I read it, but someone had a good line about youth pastors essentially playing the role of cruise ship activities coordinators.

This is a red herring. It is not surprising that the cost of care can vary wildly when the customer cannot possibly know the cost of care before purchasing it. Even a person with no immediate need for care cannot obtain the best price since no hospital will provide him or her with a price up front.

"Posting prices publicly" is not the same thing as "completely deregulating the industry" or "repealing EMTALA."

How shall emergency rooms operate? Also, how shall people make an initial determination on care when no diagnostics have yet to be performed?

> How shall emergency rooms operate?

Not all emergency room decision-making happen with blood pumping out of your pulmonary artery. There are parents who take their babies to ERs, and through repeat business decide to like one better (maybe because it's cheaper, maybe because it's a bit more expensive, but never have any waiting time) than the other. There are consumer reporters who will look into why one hospital is cheaper than the other. Smart phone "Yelp for hospitals".

EDIT: Forgot the conclusion: This will drive down prices in the general case, which will also result in lower prices for the emergency case, even if in an emergency you don't have the luxury of calmly evaluating all the options.

> Also, how shall people make an initial determination on care when no diagnostics have yet to be performed?

The same way you decide which restaurant to go to before you know exactly which dish to have: Ranking by a general cost/quality scale.

I wouldn't bank on free markets fixing emergency room problems. While anecdotally some parents may choose to take their children to one hospital or another, I doubt this is a statistical norm. I imagine most people choose the nearest emergency room for most emergencies, and hold off for an appointment with a doctor otherwise. Sometimes, it's just a baby with colic. But sometimes (increasingly in a country with a serious obesity problem) it's a heart attack, and no one is going to drive their dad 45 minutes to the cheap hospital when the one that will save his life is 10 minutes away. Because of this I don't think hospitals have any incentive to drive down ER costs.

But maybe I'm projecting, since my experience with ERs tends to be "Oh shit... get me to a hospital now Google Maps" rather than "I should Yelp some reviews of hospitals, because I have time."

Of course it's hard to predict what will happen. But right now, nobody has an incentive to even check, so obviously it doesn't happen.

Some people will live 10 minutes from one ER and 45 from the next. But some will live 25 from one and 30 from another. Or have three within 15 minutes (ie. short enough that they're equidistant for "the baby has colic"). Some will have more time than money and drive 45 minutes if it means saving $20.

But there's another factor in free markets you're not accounting for: new entrants. If an ER charges high rates because they're the only player in the area, someone could set up a competing ER and charge less.

I love how easy everyone always makes this sound. Yeah, just setup a hospital near the other hospital and make your prices lower. I'm sure they wouldn't respond by lowering costs until I'm driven out of the market and then immediately raise them again.

And amazingly we still have businesses that compete and don't price all their competitors out of business. So I don't think this is an obvious conclusion.

The reason that this is so is because of regulations.

Or it could actually have nothing to do with regulations. Something called imperfect competition: very few people want and sell the exact same thing. That makes it very difficult to sell superior products at lower cost.

As far as I can tell it is very difficult to prosecute for predatory pricing in the US. This doesn't particularly matter, since it is an awful idea and almost no businesses would do it anyway.

Actually you are not allowed to set up a hospital near another hospital; you need a "certificate of need". I'm not kidding.

Oh, a CON. Hayek probably had some fun with that.

Doctors have no idea how much a procedure or test cost (and they don't care or want that burden)--that stuff is generally insulated by insurance. In my experience, they are vaguely aware of the price of different prescriptions (after insurance) because that directly affects the patient. The economic forces are all out of whack. I'm not blaming doctors--the information should be more easily available to them to provide to the patient.

I'm not in the medical industry (but my g/f was seeking out her own insurance recently), but I would guess that the ER would work similar to a car mechanic. Where the paperwork you're already signing upfront includes a flat price you're paying for diagnostics. Then after the diagnostics (or possibly at the same time you signed the diagnostic paperwork), you agree to a price range for treatment/tests. It would itemize the fixed costs and estimate the variables. If things go outside of that range, there's an amendment. You walk home with the bill.

"Each blood test: cost $X" "Each x-ray: cost $Y"

etc etc.

That way patients can ask the doctors if the tests are actually needed.

You're right that emergency care becomes a lot more complicated.

In actuality, it would be: "Each blood test paid by insurance company $A costs $X, Each blood test paid by insurance company $B costs $Y." Etc.

I really think a big part of the problem in healthcare pricing is insurance company policies regarding networks and guaranteed volume. Your auto insurance doesn't demand you use a certain body shop, why should your health insurance?

Here's a practical example that recently came up for me. My wife is a nurse at a few clinics. At one clinic, she's got health insurance and that clinic provides IUDs via their hospital, which she wanted to get. At this clinic, the price billed to her insurance would be $4700.

At another clinic she works at, she could get the same IUD brand and procedure for $600.

When she asked her insurance about it, they said they would pay 100% of $4700 in-network but 60% of $600 out-of-network. Obviously, being selfish, she decided to let the company eat the $4100 they would otherwise save so that she would pay $0 instead of $240.

Because that $4700 isn't the cost the insurance company is paying. The real reason you can't go without insurance in the US is they're negotiating steep discounts - where I live it's supposed to average 80%.

It may well be they paid less than $600 for a procedure that lists at $4100.

And of course the government numbers don't take this into account, so what they've published is pretty much worthless.

I doubt it. That $4700 is what was listed in the insurance packet, then again in the bill along with a few other minor expenses incurred during the procedure, and finally paid for by insurance in a later notice to us. The 100% is because of ACA requirements.

I don't disagree with you that insurance companies negotiate different discounts, though, which is what I was trying to get at in my post regarding pricing.

The gov't lists medicare reimbursement which is basically the insurance price maximum. Some insurers get better than medicare pricing.

You know what is wild though? Federal employees aren't insured by medicare but instead the federal govt pays private insurers to insure them!

If the Feds went to single payer for its employees, things would change quickly.

>That way patients can ask the doctors if the tests are actually needed.

How does this work? If a doctor prescribes a blood test, he's already said it's needed. Put yourself in a doctor's shoes for a minute. You told the patient he needs a blood test. Then he asks you whether it's actually needed.

How can you possibly say "Nah, just kidding. We don't need that one"?

One of the most important questions you can ask of a doctor is "what happens if we do nothing?"

That works for treatment, but not so much for tests. If you don't know what's going on you don't know what happens if you don't do anything.

Doctors order tests to help them choose the right treatments.

If they have absolutely no idea what the possibilities are then they wouldn't be ordering tests anyway.

>Doctors order tests to help them choose the right treatments.

No they don't, except in very rare cases. Doctors order tests to make a diagnosis. The treatment follows from that.

>If they have absolutely no idea what the possibilities are then they wouldn't be ordering tests anyway.

I'm not sure a doctor would have "no idea what the possibilities are" unless you don't have any symptoms. If you don't have any symptoms, why are you at the doctor's office?

> > Doctors order tests to help them choose the right treatments. > No they don't, except in very rare cases. Doctors order tests to make a diagnosis. The treatment follows from that.

What I said didn't contract what you said. If test => diagnosis => treatment then test => treatment.

Without a diagnosis, how could a doctor possibly know the answer to the question "what happens if we do nothing"?

I never said without a diagnosis.

It's pretty rare to arrive at a diagnosis without tests.

Overtesting is more or less a thing in the U.S. Many tests are not harmless, so even a person who carries an infinite amount of money around would do well to question the necessity of tests.

>Overtesting is more or less a thing in the U.S.

I don't believe that. Over the years I've had to fight to get tests that turned out to be important, and I'm suspicious of government studies showing "overtesting" right when the government is in the process of taking over health care.

You can certainly eliminate a lot of testing without affecting mortality rates significantly. But that's because in absolute terms a lot of extra people have to die before mortality rates are affected significantly.

need it != it would be useful

Because a plumber from idaho can make better decisions about whether the hacking cough + bloody sputum requires a chest x-ray than his doctor.

Right.

The customer generally cannot even know the cost of care after purchasing it. Not only is the issue muddled by insurance companies' negotiated rates, but the line item prices on doctors and insurance statements are almost complete nonsense. Really they just say what broad category the care fell under for record and insurance purposes, and there is no way to tell if you have, for instance, been double billed for a procedure. The only times I've been able to clearly tell what I paid for was when going to a specialist for a very specific procedure.

