
The U.S. could slash health-care costs with two fundamental changes - Reedx
https://www.marketwatch.com/story/the-us-can-slash-health-care-costs-75-with-2-fundamental-changes-and-without-medicare-for-all-2019-08-15
======
rayiner
What I’ve always found amazing is how cheap dental and eye care is in
comparison to other types of medical care. The fact that you can get laser
surgery in your eyes for a couple of thousand dollars is incredible, given
that a diagnostic test like an MRI can often cost that much. Clearly there is
room for competition to reduce costs.

Clearly that doesn’t work for emergency services. But is there room to
distinguish emergency from non-emergency services? I had surgery for a
deviated septum. I don’t know what it cost, but if I had an incentive I
could’ve price shopped for it. There are a lot of non-emergency procedures
(colonoscopies, hip replacements, knee surgery, etc.) that could be subject to
competition.

Also, the comparison to Singapore’s health outcomes is a bit odd:

> The result is not only 77% less spending than the United States but also, as
> Bloomberg Businessweek reports, one of the healthiest populations in the
> world.

Fun fact: Life expectancy for Asians in the US is 86 years (almost 90 in New
Jersey!), quite a bit longer than the 82 years in Singapore.

~~~
criddell
> if I had an incentive I could’ve price shopped for it

In my experience hospitals and surgery centers can't or won't tell you what
something will cost up front.

~~~
gremlinsinc
I'm pretty sure though they have to supply an 'itemized' list if you ask for
one, which you can contest anything on the list and a lot of times take them
to court over if they don't budge. Often they will because they know $35 for
an ibuprofin is absurd but most people don't think they can win against a big
bad hospital.

~~~
pfranz
Here's how it went when I tried to do it upfront. My wife was pregnant, so we
had 9 months of routine, scheduled visits. I asked "how much will this cost
ignoring any unexpected costs." My insurance had a helpful PDF showing $650 as
an out of pocket example with an asterisk saying not to use this number for
reference. Reading up, some places offer a "package deal"\--our's didn't. I
was told to call the doctor's office and write down their itemized list of
procedures. Then call their billing office to get an itemized list of billing
codes. Then call my insurance to get the out of pocket cost. The final cost
was a few multiples of that cited value (although there were additional,
unexpected costs).

------
smacktoward
I bristle when I see health savings accounts presented as a solution to the
health care crisis. The median household income in the U.S. is about $64,000 a
year (see
[https://www.census.gov/library/publications/2019/demo/p60-26...](https://www.census.gov/library/publications/2019/demo/p60-266.html)).
When a single major medical procedure can result in a six-figure bill, there's
just no way that the average person could ever save enough. You end up with
people who are lucky enough to never need to tap their HSAs, and people who
are unlucky enough to get sick, whose HSAs just present a speed bump on their
slide into bankruptcy.

There's only one thing HSAs are really good at, and that's creating a huge new
tranche of money for Wall Street to suck fees out of.

~~~
nradov
HSAs are part of high deductible insurance plans with out-of-pocket maximums.
No one with such a plan would ever receive a six-figure bill. (With the
possible exception of surprise billing from out-of-network providers, which we
ought to ban.)

~~~
cneurotic
Oh, people on such plans incur massive bills all the time.

Suppose you're in a bicycling accident, you're knocked unconscious, and an
ambulance takes you to a hospital that isn't in your insurance network.

Boom. Out-of-network charges.

If your bicycling accident was so bad that you need surgery, a five figure
bill is a certainty. A six figure one is rarer -- but absolutely possible.

What's really messed up is that, even if you end up at an in-network HOSPITAL,
you might get care from an out-of-network provider.

In this bicycle surgery hypothetical, for instance, your hospital and your
surgeon might be in your network - but the anesthesiologist isn't.

Boom. Another out-of-network charge.

(Thats called Surprise Billing, btw)

At median income levels, there's no amount of HSA savings money that can
insulate you from costs like that.

The current US insurance system asks consumers to walk an insane tightrope of
cost controls.

It's no wonder a lot of us fall.

~~~
secabeen
> (Thats called Surprise Billing, btw)

Yes, and in some states, it's starting to be illegal.

