Comment by codegeek | Hacker News Reader

Comment by codegeek | Hacker News Reader

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The entire medical bill and insurance system is insane. I say this after going through 2 pregnancies (with my wife) and now with 2 young kids.

The process is that you go to the doctor, they will NOT tell you how much it costs out of pocket because that amount is probably insane anyway but you need insurance to "bill" that insane amount to the insurance company. The doctor will send say $1000 bill to insurance company for a simple checkup (yes, it can be that bad). THe insurance company then will say "no no sir, we only allow $200 for this specific item". Then insurance company will figure out how much you the patient ius supposed to pay out of that $200 (copay, co-insurance etc) and THEN they will pay the remainder to the doctor.

See the issue here ? The price of a simple checkup is inflated from $200 (we can argue on this too) to $1000. This $1000 is just to scare you but really does not mean shit.

Imagine that the doctor could bill you that $200 directly anyway or whatever amount they eventually get from insurance company. It will save their time, your time, their staff hours and probably save more for them in terms of resource usage.

What we need is a system where not everything goes through insurance. This scare of having mandatory insurance is the root cause. Doctors/hospitals need to have transparent pricing just like other businesses and insurance should only bee needed for really catastrophic events like cancer, major accident etc.

I would much rather pay $200 to a couple of visits instead of paying insrance $1000/month just to "insure" myself.

Or you get a single payer and this charade goes away because the single payer's price list is fixed. This is how the rest of the world does it.

Western Europe != rest of the world.

The Indian system is a 1 billion payer system. The single price is also fixed and usually written on the wall, or maybe in a big book of prices. You ask for a price quote, receive it, pay that much and get it done. If the price is too high you go elsewhere.

It works nearly perfectly. For any medical conditions I have that permit flight, I'm voting for it with a plane ticket.

As a counter-point, a lot of Eastern European systems are single-payer (inherited from the Soviet days of free medical care), and because the fixed price amounts to pretty much nothing, there's lack of supply of doctors and implied cash gifts for each and every transaction you undertake at the hospital.

You can have a fixed price list without single payer. Examples include Germany, Japan, and Switzerland.

"What we need is a system where not everything goes through insurance. This scare of having mandatory insurance is the root cause."

I think providers should not be allowed to bill patients any more than what they would bill insurance companies. Period.

Also, they should streamline 'accumulators / indemnities", which are dirty insurance tools designed to not pay. Copay was simple enough. But now we have co-insurance, deductible, out of pocket cost, out of pocket maximum, health savings accounts, family vs individual deductible and/or maximum out of pocket, etc.

Nobody really understands this.

We should have two things: percentage-based co-insurance payment where insured people pay percentage of the service, with adjustments for people who have pre-existing conditions.

If you've delivered a baby under anesthetic/epidural then you've probably also encountered the "independent" anesthesiologist who works as subcontractor to the hospital and not the OB delivering the baby.

So now you have everything in-network, except the coin-flip of a guy that shows up 30 minutes before you hit the end of early labor. One time I got hit with an out-of-network refusal on the epidural and I flat out refused to pay it. It eventually (mysteriously) changed to an in-network charge.

Insurance is a problematic industry in general, because the insurer's incentive is to fail you when you need them: to take your premiums while things go well, then fuck you over when a disaster happens, often on a technicality (e.g. "you had hurricane insurance but no flood insurance" in Katrina). It's just a terrible model for health issues, which are generally more complex than event-based insurance policies. We should have gone single-payer in the 1940s; we didn't get it then, because a bunch of Southern racists didn't want to desegregate the hospitals.

Doctors themselves often don't know what their services cost. The hospital does the billing, not them. And hospital bills are obscene, bizarre, and intentionally obfuscated. An aspiring costs $70 and a box of tissues becomes $150 "mucus collection therapy".