No, it's not a red herring. It's two different problems with the same industry.

It is not surprising that the cost of care can vary wildly when the customer cannot possibly know the cost of care before purchasing it.

Even the healthcare professionals can't estimate the price of care before providing it, because it depends on the outcome of things like surgery and reaction to treatments which cannot be predicted. So there's no way to tell the patient beforehand that their care will cost x amount. In addition to this the customer often doesn't know what they want and has no basis for making an informed choice before seeing a doctor. This is fundamentally different than (for example) selling products in a supermarket where costs are known up front, shops can vary prices and quality, and people can shop around. So the benefits of patient choice of hospital and treatment etc are questionable.

Other countries spend far less using a single-payer system with comparable or better outcomes than the US according to the statistics on life expectancy and expenditure per capita on healthcare, so IMHO the US should have more and better regulation of the healthcare market, not less. Cutting out the insurance companies completely would be a good start, as at present they run a racket extracting billions from the US tax payer for questionable results.

> So there's no way to tell the patient beforehand that their care will cost x amount.

I call B.S. -- unless you're calling B.S. on the data.

There's something called "estimation" which comes in very handy when you don't know something with certainty.

If you have absolutely no idea, then you just guess the average cost for each patient with a similar background, with a disclaimer that it may not be accurate.

Problem solved, unless you don't want to do it because then it'll prevent you from ramping up the prices unnecessarily later.

Tell me my surgery will cost $100,000 at hospital X and $200,000 at hospital Y (both of which are close to me and staffed with competent employees). It won't influence my decision as long as my insurance company doesn't care. I'll pick based on the doctor and the insurance company can negotiate either bill (down to a very similar level, I presume).

If I don't have insurance, I may be swayed by the $100,000 price, but either way they'll have to sue me to get all of the money that they ask for.

Problem definitely not solved. There's too much uncertainty, and comparisons are too hard.

This happens all the time in software. Non-techies put a project out for bid. They will get estimates from a variety of consulting companies. The estimates could easily vary by an order of magnitude. Do they go with the lowest, because they are the most efficient operation? Or is the low price a sign that they're the dumbest, and are underestimating? Do they go with the highest, because in a market economy price is correlated with value? Or are those guys just the gougers?

And medicine is worse, because things are so contingent. Complications get complicated indeed. And the person trying to make the decision is pretty likely to be sick. I tell you true: deciding what to do about cancer is hard enough without trying to organize and judge a multi-round competitive bidding process.

Claiming something is "too hard" never got anyone anywhere.

Neither did waving away problems as if they didn't exist. If you can solve this, solve it. But arguments of the form "in theory there's a solution, so problem solved" aren't a step forward; they're a way to prevent others from trying.

> they're a way to prevent others from trying.

What exactly was I trying to prevent others from trying?

Well, I was assuming that you were participating in the conversation, rather than just seizing upon a sentence and nitpicking.

The conversation was about the role of the free market in health care.

User curt said that the only way to solve health care pricing was through the free market via individual choices. Mikeash said that would only work if we were happy to let people die of treatable diseases. Anonymoushn said that was a distraction, that the market would be fine if people could know prices up front. Grey-area said that predicting costs was basically impossible, so the market-based solution was unworkable.

You jumped in to say that prices were predictable through this new thing we hadn't heard of called "estimation", saying that this solved the problem. The problem, presumably, being how price opacity and unpredictability make a hash of individual-choice market mechanisms.

So I have no idea what you were trying to do, but as far as I can tell, it was either a) pushing people back toward an unworkable market-based solution for health care, thus preventing them from moving toward a solution that doesn't fit with the fundamentalist liberarian ethos so popular on HN, or b) you're doing this: http://xkcd.com/793/.

Given that you ignored the meat of my point twice in a row with nitpicky comments, as well as doing the same to the previous poster, I'm figuring b.

I was actually responding just to the issue of predicting costs, not to the upthread issue of whether or not a free market is a good idea.

Predicting costs is a benefit regardless of whether or not we have a free market -- I was saying that nothing is completely unpredictable; estimating based on the average value of a treatment gets you much further than knowing nothing at all.

Claiming costs are inherently unpredictable is equivalent to calling B.S. on this report -- that the values in the report are meaningless. Clearly, they're quite meaningfull.

I never claimed estimation = "problem solved", I just said that it's a step forward that needs to happen. But you came along and just dismissed the idea because it wasn't a solution.

And my reply, which you thought was ignoring your comment, was that a step forward doesn't have to be a solution -- you can't just dismiss it because it doesn't stamp "Problem solved" on the bottom of the page.

Unless you or others are claiming that being given an estimate of costs HURTS anyone, I don't see how you can argue it's a bad idea. "Problem not solved" never solved any problem.

Responding to some random sentence in the middle of a discussion as if you actually have something relevant to say is annoying, and a big waste of other people's time. If you want to go off on a tangent, say so. Then nobody has to try to figure out what you're on about.

Predicting costs is not an inherent benefit. That only is useful if somebody will change a decision based on the prediction. Otherwise, it's wasted effort. My mom was on Medicare throughout her cancer treatment, and I promise you: not knowing the costs was perfectly fine.

In fact, not knowing was better. The cognitive load of a major illness is huge. Not knowing is also better for most medical personnel. Their goal should be to maximize patient outcomes. Asking them to juggle some sort of cost-benefit tradeoff in the middle of treatment adds an insane and impossible burden.

Also, you quite literally did say "problem solved" after proposing SWAG estimation as a solution to a problem. Maybe you wanted me to have some other understanding, but I have no idea what it would be. And, since you admit you are off on some sort of tangent, I don't really care.

Alternatively just charge everyone the average cost, with no disclaimer.

In fact you can do that before the need for care is even known, and you can call it insurance.

And why should healthcare cost money? That's pinning quality of health to how much money you make.

And that's just plain immoral.

Well, let's look at the alternatives. If we don't want people to have to pay for the services they use, we can let people enslave doctors. Or, we can steal from every citizen in the whole country and use the resulting money to pay the doctor. This second option would be called "single payer," and it is my preferred policy, but it does not seem to be obviously morally different from enslaving doctors or obviously morally preferable to requiring people to pay for the services they use.

Or, and I'm going out on a limb here, and we could have a thing called a "democracy", where we jointly decide to pay for health care for everybody. And then we could come up with some sort of system for sharing out the costs of the joint project in a more-or-less equitable fashion.

Right, this is what I proposed. We should democratically agree to use the threat of violence to steal money from everyone to pay for medical services for everyone.

Theft implies unwillingness. So sure, in the sense that paying your share of a group meal you ordered is theft, yes.

More like: we agree together to set up a society, then people in it have to follow the rules. If you don't like that, there are rules that let you change the rules.

"equitable"? That's a 100% subjective term. Of course if someone else is paying it's equitable. If you're paying for someone else, it's not.

Actually, if somebody else is paying for me, that's inequitable. I like to pay my way.

That something is subjective doesn't mean that it's unknowable. Justice is subjective, but that doesn't mean we should abolish the courts and the police. Those institutions will never be perfect, but we can nonetheless always work toward perfection.

First off the courts and police have nothing to do with health care. Secondly, the courts don't dispense "justice", and judges will tell you that first thing as you arrive for jury duty. They dispense the law.

Justice is 100% subjective, but we have a reasonably good system for it. Equitable is also 100% subjective, and it is equally possible to pursue it.

We call it a justice system, but it's not. It's a legal system. That was my point. Once you start trying to dispense justice you fail.

So? We have sewage systems, but their purpose is health. Imperfect systems are how we work toward ideals.

We evaluate the legal system in large part by whether the outcomes are just. For example, the revision of the three strikes law in California is happening because a number of people have received obviously unjust sentences. And we got the law in the first place because many people thought that letting serial offenders free to harm people again was unjust.

"Equitable" is another one of those ideals, and that it is just as subjective as justice or health. But we can work toward it.

Which is the greater moral disservice - a set price, to be paid for by a non-profit, heavily regulated healthcare org -- or letting people die because they can't afford to go to a hospital that isn't overrun by MRSA?

It's not clear to me what you are proposing. Particularly, the source of funding in your proposal seems to be something like "A miracle occurs, and then the healthcare org is sufficiently funded to pay for people's health care."