[https://www.nytimes.com/2019/09/26/upshot/california-
surpris...](https://www.nytimes.com/2019/09/26/upshot/california-surprise-
medical-billing-law-effects.html)

------
codingdave
As U.S. the election season warms up, it is important to recognize a political
piece when you see it. This starts not with presenting the problem, but with
implying that the changes proposed by Democrats aren't what is needed. And
later on calls out data gathered by Republican office holders.

Even if the topic is health care, those bits of the writing should indicate
the political motivations behind the article. I'm not going to tell anyone
where to fall in politics, and HN is the wrong place for it anyway... but I do
encourage everyone to be aware of it over the next 12 months.

~~~
orhmeh09
It’s nice of you to underscore the issue, but I suspect most readers would
catch on based on the first line of the article, wouldn’t you?

> As the Democratic presidential candidates argue about “Medicare for All”
> versus a “public option,” two simple policy changes could slash U.S. health-
> care costs by 75% while increasing access and improving the quality of care.

~~~
codingdave
I hope so. But HN typically shuts down political articles fairly quickly, and
this one made it to the front page and had comments on it as if nobody had
noticed, so I thought it was worth a mention.

------
dv_dt
The Indiana data point for this was only two years of study, a decade ago
2007-2009, and crossing the very exceptional 2008 recession year. This is a
questionable time period to claim proof of savings on health care costs.

The Singapore cost savings example is attributed to silver bullets of price
tags and deductible scheme while completely ignoring that most care in
Singapore are delivered via government owned corporations of hospitals &
clinics that service 70-80% of the population. Drug prices for example are
controlled essentially by government boards nationally negotiating prices with
vendors. This too is ignored in the marketplace article and seems fundamental
to making those silver bullets viable.

I would submit that the fundamental control of pricing at work here is that
the 20-30% private care needs to compete with a basic competent and majority
publicly provided care delivered at gov't negotiated prices. The financial
structuring of how the care is priced to the user base is a far far lower
contributor to Singapore care being 75% less than the US.

[https://en.wikipedia.org/wiki/Healthcare_in_Singapore](https://en.wikipedia.org/wiki/Healthcare_in_Singapore)

[https://www.vox.com/policy-and-
politics/2017/4/25/15356118/s...](https://www.vox.com/policy-and-
politics/2017/4/25/15356118/singapore-health-care-system-explained)

Edit: I would also say that it's a nice trick to keep some small component of
private care boxed into an area where it has to compete on fundamental
effectiveness. This allowance I think is a nice way to accommodate some level
of private innovation maybe helping to keep a public only system from becoming
too stolid.

~~~
lostdog
It also totally ignores that a dollar saved by skipping on short-term care can
be a thousand dollars lots five years later. Not sure how it's possible to
show much of anything in a 2 year study.

------
turc1656
First off, if something this large can drop by 75% in price then you're being
bamboozled, extorted, or potentially both.

 _" Under our current system, it’s nearly impossible for people with health
insurance to find out in advance what anything covered by their insurance will
end up costing."_

It's worse than that. Not only can you find or figure out how much everything
will cost, most places (particularly hospitals and outpatient centers) will
not even tell you how much they charge for their services. Some news outlet
did a study and called the top 25 hospitals in the country and asked them how
much a hip replacement would cost. Only around 3-5 actually gave a number and
it varied wildly. The rest refused to pin down any number at all. That's one
of the most common surgeries there are and they don't know what they will
charge for it?

On the moral/philosophical side - how can a person be held financially liable
for something they cannot possibly know the cost of in advance, even if they
try to find out? Such practices are illegal everywhere else in this nation.
And there is no legal exception for healthcare providers. How do I know that?
Because a few years ago Rand Paul tried to pass a law that would exempt
healthcare providers. It failed - which means it is still _currently illegal_
to be doing this. Yet not one of these providers or operations has been
charged accordingly. If you went to a mechanic and they took a look at your
car and you asked how much it was going to cost to fix it and they responded
with "which insurance do you have?" or "I don't know until I'm done" they
would get shut down and charged, and rightfully so. Because the logical
conclusion is to say it costs some extravagant amount of money and then
"settle" for something less. Which gee, doesn't that happen a lot in the
medical industry when people can't pay their bills? People face bankruptcy and
can't afford a $10,000 bill but somehow the hospital is just fine accepting
$3,000 instead?