It's absurd, but it also performs a social function similar to the persecution of witches, heretics, and old eccentrics. (Yes, this sounds like it's coming out of left field. Please continue.) Namely, witch hunts were mostly economic in nature; you had middle- and upper-middle class (but not rich or important) older people, often women but some men, who'd amassed sizable savings that, being weakened by age and declining health and social isolation, they couldn't really defend. Witch hunts were a great way for corrupt clerics (Catholic, Protestant, both "sides" were in on it) and enterprising inquisitors to yank the savings of old and modestly wealthy people, in a way that had enough official muscle (religion) behind it that a large portion of their heirs wouldn't deign to go into the fight (for fear of being labelled heretics or witches themselves). Witch hunting was about many things, but raising money was a primary and overlooked motive.

Older people tend to have savings without the ability to defend it. When you have undefended money, there's a risk that someone will try to steal it. In the 16th century, witch hunting was the means. In the 21st-century U.S., it's medical bills: cooking up a way to suck savings off of people who are close to death and won't need them anymore. (The 25-year-old who gets denied cancer treatment is seen as just a casualty, but she's not the main target.) Medical bills are basically an inheritance tax built to fuck the middle class, yet the conservatives (who get up in arms if you apply an estate tax to double-digit millionaires) have absolutely nothing to say about it.

The healthcare system is not a way for corrupt clerics to suck savings off of dying old people. Also, "conservatives" aren't getting rid of medicare any time soon, and you'll find that most would have a lot to say about how our healthcare system works and why it's expensive.

I agree that the specific formulation that grandparent used is probably unnecessarily provocative, and also posits a measure of intent or malice aforethought.

But re-read what he's written while thinking about the effect of our healthcare payment structures and policies, not necessarily the intent, and it makes some sense.

The great bulk of healthcare costs are due to end-of-life and chronic condition care. Even if you don't think there are nefarious plotters sitting around scheming to rob old people's savings by billing them for outrageous healthcare, in effect, that is what Medicare is. It is a way to funnel money from everybody (or, everybody who is poor enough to make their money by earning wages under 100k) to people who bill for end of life and chronic care. The role of the old and dying in this scheme is as concentrated conduits for the capital to flow to the billers. (Billers, here, meaning providers but also the cut going to the payer/insurer/processing infrastructure as well as supplies, pharma, etc -- the medical/industrial complex if you will.)

I'd also like to point out something that is little-known by the typical early- or mid-career, technologically savvy and well-employed HN poster (including may I say myself, before some family experiences clued me in otherwise): in the case of Medicaid, at least, the state puts a property lien on all assets of the beneficiary and tries to claw back amounts paid after the beneficiary's death.

In other words, there really is a department in the state government that is in charge of taking title to a dead old person's house and car, and auctioning them off to repay amounts that the state had advanced to the medical-insurance complex on that person's behalf.

So. When I think of that, and when I think of those TV ads that promise they can sell scooters to sickly oldsters who can little afford them except for a Medicare subsidy ... it has more than a mere echo of resonance with grandparent. In other words, much of the medical system sees "dying old people" as pretty instrumental for concentrating and slurping up cash, if not to say "suck[ing] savings off" of them.

> It is a way to funnel money from everybody (or, everybody who is poor enough to make their money by earning wages under 100k) to people who bill for end of life and chronic care.

You can say those words (modulo one hundred thousand) about many single-payer healthcare systems. It is not right to do this, to interpret medical systems under a cynicism maximization principle. It doesn't tell the Truth. After all, these services also provide concentrated conduits for medical care to flow to the citizens.

> So. When I think of that, and when I think of those TV ads that promise they can sell scooters to sickly oldsters who can little afford them except for a Medicare subsidy

I think those scooters greatly improve some people's quality of life. If you want to hear stories about companies trying to take advantage of medicare/medicaid, I could tell you quite a few myself -- I have a close relative that worked on the government side of things there.

No, it's not a way for corrupt clerics to suck savings off of old dying people. We're not in the Wars of the Reformation anymore. It's a way for corporations to suck savings off of old dying people, and it works.

Do you have anything more to say?

this is actually a striking good analogy

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