One could just as easily ask "Which is the greater moral disservice - a global food distribution network that ensures every person will have safe sustenance, or letting people starve because of regional droughts, tyrannical governments, and currency speculators?" but the question does not apparently lead to any actionable policy decisions.

Why should food cost money? Why should shelter cost money? Why should heating oil cost money?

Because those industries work better when they do*

Just like health care works better when it is provided by a single payer.

* In the case of shelter, temporary shelter for those who need it is also provided free of charge, but that is not the normal situation for most people.

He said reintroduce market forces, not remove all regulations.

I'm a pretty big fan of the swiss model, I think it contains the best of both worlds:

You're forced to buy a certified policy with a certain (broad) coverage. If the cost of such a policy exceeds 8% of your annual income, government makes up the rest.

Both insurers and providers are regulated heavily for quality control, but compete freely for their business.

The result is a generally consumer driver system, as opposed to an insurer driven (US) or state-bureaucracy driven (most of Europe) model.

What's your definition of "best"?

There are only two measures of effectiveness.

Per capita costs and life expectancy.

How does Switzerland rate?

There are only two measures of effectiveness

In the free market you could argue that 'customer satisfaction' is the only measure of effectiveness you need to consider. Equating customer satisfaction with best solution fails in everything from automobile ratings to elections.

> There are only two measures of effectiveness. Per capita costs and life expectancy.

Uh, no. Health care is a lot more than keeping people alive.

Cost: More expensive than the European average, quite a bit cheaper than the US.

Life expectancy: second in the world, at 81.81.

https://en.wikipedia.org/wiki/Healthcare_in_Switzerland

https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

EDIT: And, since it apparently wasn't clear from context, by "best of both worlds", I mean that it manages to get a competitive, consumer oriented system without sacrificing universal coverage and regulation of quality.

Life expectancy correlates nicely with wellness.

Adopt the phrase "patient oriented system" and I'm totally on board.

> Life expectancy correlates nicely with wellness.

It may correlate reasonably well, but there are plenty of ways life expectancy can be the same for systems with very different level of "wellness". For a long time, Sweden had special wards for people in persistent vegetative states because there was no provision for ending care, for example, resulting in people being kept alive for years long than they otherwise would. I believe they loosened the requirements for ending care quite a while ago. But there are plenty of other ways that life expectancy can correlate badly with "wellness", e.g. poor treatment of patents with long term conditions such as dementia where patients can often easily survive for a decade or more but where quality of life can be massively different depending on treatment.

Defining "wellness", I can do no better than rely on societal norms.

I've spent much time in critical care, as both a patient and an advocate.

Quality of life is of utmost importance. I support DNRs, euthanasia, and so forth.

But I would not presume to impose my values on anyone else.

Switzerland is likely first in the world. Japan's number is bogus, it's artificially inflated by rampant benefits fraud.

>There are only two measures of effectiveness.

>Per capita costs and life expectancy.

This is laughably wrong. The biggest influence on life expectancy isn't the medical system at all - it's the lifestyle habits of the populace. Genetics play a big role as well.

The most important contributors to those two things are likely to be something other than the health care system.

For example if you increase the tax on cigarettes you increase life expectancy.

And if you increase immigration, and therefore decrease the average age of your population, you will decrease per capita costs.

If everyone has insurance, what makes providers compete on price?

I don't understand, they compete like any other business? The same for less money or a better product for the same (or more) money (a poor product for even less money, of course, is not an option).

The people choosing who to patronize aren't the people paying, so where's the incentive to compete on price?

Providers, dammit, not insurers. Makes sense now. Sorry.

Good question, I don't actually know. Surely the insurers will make them compete, but that should also happen in the US, and obviously not fixing the problem.

To get more customers from 'the other guy?' If they all cost the same, then no one will switch, but if Insurance Company A is cheaper, then maybe someone will switch from Insurance Company B.

[ I'm assuming that you mean 'insurance providers' and not 'medical care providers.' ]

Odd how three people all responded to me with the interpretation that I was being a moron rather than the interpretation that I was asking a tough question.

Think of car insurance, which is mandatory (agree some people still ignore it) yet is super competitive. And they don't compete on price. They just differentiate in the market around price and services.

The UK healthcare system is 96% or so publicly funded. Yet I choose my private GP. If they don't treat me well, I go somewhere else. So while they can't compete for me by price, they need to be efficient enough to be able to afford to provide care their patients are happy with, or they loose their patients, and with it their funding.

They also need to keep their cost under control, as their cost determines their profitability: The rate they get paid to take NHS patients is set across the board.

And if/when the NHS sees the cost of providing certain care drops across the board, they can and do push the price they are willing to pay for it down.

The UK incidentally has a healthcare system that is substantially cheaper than the US, yet ranked substantially higher by the WHO.

I spent 5 weeks in hospital last year for Pulmonary Edema (fluid on the lungs) related to diabetic-induced heart problems. Two ops and 5 stents later I can't fault the UK NHS model. It's not perfect, but it does a great job without bankrupting the patient.

> If everyone has insurance, what makes providers compete on price?

Strictly speaking, they don't.

But they have a strong incentive to limit costs because of insurance company reimbursement policies and the conditions for getting "in network" for HMO-style plans.

Sounds quite a bit like PP/ACA.

Didn't the US basically go with the Swiss model with the ACA?

We've still got all of our previous healthcare systems (Medicare, Medicaid), but the ACA added mandatory insurance with specified minimum coverage, and helps pay for the insurance of the poorest people.

There seems to be elements, but hardly the important ones (making insurance and provisioning consumer facing).

The thing is, poor people are still dying of treatable diseases. Many of them by choice (McDonalds, smoking, etc)

Sure, but the system is still bent by the attempt not to let this happen, and serious market forces won't be allowed to do their thing as long as people continue to insist that this attempt be made.

>>>that it's acceptable to let poor people die of treatable diseases

This already happens if you have poor dental health.

For Want of a Dentist http://www.washingtonpost.com/wp-dyn/content/article/2007/02...

Man Dies From Toothache, Couldn't Afford Meds http://abcnews.go.com/Health/insurance-24-year-dies-toothach...

Obamacare, AFAIK, excludes dental care. Dental care is somehow considered "vanity" medicine, even if prosthodontics are medically valid.

Only the government can take care of poor people?

I hope you're not trying to imply that it is unacceptable to let poor people die of treatable diseases. Spending 1 million in other people's money to save one life when that money could also save 1 thousand lives elsewhere (givewell cost per life calculations) is morally inexcusable.

No, I'm implying that society in general appears to find this to be unacceptable. Whether or not you or I agree with that is basically irrelevant.

"Letting" someone not get treated because they can't afford it is no different in terms of my obligation than "letting" someone not have a new car, a new TV, an education, clothing, food, or anything else they need to live.

None of us are born in hock to the needs of others. If we were, that would be moral slavery.

Let me know how that works for you the next time you don't pay your taxes that fund the Interstate I take to get to work.

This does nothing to answer me. I was making an ethical point, not a political one (although it does have political ramifications).

I don't advocate that people not pay taxes. That's just a good way to get fined and/or go to jail. But I do advocate that people fight to abolish taxation, and especially the ethical ideas that support it.

Oh, I get it, you're one of those guys that thinks all roads should be toll roads and you should only be protected by the police and the military if you can personally pay for that protection and all schools should be private -- wanna learn? gotta pay.

Yuck. Never mind I'd rather not debate this with you.

No, that's not what I'm saying at all.

I'm not an anarchist. We need a government! Without creating the conditions necessary for a market, that market cannot exist. What are those conditions? The only fundamental one is to retaliate against anyone that initiates physical force against another. (Examples of this include murder, theft, fraud, assault, etc.)

I suspect you need a lot more than that. You need a police force to enforce it, for example, courts to try and prisons to put away offenders. Then you need communications so people know what the penalties are, and somewhere they are compiled, and a system for changing them and keeping them current.

And then you'll need a financial system to pay for it, which means you will need some sort of currency combined with laws to regulate counterfeiting and some sort of contract law to let people make deals. Oh, and it might be an idea to have a boundary so people know where the law is valid, as well as a language in which the law is written, which means it's a good idea to educate people in that language.

Then what happens if someone doesn't initiate force against another, but just abandons them - eg a mother abandoning her child. Has she committed a crime? What about international fraud? Better have inter-country arrangements in place. But then you might need diplomats, and maybe an armed force just in case.