~~~
mschuster91
> Not only can you find or figure out how much everything will cost, most
> places (particularly hospitals and outpatient centers) will not even tell
> you how much they charge for their services. Some news outlet did a study
> and called the top 25 hospitals in the country and asked them how much a hip
> replacement would cost. Only around 3-5 actually gave a number and it varied
> wildly. The rest refused to pin down any number at all. That's one of the
> most common surgeries there are and they don't know what they will charge
> for it?

Because in the US model the insurances negotiate with the hospitals what they
pay, and you will almost always be given a number that is way higher than the
highest insurance amount - as when you pay yourself the hospital has a high
risk of never being able to (even partially) collect the bill. Also, it must
be higher than the highest insurance amount so that if you were an undercover
agent of your insurance you would still believe you pay less than others.

~~~
turc1656
That's not how any other insurance works. Providers charge the same amount
regardless of coverage, insurance, etc. and whatever your insurance covers
(including nothing at all) you are responsible for. But they also tell you up
front what they are going to charge you and you acknowledge that you accept
responsibility for making sure they get paid that amount either out of your
own pocket or by covering the gap of what insurance pays.

The idea that having insurance changes the cost is sort of a misdirection.
There's a chance my plan doesn't cover some or all of things that will be
billed. So there is always a risk of non-payment or partial payment. Yes, they
sometimes do pre-approvals for specific procedures but that doesn't always
translate to proper billing/coding that gets covered.

The vast majority of healthcare are not ER visits which means people have a
chance to review and accept the responsibility of payment. But that would also
mean they would know what the hell they would be charged. There's no _good_
reason for a hospital to say "oh you don't have insurance so we're going to
basically mark your bill up 3x just to be safe. Marking the bill up 3x, for
example, doesn't change the fact that they are really only seeking 1x so the
people who can afford to pay 3x are legally required to do so because for some
reason this is viewed as a legit practice and not fraud. And the people that
can't settle for something less than 3x, usually much less. Maybe 1x...in
which case the providers gets what they were after anyway and just indicates
further that this is a sort of fraud and extortion.

~~~
creaghpatr
>That's not how any other insurance works. Providers charge the same amount
regardless of coverage, insurance, etc. and whatever your insurance covers
(including nothing at all) you are responsible for.

This is incorrect. It's absolutely the other way around.

~~~
turc1656
You're talking about something outside of healthcare charging different prices
to people based on which insurance they have _and_ said practice is legal?
I've never heard of such a thing.

You're not referring to the common practice of bill inflation are you? For
example, a tree falls onto your house and the damage is covered by insurance
but the contractor knows insurance is paying for it so he jacks up the price
once he finds out what you are getting from the insurance company (they tend
to ask so that they can "plan" accordingly to stay within budget, but really
they just want to make sure to capture the entire insurance check). This is
100% illegal but very hard to prove, hence it goes largely unenforced. With
healthcare it's well-documented but still unenforced.

If you are referring to something else I would be very interested to know what
else operates in such a manner.

------
mattrp
This article misses one other potential savings — allowing patients to cross
state lines to buy plans in cheaper states.

In terms of HSA’s, I think they are a great idea.

But I have a more radical solution than an HSA:

Allow the first $100k of income to be contributed pretax to a unified savings
plan. We would do away distinctions between 529, ira, 401k and HSA. It would
just be a unified account. You could withdraw prior to 59.5 to cover health,
education and first home purchases up to any amount. Anyone (employer, family
member, friend, charity) could match up to 100% of whatever you contribute in
a year into the account. Cash and stock contributions would be accepted. There
would not be a minimum age to participate - anyone with a ss#.

Like I said, there are holes in the above - I’m sure with some thought they
could be addressed. The general idea would be to turbocharge personal savings
and create a unified structure that helps one build and protect a savings
account with utility beyond just retirement.