I could go on. My dream if ever a libertarian paradise comes to fruition is to buy up a one mile strip of land fully enclosing a village and refuse everyone the right to cross it - food delivery, immigrants, emigrants - everyone, trapping the people inside and letting them starve. After all, I can do whatever I like with my property, and the only law we need to implement is property rights, correct?

You need a new TV to live?

All of us are born incredibly dependent on others. After a long period of investment, we can function on our own. (Well, if by "on our own" you mean "without being directly dependent, but requiring a rich and complicated society where other people take care of most things for us".) Most of us choose to pay that forward by contributing to the maintenance of society and the species.

If you don't want to, godspeed. There is no law preventing you from being a selfish ingrate. You are allowed to opt out at any time and move to a country that is less interested in, say establishing justice, promoting the general welfare, or securing the blessings of liberty for the citizenry current and future.

For example, I hear that the tax rates in Somalia are very reasonable. Do start a blog! And maybe we can start a pool on how long you'll last in a place where helping others to survive is seen as optional as having a new TV.

Why is "If you don't like it, get out" perceived as a reasonable response to only a very narrow set of ideas? It seems very strange to me. Nobody says "If you don't like your neighbor owning guns, move to Canada," "If you don't like the small size of your future social security payouts, naturalize in some country with larger entitlements," or "If you want to sell cars directly to consumers rather than to dealerships, just do it in Europe," because of course it would be completely unreasonable to say these things. Instead, for most ideas, people will bother to agree or disagree, knowing that both society and the law tend to change over time based on the views of people.

I think if somebody is saying, "I fundamentally disagree with the foundation of our society", then "try someplace else" is a reasonable answer.

In this case, though, I'm not expecting anybody to move to Somalia. I'm pointing out that places with no effective social contract or taxation system are hellholes. It's not a literal recommendation; it's a reductio ad absurdum to show that the poster's views aren't thought through.

All of us are born incredibly dependent on others.

"Others" as you use it is far too imprecise. A person is born dependent on his parents, who have an obligation to raise him once they've chosen to carry a child to term. That obligation does not extend to people that didn't make the choice to bring the child into the world.

Also, you're attacking a straw man. I'm not an anarchist.

Sustaining a rich and complicated society requires that people act as traders. That entails producing things that are valuable to others, in exchange for things that are valuable to you, quid pro quo. And that requires a government, whose sole duty is to retaliate against people that try to bypass that process by force or fraud. A market cannot exist without an objective arbiter that keeps the peace (which can only be accomplished by having a monopoly on force - private armies, courts, police forces would lead to war) and enforces laws.

Yes, that's the fundamentalist libertarian perspective. Like most fundamentalisms, it is hermetically sealed: you can never convince a Freudian it isn't all about sex, or a bible thumper that it isn't all about God's word.

I always find that a little depressing with libertarianism, as there's enough useful material there that I hate to see fanatics turning people off to it. There's a giant difference between "an important function of government is" and "government's sole duty is". The latter is appealing to people looking for simple answers to complicated problems, but is actively off-putting to everybody else.

I understand you don't think you're an anarchist, and, for a different reason, I'd even agree. I think the step-over-the-dying school of libertarianism would turn out, in practice, to be indistinguishable from the sort of chaos that people who don't know any actual anarchists think when they say "anarchy". (The interesting sorts of anarchism, like what the anarcho-syndicalists were pursuing, depend upon a human moral sense. Which, bringing this back, include compassion for the ill.)

The reason things will fall apart lies in another gap in your thinking. Parents are the most obvious thing a child depends upon. But try telling a teacher or a grandparent or a cop or a social worker or a neighbor or an aunt that they don't matter, that they don't have an impact on the kids they deal with. It takes, as they say, a village. Or, if you'd like a richer society, a lot more than that. You'll of course wave that away as inconsistent with your chosen theoretical framework. But that you can't perceive the value in something doesn't prove that it's valueless. It only shows you haven't bothered to really understand it.

You need a new TV to live?

You're making the mistake of defining "life" as only the things you need to for physiological/material functioning. But there's more to life than metabolism!

A human life also includes art, music, fine cuisine, fresh cut flowers, travel, and an almost endless number of other things, depending on whose particular life you're talking about.

Think of someone that loves movies. He definitely needs a new TV to live, and he's got a right to it as long as he's earned it.

This seems like a further attempt to muddy the waters. There is a vast difference between "let's make sure people don't die from easily treatable disease" and "let's give everybody free TVs". I understand why, rhetorically, it's convenient for you to pretend they're the same, but the approach mainly persuades me that you're not serious.

poor people might find better services locally if the Federal government allowed insurance across state lines. This would increase competition and bring costs down. With lower costs more money would be freed up to service those who cannot pay.

I have not heard of my local hospitals refusing care. If anything the ER seems to be majority sniffles or need a ride people.

I would never make a personal health care decision based on price.

I don't want to live in a society where we would let people suffer or die if they can not afford health care.

Given these two conditions, free-market forces aren't very helpful.

You already make personal health care decisions based on price. Did you get a complete physical and blood test today? If yes, will you do the exact same thing tomorrow?

I'm guessing that those are a lot more based on the inconvenience of doing such things daily than their price.

Price is about more than just cash.

That's a surprising conclusion given that countries who have the free market much less involved in health care have a much lower cost of care.

Free market doesn't really apply for emergency medicine. "Oh excuse me sir I am having a heart attack and dying please bring me to the hospital 30 minutes away because its 10 times cheaper"

healthcare is only a free market to an extent. unlike consumer products, people are willing to pay any price for life or a guarantee of good health. and given care is so hard to quantify and there is so much uncertainty in comparing care, people will always simply trust the physician to pick whatever he/she thinks is best, with total disregard to the 'free market'. just my take on it.

It's incredible how ideology can completely make you blind to facts. In most European nations hospitals are actually taken away from the free-market - they are State-run - and, guess what, health care is much less expensive and yet very effective by all metrics.

How come all the other countries that have regulated healthcare have costs that are usually at a fraction of the US? (http://www.pbs.org/newshour/rundown/2012/10/health-costs-how...)

You do realize that the regulations are in place to try to prevent quacks from killing people, right?

You sound like one of those Tea Party idiots. You have no credibility.

You can only get true free market in health care if people have the choice of when, where and how they fall ill and can evaluate quality of care themselves before buying it. Unfortunately getting sick is not like buying a TV.

Not really.

You're mixing up insurance costs with service costs.

California is more expensive because all ratepayers are bearing the costs for people who do not participate in the insurance system or pay. We have this crazy system where we want cheap workers to build things and farm, but we don't want to provide them with the benefits of legitimate status.

So, when a day laborer being paid off the books falls off a scaffold and requires hospitalization, that care turns into an unpaid debt. Because he gets kicked out of the hospital as soon as possible, he doesn't recover well and ends up back in the emergency room in a few weeks.

> How is this surprising? We've completely taken the free-market out of health care. The only way it will ever be solve is if we re-introduce market forces back into the mix.

The theory of free market efficiency is based on low-entry-barrier wide-open competition, and perfect advance knowledge of costs and realized utilities by both buyers and sellers. There's lots of goods and services for which this is close enough to reality for the theory to mostly hold, but there's not much reason to think that healthcare is among them (and comparative quality and cost measures among real world healthcare systems don't support the idea that its a market where more "market forces" equals more efficiency.)

Why apply free market tactics to a service that is almost certainly necessary for everyone in their lifetimes? If anything, I feel like that would make things more expensive because this is a resource that people can frequently NOT decline (at the risk of losing their life) because the cost is too high. People are essentially a captive audience, so that's where regulation should ideally step in to keep costs down. Obviously that's not working, though..hmm..

As an outsider living in a country with socialised healthcare, the US's healthcare system honestly scares me enough to consider not working there.

I understand that insurance is almost always provided by jobs and that it can be comprehensive if the job is decent, but I still fear the risk that some set of circumstances may conspire to leave me uncovered for something, or that the insurance situation might be sticky enough that although I am 'covered', I must wear the out-of-pocket costs whilst fighting to get reimbursed. Yes, I'm paying it every year and may never use it but the nature of insurance is that I'm Doing It Right if I never have to use it.

I also struggle to align myself with the attitude that 1.5-2.5% of my wage is worth more than the safety net that I and my fellow countrymen can rely on to be mostly protected from most life-threatening health issues if and when they need it. To me, the well-being of all of the people in my society (no matter how poor or rich) is worth 1.5-2.5% of my wage.

It's certainly fascinating looking in from the outside as the US wrestles with topics such as universal healthcare, gun laws, etc. It strikes me as stemming from core philosophic viewpoints that seem to be ingrained in the US psyche but absent from many other western nations.

In the end, I'm very grateful that I live somewhere with socialised universal healthcare.

The insane part is that the hospital only receives a tiny fraction of the billed amount from the insurance company, yet uninsured people have to pay the full amount.

The US healthcare system is broken on many levels, and I don't think anyone has the balls to really fix it.

Some ideas:

[1] Free basic medicare for everyone, but allow people to pay for faster/better service. This is the way it works in the UK, and it works very well. The basic service is fine for most people, but if you want a room to yourself or you want to jump the queue, you can pay to get US-style service. Overall it works out much cheaper and fairer than the US system.

[2] Set up a system that allows uninsured people to get the same rates as the insurance company. It's a bit of a scam at the moment - basically the hospitals seem to be out to screw you if you're not insured.

It's quite possible to get a lower rate than what's billed to the insurance company if you're uninsured. Maybe not at all hospitals, but at many.

Perhaps, but it seems to be down to your negotiating ability.

I had a major bike accident in 2006 and was taken to a hospital emergency room. The hospital told me they take my insurance. They really meant they'll bill my insurance.

My insurance company didn't have a negotiated rate with the hospital and the treatment was considered out of network. Instead of paying only the maximum out of pocket cost of $4,000 USD per year, insurance only offered 50% and I got hit with a bill for $50,000. It eventually got worked out months later after months of fighting the hospital, doctors, and insurance, but it sucked big time.

Health care but Financial death.

UK doesn't not work as described in [1], and I don't think any other country works like that.

In the UK, if you have a certain income (as low as £8,000), you must pay for national insurance, whether you like it or not, whether you're going to use it or not. If you want to use the faster/better service, that is private insurance, then you have to pay for your private insurance, as well as national insurance, both in full.

You are going to use it... it's just a question of when and how severely the need will be.

"whether you're going to use it or not"

Wat? This is the exact use case of insurance. It protects you should you need it, but ideally you won't.

The point is, you're forced to pay for the government "insurance" (which is actually called insurance, although it's not actually insurance), even if you have private insurance on the side that pays for most things the government insurance would, and more. Thus, "don't need it".

But NI covers other stuff such as unemployment. Also, I'm pretty sure it's still cheaper than US health insurance in total.

No, NI is just tax. It doesn't "cover" anything.

The point still stands: even if you have private health insurance, you still have to pay your share of the NHS, even if that share is not a line-item anywhere.

> It doesn't "cover" anything

Yes, it does "cover" other stuff, and gaps in your NI payments can leave you not getting that other stuff. That's why you're allowed to top up your NI payments.

EDIT: Also, while it's true about health insurance (if you go private you have to pay both) it's not true for pensions. You get a reduced rate of NI if you opt out of the national pension scheme and opt in to a recognised provider.

"Other stuff" is state pension. Which is an earned entitlement, not an insurance.

That's a little bit simplistic.

(https://www.gov.uk/national-insurance)

(https://www.gov.uk/working-tax-credit/overview)

You pay national insurance if you earn over £149 per week. (Which is less than your £8,000!!) You pay 12% on anything between £149 and £797, and then 2% on anything over £797.

That sounds like a lot. English NI isn't just for health care, it's for some benefits and pensions too.

And people are eligible for Working Tax credits, which cuts that number down a bit.

You get a reduction in national insurance if you opt out of the pension and opt in to a recognised scheme.

I understand how the UK works as I lived there - I was just simplifying it. However I don't believe it's a big issue that you pay twice. People in the USA still pay school taxes when they send their kids to private schools and nobody seems to be complaining. If it's a big deal then you could refund the school/health portion that people pay in taxes.

Straw man.

That's pretty close to how it works in Canada. The difference is the difference between "free" and $60/mo if your income is sufficiently high.

So, in addition to the nominal required subscription, we optionally pay for additional services at hospitals like private rooms, etc. We also pay for additional health insurance that covers prescriptions, full dental and some discretionary medical procedures that aren't, or are partially covered in the universal plan.

The efficacy of the system is manifest in one of it's largest problems: Large numbers of non-Canadians scamming the system with fake medical cards. In BC, we're currently rolling out a revised personal identification system, in large part, to address this.

In case a US cousin here on HN is tempted to make some hay with that "non-Canadian" thing, please, reconsider. :) Also note, the reason that we bother to harass you folks with how far from optimal you've strayed on this topic is that the wacky ideology 'free market blah blah', leaks into our countries and is a huge distraction from pushing our systems forward. We have to keep fighting these fights that, in all practical terms, are long dead. If you guys were to get a grip on your own setup, the rest of the world would heave a huge sigh.

I used to live in the UK, but now live in Canada. There are a few problems, but for the most part healthcare works very well in both countries and the vast majority of people are happy with it. You just get issues in fast-growing cities like Calgary, but those issues are being resolved. I agree that most of the objection to free healthcare in the US is wacky ideology. The ridiculous thing is that they have free education, but nobody is whining about having a commie education system :)

I just want to clarify a few things, as it would be charitable to say that there are a few misunderstandings in this thread. I am working on a company that is trying to solve some of these issues; this is a complicated industry that I am still learning much about: hopefully some of what I have learned will be of interest to some of you.

The PPACA (Obamacare) is seeking to address this very issue by changing medical reimbursement form a fee-for-service model (e.g. $40,000 to remove a splinter and $10,000 for blood tests and $5,000 for aspirin) to a capitated payment model with additional incentives for providing good outcomes (providing good service). This means that a caregiving organization would get $N a year to care for you, as a male patient with a heart disease in your mid fifties, with N varying as demographics and conditions change.

This change will necessitate a sea-change in the way doctors and other caregiving organizations will treat their patients. In fact, it will result in the creation of a new type of healthcare organization (accountable care organizations, or ACOs) with the primary purpose of bringing down the costs of healthcare (and improving health outcomes).

This is a paradigm shift in medical practice.

CMS (Centers for Medicare & Medicaid Services) is spearheading this change; something which would be virtually impossible to do without such a large (read: government) player taking the first move. There are a million problems with CMS and the government in healthcare, but this is one of the greatest things they have ever done.

If ACOs are similar in spirit to corporate wellness programs, I think they are going to take paternalism and nagging to a level we can not even yet imagine. It wasn't long ago that we were talking about the patient who was educated about their condition, but now it seems we're to form major financial engagements with organizations whose central premise is that they care more about our health than we do -- scary!!

To me, the scarier thought is a new conflict between hospitals and pharma.

Currently, drug companies market directly to consumers. consumers ask for drugs from doctors, and get prescriptions health care companies have to pay for. Doctors have no reason to deny patients what they want (and the sexy pharma rep keeps encouraging them too).

In the new system, the same "entity" writing the prescription is paying for it, as well as "paying" for the cost of not taking it.

I imagine doctors will have an incentive to examine the cost/efficacy of a drug, but pharma will hate that. To get around it, pharma will probably launch marketing saying "if your doctor doesn't give you this drug, shes killing you".

ACO's fighting drug companies, using the human psyche as the battleground.

Want lower prices? Encourage a system where people directly pay their own money.

If all cars cost a $1000 co-pay no matter what car you bought, who's gonna buy the Honda Accord? However, throw price into the mix and Honda Accord becomes a very popular choice.

There's no huge, magical saving of money by running all medical spending through insurance providers. In the end the doctors are going to get paid. It is a matter of whether you pay them directly or pre-pay an insurance provider and they pay the doctor. Insurance is about mitigating the risk of rare but financially ruinous events (eg, cancer or serious trauma). There isn't any risk to mitigate with a flu shot or a bad cold or a mammogram. You insure your car against accidents, not oil changes and flat tires.

As for the poor problem, that can be solved separately by providing the poor a stipend for health care. No need to re-architect the whole system because it doesn't work for 100% of the population.

The problem with that is that buying health care is far more complex than many other purchases. Now doctors simply will not provide an estimate for their services, and when you visit the doctor you don't know what kind of procedure they will have to perform on you at the visit.

In my view the system is so screwed up that will end up socialized pretty soon.