~~~
Goronmon
_This article misses one other potential savings — allowing patients to cross
state lines to buy plans in cheaper states._

Is there anything preventing people from buying plans across state lines other
than the insurance companies themselves?

~~~
jsmith45
In order to sell insurance (basically any type) to people in say New York, you
need the to follow the insurance laws of that state. This will have all sorts
of weird paperwork and rules that are different from any other state in the
country.

Having to jump through all those hoops will mean you need a few dozen
employees minimum dedicated to compliance in that state etc.

But we can overcome that by having the federal government regulate interstate
insurance, likely making these companies only needing to comply to the rules
of their home state, or by having states set up agreements to allow out of
state insurers sell under the rules of the other state.

Only a few states currently do that. Even then nobody is using this ability to
sell health insurance interstate. And the reason why is:

You also need to develop a network in the other state, which can be a
significant factor in costs. There is no way that you will get hospitals and
doctors offices in New York to accept the same small amounts that you can get
hospitals and doctors offices to accept in some low cost of living flyover
state.

Of course if you do agree to the higher prices that New York providers would
charge, well now your average costs have shot up, so you need to raise your
rates, making your cheap insurance not as cheap anymore.

------
djinnandtonic
Article's rubbish and (probably purposefully) misses a bunch of really
important points.

1\. The biggest problem with American health care is access to coverage -
publishing prices or helping pay deductables does absolutely nothing when your
insurance company refuses to reimburse or refuses to cover in the first place.
Deductables don't bankrupt people, uninsured cancer does.

2\. The exorbitant cost we pay is caused by a predatory, rent-seeking
insurance industry extracting value from the whole process.

Only medicare for all solves both of these problems!

(Finally and hilariously, the article touches on the example of LASIK, which -
free of the insurance industry, as none of them cover it! - has allowed market
forces to bring up the standard of care while simultaneously lowering the
price on average.)

~~~
noetic_techy
Uninsured people don't typically foot the bill and don't go bankrupt, the
hospital has to eat the costs because no one can be turned away from a
hospital. They then pass that along to the insured by jacking up their prices.

Imagine if health insurance was like car insurance, with radio adds telling
you how much you can save. Imagine a world where you can get MRI's or CAT
scans done for cheap in a strip mall with total price transparency, something
like "MRI's are us", instead of requiring people to go through a primary or a
specialist. No one company could sustain predatory practice without another
company lowering their price to eat their market share.

~~~
dudul
> Uninsured people don't typically foot the bill and don't go bankrupt, the
> hospital has to eat the costs because no one can be turned away from a
> hospital. They then pass that along to the insured by jacking up their
> prices.

Too true. The few times I or a relative had to visit the ER, I got an
outrageous $1,000+ bill for minor things (like suture, stuff like that). I
always called them, told them to fuck off, and they basically said "If you can
pay $~300 we're good".

It just feels like they're desperate to get any payment because I assume a lot
of people just don't pay at all, and they have to eat the cost.

------
helen___keller
I support universal healthcare, but fundamentally speaking there is no reason
there couldn't be a free market healthcare solution that works for a large
percentage of people (IE those that can afford a reasonable healthcare
insurance premium). The remaining could be covered by a government welfare
program.

However, rewrite laws as you want, a good free market solution would depend on
the following:

\- Healthcare providers are incentivized to quickly and efficiently care for
patients as necessary.

\- Every single person should be incentivized to use healthcare services
regularly and as needed, without concerns such as cost.

\- Insurance providers should be incentivized to make things as easy,
painless, and low cost as possible for both healthcare providers and
individuals. The main purpose of the insurance provider is to pool risk and
prevent fraud, not to squeeze dollars out of sick folk.

\- Regulatory bodies like congress should be concerned with regulations that
can (a) ensure the above incentives exist, and (b) lower the fundamental costs
associated with healthcare (e.g. prevent drug companies from price gouging and
such)

Current every single incentive I've listed above is misaligned in the market
today. Doctors' time is wasted with billing and insurance and risk-prevention
to avoid getting sued, many many people avoid using healthcare services out of
fear of unknown costs and bankruptcy (which turns untreated small issues into
big ones), insurance companies optimize around fleecing customers and making
billing hell for doctors, and regulatory bodies are commonly more concerned
with the politics & optics of Obamacare this, affordable healthcare that.

On top of that, our current free market solution somehow revolves around _the
employer_ giving some kind of subsidy and bargaining for better benefits,
which makes no sense whatsoever because everybody needs healthcare, not just
employees of successful corporations.

Anyways, this rambled on a bit, but my point is that any solution that doesn't
have a way to align these incentives will fail to make a big dent on
healthcare costs in this country. Period. This includes M4A or other universal
healthcare plans.