I think if people have to start paying their money, they will not tolerate that kind of behavior from doctors. Think about when you take your car to the auto mechanic. Generally you pay some money for diagnosis. Then if the mechanic recommends a fix that is cheap, you let him just go ahead. But if the fix is very expensive, you might call around several places to make sure the price is reasonable. Of course, you'd never call around if the price was a $20 co-pay no matter which mechanic you went to.

Certainly, not the perfect analogy, but I think it points to the ridiculous nature of our current system and how such a ridiculous system will of course lead to costly behavior.

This analogy is for more predictable things like shots, checkups, bad colds, etc. For catastrophic illness and trauma, that's why you have insurance.

Health care in the US is the most broken one on this planet (I have been in Hong Kong and China). It is even worse than the communism countries like China. In China at least all the prices are listed before you decide to take the treatment. And the price is the same for everyone. Not to mention it is much lower than in the U.S. (abdomen sonogram is like $30 or less while in the US you can easily get billed $1200).

The ultimate solution IMO would be globalized free market just like the IT industry. If doctors and medical professionals from other countries can come to the US as easy as software engineers, I would expect the cost will go down to a level that we don't even need to be insured.

This is absolutely a reality I am vouching for. Right now the AMA (American Medical Association) actively places roadblock in the way of foreign doctors who want to practice in the US by forcing them through additional testing and years of training. We commonly joke that the purpose of one of our medical exams, Step 2 CS, functions to weed out foreign non-English speaking doctors (there is a whole section of the exam devoted to english proficiency), and for AMA to profit from the exam admission fee.

It always surprises me to see to see my state (Arkansas) in a headline.

Just wanted to throw out there that Arkansas actually has pretty good hospitals and whatnot. There are a strangely high number of multinational companies (Tyson, Walmart, Axciom, JB Hunt, among others) based here who donate lots of money to various institutions, most notably UAMS (University of Arkansas for Medical Sciences).

A North American friend of mine went to Cuba a few years ago. He had a piece of glass in his elbow that had been there for a few years. He knew it would cost at least $700 to have it removed in the US, so he never did it. When he was in Cuba, he went to the hospital to have it removed. They did it, straightforward, normal hospital. The final bill? $7. That's SEVEN dollars (although he paid Cuban currency, of course).

This same friend was in Papua New Guinea a few years before that (he lived there). Similar story - he was cutting wood and hit his toe with an axe. It wouldn't stop bleeding after a long time, so he went in to a local hospital and got stitches. I forgot what the exact bill was, but it was on the order of $5 (five US dollars). Again, it was a normal hospital, not some grass hut or something.

I'm not sure what this all means, except that if I need some expensive medical care that I am able to plan ahead for, I plan to look at places like Thailand for reasonable health care costs. Emergencies, of course, are different, so I may have to go to an American emergency room in that case. And I suck it up for my yearly physical (around $150).

It should be no surprise that the more government "regulates" and subsidizes health care, the more expensive it gets. And the answer to high costs is always more regulation!

I keep reading more about doctors who are opting out of the medicare system and switching to cash-only services. In the name of providing care to all, the system is breaking down and stratifying. Obamacare is an abomination of payoffs to special interest that will do nothing to reduce health care costs.

Health care must be rationed. It is a finite good. The question is how it gets rationed. Market forces? Private insurance? He who can pay? Whoever the government decides gets it? The bottom line is that the more government decides who gets it, the more expensive it becomes. There's gotta be a happy medium, and my intuition informs me that the happy medium is closer to the free-market side than the mega-regulation side.

> Health care must be rationed. It is a finite good.

Instead of FWD.us initiative of bringing over competent technology people from abroad, maybe we should instead try to attract more doctors/medical professionals from India/China into coming here.

I dunno about "instead of," but not granting citizenship to any qualified doctor who wants it is pretty stupid on our part. Easy for me to say, though, since the AMA won't run ads about me killing babies for voting for such a thing.

I don't think that is the answer. Can every student in the USA who is willing and capable of being a doctor get into med school? I would guess that this is probably not the case.

Increasing the number of doctors produced locally would seem to me to be a much easier way of increasing supply.

> Can every student in the USA who is willing and capable of being a doctor get into med school?

No, but it's not because they aren't good enough. In grad school, I TA'd a physics class for pre-med students, which were widely considered to be one of the most miserable and obnoxious groups to teach. Each student felt entitled to an A, even though the department mandated that only 25% of students could receive an A. In reality, probably more than 80% of the class earned an A, and I would have felt comfortable that most of the rest were smart enough to one day give me medical advice.

Yet, less than 45% of people who applied to one or more medical schools [1] are admitted (and this is a self-selected group: those without 4.0 GPAs, three extra-curriculars, and a side-business of helping old ladies across the street generally don't apply). I would estimate that only about the top 15% to 25% of the class actually applied. So, from undergrad pre-med to MD, there is about a (hand-wavy) 90% attrition rate of people who are probably smart enough and probably willing to work hard enough, and who have the desire to become doctors.

> Increasing the number of doctors produced locally would seem to me to be a much easier way of increasing supply.

I agree, but the medical profession is not willing to allow this to happen. Each medical school has a quota, and nobody wants to rock the boat. The trouble is, there isn't really any way to force medical schools to admit more students.

[1]http://en.wikipedia.org/wiki/Medical_school_in_the_United_St...

In fact, the economist Dean Baker has been arguing for just that as a free-market reform that would actually bring health care costs down. And the converse, too: that Medicare/Medicaid patients should be allowed to get cheaper health care abroad.

http://www.cepr.net/index.php/op-eds-&-columns/op-eds-&#...

http://www.guardian.co.uk/commentisfree/2012/dec/21/free-tra...

Or we could open more medical schools? https://en.wikipedia.org/wiki/List_of_medical_schools_in_the...

Regulations and the free market are not the only options. There's a 3rd one which I personally want: completely socialized healthcare, where doctors are paid a fixed salary and all drugs and medical equipment are purchased at negotiated and aggressively low prices.

I suspect the quality of care will not blow anyone's mind, and we'll have to work on that. But at least we'll finally graduate from a medieval society we are today. Private healthcare is no different from private armies: too few can afford it, that's why we need the state.

If you are a free market believer, my position is not easy to agree with. But at least I hope it is understandable because at this very moment I am sitting on $41K in medical bills which I got for a 4 hours at the hospital (surgery+time in a recovery room).

Yes, that is $2.8 per second and it wasn't a brain surgery, it was a skiing accident - broken arm.

So, socialized healthcare, despite its flaws, despite that its quality indeed does "not blow anyone's mind", at least has simplicity going for it.

But what you're asking to be "understandable", is that someone else should pick up the tab because you like to play wild in the snow and couldn't be bothered to get properly insured first. Now that is a poor argument for socialized anything.

You're making a few incorrect assumptions here. First of all, I am insured and most of the bill will be paid by Humana (after hours and hours of painful phone calls which nobody is paying me to waste my time on).

Secondly, I find it very typical that you've ignored the insane and mind blowing amount. Too many healthcare discussions are focused on "who" should be paying, instead of asking "why so much"?

There is no way in hell they should be charging $250 for a "recovery kit" containing a can of apple juice, 5 crackers and 4 pills of ibuprofen. My Humana policy is STAGGERINGLY expensive.

And finally, I paid more taxes (state+fed) here in California this year than most EU residents did. In my view, I already paid for my healthcare, they're just not delivering it to me, spending my money somewhere else.

> You're making a few incorrect assumptions here.

> "at this very moment I am sitting on $41K in medical bills"

Uh-Uh. I think you're playing very fast and loose with the language here. I doubt anyone would read that as "my insurance company is settling a bill for $41k for me". Especially when your anecdote does nothing more than confirm what is mentioned in the article: That healthcare in CA is stupidly expensive.

With an high deductible plan, which many have, or for those with less money to afford good insurance, they very well COULD be stuck with a bill like that, or a large portion of it.

For a broken arm. I think we had a lower bill for my kid's childbirth costs.

Child birth costs my parents paid for me: ~$30

Child birth costs some friends paid for their kid: ~$60

Child birth costs I paid for my kid (poor insurance plan): ~$3300

I think that the total bill for the child birth (in my instance) was around $18K. I'll note that if you were uninsured, that would probably be significantly more. That $18K cost is negotiated between the hospital and the health plan I had at the time.

  | someone else should pick up the tab because
  | you like to play wild in the snow

Do you believe that broken arms are 100% avoidable, and only result from people taking unnecessary risks? It's not like he got some injury that was very specific to skiing or 'extreme' sports.

Of course they are not unavoidable, they are just a lot likely to happen when you go skiing than when you don't.

The problem with socializing risk is that you get the tragedy of the commons when some people choose to take high risks (skiing is definitely in the moderate end of "extreme sports") and pass off the risk to the "commons".

In Denmark, where health care is socialized, the argument that "society is justified in regulating activity X because we will pay for your hospital stay if/when it goes wrong" is absolutely a part of political discourse. Unhealthy foods, not exercising enough, smoking, mandatory bicycle helmets etc., it's pretty universal.

I don't see mandatory bicycle helmets as a good example of 'government overreach.'

What, it's bad they're actively campaigning against smoking and unhealthy foods and for having regular exercise?

Are you kidding me?!

I think that 'bad' part is that these things may be mandated by law, which limits freedom.

Partly that, partly that the motivation is that the government justifies the law by the expected savings in other places (healthcare). This boils down to the fact that, because the government has promised to "repair" you if you "break", it also has a right to "perform maintenance" on you as it sees fit.

Even less palatable is the argument that healthy long living citizens spend more time on the labour market, generating more tax revenue.

This whole entitled "why should I have to pay for you?" attitude is the exact reason why universal health care won't happen in the US, and it needs to stop.

Universal health care, along with fixed prices, will cause everyone's rates to decrease, and will also lower the anxiety level of the general population. No more "oh shit, something's wrong with me, but I can't go to the doctor because it'll cost X" or "I need this medicine, but it's expensive". I've experienced first hand how great universal health care is in Canada. I don't worry that I need to pay a thousand dollar bill for visiting the doctor, and the waits have never been horrible.

Being forced to choose between getting the treatment that you need or eating is the worst decision, and nobody should have to take it.

There are plenty of people who CANNOT AFFORD insurance, because it is HIDEOUSLY expensive. And even if they can afford it, the companies can drop the policy or refuse payment for a huge amount of reasons.

What, do you think you'll be going bankrupt if your taxes contribute to the health of all people with a few cents, heck, even a few dollars?

Which would, of course, lead to a completely calcified health care system with no incentive to improve or innovate.

I'm sorry for your $41k bill. I really am. But the problem isn't that we need more control by central authorities. They are what lead to that bill in the first place. No one can seriously contend that the actual cost of the services you received could be anywhere near $41k. Clearly there is a significant distortion of pricing occurring. My GP physician charges $70 for a visit, which lasts maybe 30 to 45 minutes, and that of course covers his overhead as well. Extrapolate that out how you will to your situation, but it's clear that your situation is a failure of the system as it is.

Having experienced medical care in a number of different countries, I am convinced that rationing is the heart of the problem.

For example, as more treatments for symptoms of old age are invented, more is demanded and spent per elderly person (who can blame them). The problem is that in the West the elderly are increasing relative to the working population (medicare enrollment in the US is expected to double in the next 15-20 years).

Governments in socialized healthcare countries have to decide how to allocate services between the young and the old. Free market advocates would argue that a true free market system would allocate resources appropriately (richer older folks would sacrifice medical care for themselves in order to pay for their younger relatives).

I don't know what is the right solution. The idea of a lightly-regulated free market where innovation happens appeals to me, but I can't see it happening in this political climate.

What we need is mandatory health insurance. It works with auto insurance, it will work with health insurance.

If Obamacare was as simple as that - that every resident must have a minimum level of health insurance, and banning pre-existing conditions as factors - it would be perfect. It's so simple, and many conservatives and liberals come to the same conclusion, with the main disagreement being whether there should be private insurers or a single public one. (I believe in private insurance.) Various other regulations, like transparent pricing, also need to be enacted.

This distributes risk across the whole population and gets everyone health care. People who do not purchase health care of course need to be taxed and given a default plan, which should always be less attractive than private plans.

> It should be no surprise that the more government "regulates" and subsidizes health care, the more expensive it gets. And the answer to high costs is always more regulation!

I am guessing that you might be American. Do you think you have adequately considered health care else where in the world?

Looking at health care around the western world, the country where the government regulates and subsidises health care the least is the US. And in that country health care costs twice what it does anywhere else in the world.

On another topic effective markets require good regulation. For example in Australia phones work on all networks (government mandated GSM), and you can take your phone number between carriers (required by regulation) etc. This created a more effective market. One barrier to an effective market is complex pricing (deliberately introduced to avoid market forces). Regulations to limit pricing complexity would improve the workings of the market.

Similarly in health care, requiring publicly available prices and quality reporting is what enables comparisons made, and make competition possible. Economic entities don't want competitive markets, they want excess profits.

In summary markets are not an alternative to regulation. Regulation and markets work together to form a system of management.

I'd highly recommend checking out the linked dataset.[1] One quick observation: subtract Average Covered Charges from Average Total Payments and sort to see what procedures are most overcharged: 7 of the top 10 are "207 - RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS". Average overcharge among those top records is 601K. What is going on that they routinely charge 601K more than they collect?

I'm excited to see what all everyone else comes up with.

[1] http://www.cms.gov/Research-Statistics-Data-and-Systems/Stat...

Here's a quick and dirty visualization of the distributions for each kind of care across lots of different hospitals: https://www.statwing.com/open/datasets/c5fc084c00d24cf221c17...

Other visualizations today:

NYTimes -- http://www.nytimes.com/interactive/2013/05/08/business/how-m...

Washington Post (low on the page) -- http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/08/o...

I went through a cardiac event, and in the end it cost me $12,000.00 to find out I was fine. That was just the cardiac part of the testing. I also spent a grand or two to find out where the problem lie neurologically. Turns out the same nerve that allows you to know you're having a heart attack, can also have totally unrelated issues itself, and basically give false positives.

A picture is worth a thousand words?

http://upload.wikimedia.org/wikipedia/commons/f/f8/HC-Graph....

Source: http://en.wikipedia.org/wiki/Health_systems#Cross-country_co...

Within smaller areas, too: https://twitter.com/HuffPostData/status/332244607805050880/p....

$7,044 vs. $99,690 between New York and New Jersey! Might be worth that drive.

"Health care in the US is idiotic" doesn't really warrant a headline anymore, everybody gets it.

No, they really don't. Many people are resisting reform because they don't see why we should change a system that they see as working well already.

Do you think it's possible to show or educate those people that in fact the system is dysfunctional?

Any ideas how?

I think that continuing to discuss the bad parts, like this, is helpful, albeit only gradually.

The people with this attitude are generally either young, healthy people who have never needed serious medical attention, or people who have always had stable jobs that offer good insurance, and have never seen a hospital bill that didn't have 95% paid by the insurance company first. They've never been injured on the job and then forced to pay a year's salary for the surgery they need to continue working. They've never been prevented from starting a business because their employer's group plan is the only way they can afford their life-saving medication. They've generally only seen the system work. In the rare cases they've seen it fail, it has always been for people they don't know closely, and it always looks like an anomaly.

Showing these people that these problems are real, common, and affecting a huge number of people is a start.

Publish data showing the disparity of medical costs across the US?

I know a lot of people who are against certain commonly suggested reforms, but none of them think the US system works well. Instead, they think certain proposed reforms will make an already poor system even worse.

One of the problems when we discuss "healthcare" is the wide variety of price points for healthcare. So at one end of the market you have fully insured people asking for and/or being prescribed an array of drugs. Often quite literally they take a new drug to offset the harsher side effects of another drug so that it builds to the point whereby they'll start their day with 6 - 10 different pills. At this end of the market you could apply market forces and have significant results. If people more fully feel the burden of cost with those drugs they might very well tackle the underlying causes around obesity, diabetes etc. "If you could drop 30 or 40 pounds you'd probably find you're spending $200 less per month on medication" Sign me up!

However, at the middle of the market and the most serious end of the market you're looking at procedures and ailments that can cost $10,000 to $250,000. Here, if you have free market forces at play you're asking people (including many parents) to make horrible decisions between what they can afford and what is best for the quality of life for years or decades. Some will be comfortable with that I know but it appears, given the acceptance and re-election of Obama, that the majority of people in America are more open to the government running healthcare. (I wrote a blog post where I said that the fear of being financially and emotionally destroyed by healthcare was now on par with foreign invasion. As such, just as no one wants free market forces in terms of national defense they now don't want free market forces in healthcare - shameless plug and done! http://jmlite.tumblr.com/post/46257541683/why-healthcare-in-...