~~~
noetic_techy
The problem is your incentives breed more bureaucracy and its exactly that
bureaucracy that leads to higher costs and a system where nobody knows the
price of a procedure. Laws get passed with good intentions, but with bad
overall outcomes on the system as you pile on more and more mandates. You have
to back off from these requirements and let the market work. Imagine if anyone
could get a MRI or a CAT scan or a blood draw anytime just by walking into a
small private clinic in a strip mall. No requirements to go through a primary
or a specialist, a registered nurse can and should be able to do this with
minimal licensing. No insurance company forced to be involved. No over
regulation mandating that "thou must do the following". Imagine next if health
insurance was like car insurance, with companies blaring ads about how much
you could save if you switched to them. No mandates that it must be employer
provided. No hospitals being forced by law to fit the bill for the uninsured,
thus driving up the cost for the insured.

My point is you need to back off the list of mandated incentives and let the
market do its thing. Then, once it appears that things are stable and there is
healthy price competition, you can maybe pass a few laws to take care of the
edge cases and bad actors.

------
zip1234
Why is price transparency not a thing already? The government should do that
immediately and see what happens before doing anything extreme.

~~~
tathougies
President Trump has already started that process, and has asked Congress to
help: [https://www.npr.org/sections/health-
shots/2019/06/24/7354323...](https://www.npr.org/sections/health-
shots/2019/06/24/735432387/trump-administration-pushes-to-make-health-care-
pricing-more-transparent).

For example, they've already started mandating drug pricing transparency in
advertising: [https://www.nytimes.com/2019/06/14/health/drug-prices-tv-
ads...](https://www.nytimes.com/2019/06/14/health/drug-prices-tv-
ads.html?module=inline), but are being opposed by industry groups obviously.

------
thatfrenchguy
> The second policy—deductible security—pairs an insurance policy that has an
> annual deductible with a health savings account (HSA) that the policy’s
> sponsor funds each year with an amount equal to the annual deductible.

Yeah, people avoid care when they have those plans. Is that a good outcome ?

~~~
partiallypro
In many cases, I would say yes. A massive amount of ER visits are not needed
for instance, and are more suitable for walk-ins and primary care. And just in
my experience my Doctor will often push for various tests, which aren't
needed. I've had multiple people tell me the same. Then I've gone to other
doctors that wonder why such and such doctor did that other than just to
gouge.

~~~
notadoc
Most ERs would be well served by opening all-hour urgent care clinics directly
adjacent, and triaging the roughly 70-80% of people with non-emergent and/or
minor issues into that wing rather than to the ER.

~~~
xyzzyz
How exactly? Since it would do the same thing as ER, it would cost as much to
operate as ER. The patients and insurance would win if this made them pay
less, but the hospital would be a loser here with reduced revenues.

~~~
mschuster91
> How exactly? Since it would do the same thing as ER, it would cost as much
> to operate as ER.

No. The ER and its expensive specialists (e.g. trauma/accident specialists)
can be reserved doing their actual specialized jobs (taking care of patients
injured in car crashes, for example) without being clogged by some dude with a
toothache. The ER _only_ handles the real hardcore cases that can escalate to
death in a matter of seconds, and the urgent-care facility only handles the
"everyday" harmless stuff, which needs less and especially less-
certified/experienced and thus cheaper staff.

~~~
xyzzyz
The ERs should already be doing this: if they have too much toothache cases
for one trauma surgeon, they clearly won’t add a second trauma surgeon to the
shift, they will add a general practitioner. If the trauma surgeon is not busy
putting car crash victims together, he can handle the toothache just fine: he
is already getting paid anyway, so it doesn’t make sense to keep him idle.

------
noetic_techy
Glad to finally see someone pointing out the obvious, that simple price
competition would lower prices, and that Singapore does have a private
insurance system that works!

You can only have two out of three: Low Price, High Quality, Universal Access.
Europe chose Price and Access. Singapore chose Price and Quality, and they
have done some interesting things to make sure that at least their poorest
have no-cost access with a tiered system. You will have a mass wave of doctors
quiting the profession if everyone goes on medicare, the reimbursement rate is
too low to make any money.