I think free market forces can be applied at certain price points but I can't see how it can be the driving principle across the entire spectrum. I think state run pricing and procedures that cover 80% + of the population with a legitimate private option for those with the drive or means to pay is the best possible outcome from a tough position.

I imagine a large difference is the number of patients with health insurance - if Arkansas has significantly more uninsured, then they need to recoup costs on them. If California has enough insured patients, then their "cost" is a figure they expect insurance to bargain down from.

False. Arkansas has fewer uninsured.

http://en.wikipedia.org/wiki/Health_insurance_coverage_in_th...

Thank you for that.

And my heart attack bill in Canada is $0.

In England the treatment is free at the point of delivery to almost everyone[1]

Any meds will be about £8 per item per month. Discounts are available if you need to buy lots of meds. And many people are covered by various exemptions and won't have to pay anything. (EG: People taking thyroxine will get a medical exemption certificate and not have to pay for any prescription medication at all).

You don't need to use NHS hospitals. You can go to private health care any time you like. You don't get to opt-out of the national insurance payments. I'm not sure if there are any private emergency rooms. And there's a recent "protective" change where some cancer patients have to pay for all of their care if they buy a few specific (not effective, not efficient, very expensive) meds. Some pharma groups have been unscrupulous in targetting very ill people with bad, and expensive, meds. They funded patient advocacy groups to agitate for changes to prescribing rules to allow for these ineffective meds to be available on the NHS.

I've been careful to say "at the point of delivery" because I recognise that there is a tax burden that needs to be paid.

[1] In theory only emergency stuff is available unless you're entitled or you have equivalent national insurance or you have private insurance, but in practice "health tourism" is said to be a problem here.

Oh, really? Nobody mentioned this in the last thousand times people discussed US health care. Glad you brought it up.

I have several Canadian friends and they've all told me that they never understood the price of healthcare until they had to take their dog to the vet. They all pay for it, of course, during the course of their lives, but they don't ever have to worry about not having access to it or being bankrupted for it. The medical industry hates this, of course, because it means that hospitals can't charge $2 for an aspirin that can be bought 100 to a bottle for less.

You might want to reconsider your number when you file your taxes every year.

I genuinely don't get this line of thinking. I understand that the US prides itself on individualism, but I can't understand the utter lack of empathy.

I know you're disputing the 'paid $0' part of the OP's comment, however your response comes across as quite glib and seems to imply that the OP genuinely thinks that nobody paid for his care.

Yes people in countries with 'socialised' health care pay for health care that benefits others. Yes this is a good thing.

Let's use Australia as an example of a more empathic way to approach this issue.

Recently there has been a federal budget shortfall. There isn't enough money to pay for a National Disability Insurance Scheme (NDIS) [1]. Our two major parties both agree that funding should come from a ($350/year) levy.

I'm not disabled. I don't know anyone that is disabled. I'm not rich so $350/year is not pocket change. All considered, I'm still more than happy to pay my share to make disabled people's life easier.

[1] http://www.abc.net.au/news/2013-05-05/gillard-says-ndis-levy...

> You might want to reconsider your number when you file your taxes every year.

You might want to consider the fact that the US government healthcare spending per capita is greater than Canada's (and every other OECD country except Norway and the Netherlands), even with the huge private healthcare expenditures that are on top of that in the US (while Canada and other OECD countries have very small private expenditures in addition to the government costs.)

The US hybrid public-private hybrid system is by far the least efficient healthcare system in the developed world.

Even if you count tax costs alone and ignore the vast out-of-pocket private costs, you are still spending more on healthcare in the US than you would be in Canada.

Let me know how that works out the next time you drop a quarter million dollars for a treatment that costs a couple thousand in another OECD country because the hospital you went to is trying to make up for all the money they lost treating uninsured or bankrupted patients.

When I lived in the US my taxes were about the same (maybe three or four percent less) than what they are now in Canada.

Further, the amount of money I had to pay out of my own pocket each month for health insurance in the US was about three times what provincial medical premiums are in BC. In the US, health insurance was about $1000/month, out of which my company paid about $600/month. Up here in BC the monthly premiums are $133/month, out of which my company pays $133/month.

Further, even though I was paying $400/month in health insurance costs in the US, every time I had to see a doctor I had to shell out $10. Even though I was paying $400/month in health insurance costs in the US, my daughter's birth cost about $1000. Doctor visits are free in BC. Births are free in BC (you'll probably have to shell out a nominal fee for anesthesia or supplies though, but I've heard that'd be less than $100).

So yeah, my taxes might be higher, but not appreciably, and that's massively outweighed by the amount of money I would have to shell out to the medical industry in the US.

I think the only thing relevant about this article is the linked dataset.

Same thing about the Washington Post article from earlier today. I'm not sure why it wasn't a direct link to the data with a headline of "Feds release huge hospital cost data base".

I don't know if there is a useful service to pull out of the data (other than analyzing it for journalists) since most people don't have much control over where they are hospitalized and if they do have control, they shop by doctor, not price. Insurance coverage means that I have no skin in the game when it comes to price (unless the insurance company puts a hospital on the out of network list).

Speaking of, which editors are people viewing the .csv in?

I don't get the best performance in Sublime Text 2 on a pretty decent desktop.

Excel in Office 2013, which I pay a $99/year subscription to use on 5 PCs/tablets.

The amount of bullshit I've seen in the hospital gives me little faith that any policy change will solve the problem.

The real solution lies in producing safe consumer usable technology that moves all diagnostics out of the hospital. When we can get our comp, CBC, liver enzymes all with a drop of blood on a 1$ chip, when everyone and their neighbors own low cost portable MRI machines, when we can all read our EKG right on our cellphones and have it be interpreted for us 24/7 holter monitor style. Then it would only takes a team of engineers to produce software to quickly crunch all the data to produce a picture of our health... and save everyone from that expensive trip to the hospital.

So answer me this.

Why is not like every other tech startup not making medical equipment and software then? It's a market that is growing, prices are going up, the software they use is terrible.. You're telling me we can't make a device that takes an xray and is more portable, safer, faster, and radically cheaper? (just as one example) And then there is the money.. you can have 3000% variance for the same service?!? and every VC in the world isn't just begging to get in?

I just can't believe that the regulations and the red tape can overwhelm and even defeat the greed.

Several YC companies/founders have talked about how incredibly difficult it is to work in anything that even remotely touches healthcare. The regulations and the red tape create market barriers so significant/costly to overcome that many VCs don't have the resources to break into those markets.

Everything related to medical devices is very capital intensive. From regulation compliance, to quality procedures, to patents and licensing, you need a lot of specialized people working for years to bring a product to market.

To all the people who think the free market and medical care are compatible:

Boom! You just had a heart attack, you'll be dead inside of 15 minutes. Now, go shop around to find the best price for your treatment.

>>>Your heart attack bill: $3,300 in Arkansas, $92,000 in California

And: Your rent bill: $600 in Arkansas, $2,500 in California.

Somebody PLEASE do an app with this data. If I have to schedule <expensive-medical-treatment>, I would love to know which of the dozen odd regional medical centers has the lowest price. Or at least which ones have excessively large prices.

I've been working on this exactly for a couple months with a similar dataset, and will clearly now bring in the medicare data. Email me (jparker165@gmail.com) if anyone wants to learn about the project or contribute.

healthcare is something that should be like water.

Even drinking water is subject to regulations, though. Nothing is ever that simple. :)

"Even"? Drinking water is heavily regulated for good reasons. It's also extremely cheap. There are a lot of other examples of highly regulated industries providing cheap services, something I wonder of others are aware of when they talk about the need to reduce regulation to cut costs.

Health care as a regulated public utility like electricity, water, and phone lines doesn't seem like a bad model to shoot for.

Except that I literally cannot find two industries that are less comparable in any meaningful way: mass produced commodity goods on one side, complex and neccesarily individual services provided by highly trained and specialized professionals on the other.

Bonus: you get a second heart attack when you see the bill.

And death, everywhere, if you fail to look after yourself properly. Prevention is free.

Serious question - can you negotiate your hospital bill like insurance companies can?

Perhaps in this market, Arkansas can leverage economies of scale.

A big factor as to why can be explained in two words.. "Illegal Mexicans"

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