------
js2
Looking at Singapore is a bit disingenuous. They have both public and private
systems, with the private system being vastly more expensive. The public
system costs are regulated. (Other differences: adult obesity in Singapore is
below 10%. In the U.S. it's 40%. 65+ population in Singapore was 9% in 2010.
In the U.S. 65+ population was 13% in 2010. Singapore has a population < 6M.)

[https://en.wikipedia.org/wiki/Healthcare_in_Singapore](https://en.wikipedia.org/wiki/Healthcare_in_Singapore)

[http://assets.ce.columbia.edu/pdf/actu/actu-
singapore.pdf](http://assets.ce.columbia.edu/pdf/actu/actu-singapore.pdf)

[https://www.vox.com/policy-and-
politics/2017/4/25/15356118/s...](https://www.vox.com/policy-and-
politics/2017/4/25/15356118/singapore-health-care-system-explained)

[https://www.nytimes.com/2017/10/02/upshot/what-makes-
singapo...](https://www.nytimes.com/2017/10/02/upshot/what-makes-singapores-
health-care-so-cheap.html)

If I were starting from scratch I'd go with single-payer but given where we
are, it seems easier to get to a Bismarck-style regulated multi-payer system
like Germany or most recently, Switzerland:

[https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/...](https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/)

Still, Singapore is an interesting system. The craziest thing about the U.S.
is how many different systems we have: the V.A. is effectively a Beveridge
system, Medicare is an NHI model, Medicaid is a weird Federal/State hybrid,
then we have private insurance, and on top-of-that, out of pocket. There are
vested interests throughout. It's 18% of our GDP. It's going to be hard to
fix. I think Medicare as a public option with subsidies is a good start.
Doctors and hospitals are not going to be happy with the reimbursement rates
though.

------
tempsy
I'm a fan of M4A, but I think something the gov't could do is allow people to
earn tax credits for practicing preventative care that help lower whatever tax
increase would be created to fund healthcare. That creates a financial
incentive to try to be healthy while not necessarily discouraging people from
going to the doctor when they really need to (which can happen with out of
pocket expenses, HSA or not).

E.g. on one of my old plans I got a $300 visa gift card just for going to a
checkup.

------
markus92
This could sort-of work.

In The Netherlands, healthcare is billed according to a"diagnosis-threatment
combination" (DBC, diagnose-behandel combinatie in Dutch), which is a
government-mandated set of billing codes. Each code covers the whole
diagnosis/threatment pipeline, for example "uncomplicated total knee
replacement" which covers imaging, surgery, and a few days of revalidation
until you leave the hospital. As these codes are standardized, it is
relatively easy to know in advance what it's going to cost the insurance
company.

The codes are sort of overlapping, for example a breast MRI has it's own code
(usually 270eu, but with outliers both ways), but there's also a code for the
combination of a mammography, breast MRI + lumpectomy.

Hospitals are nowadays obliged to publish these pricelists, even though
insurance is mandatory etc., after some court cases involving uninsured people
not knowing costs in advanced. Just having these lists could work wonders in
terms of transparency.

------
nickgrosvenor
This is a critical issue that could throw the whole economy into a recession.
Fixing this and the recent prevalence of foreign, disease carrying mosquitos
are the two biggest policy issues, that if fixed will cause a world of good.

~~~
Accujack
>the recent prevalence of foreign, disease carrying mosquitos are the two
biggest policy issues

This is a weird idea. Are you arguing that native mosquitos carry fewer
diseases?

Also... I can agree that health care is #1, but mosquitos are not number 2...
more like number 900 or so. The amount of disease caused by them is tiny
compared to e.g. smoking or obesity.

~~~
nickgrosvenor
It's more of a local policy issue for southern California residents.

Of course all of this can be debated, and perhaps it's not the 2nd most
important, but it's much more important to me and all my friends than most
policies.

Native mosquitos on the west coast (Culex) do not carry west nile or zika.

The new Aedes species does and is extremely hard to control.
[https://www.latimes.com/science/sciencenow/la-sci-sn-
aedes-m...](https://www.latimes.com/science/sciencenow/la-sci-sn-aedes-
mosquitoes-california-20180901-story.html)

Further, it caused everyone I know in the Los Angeles area to stay inside
during this last summer. My kids and friends kids stayed inside all summer. It
was like night and day compared to every other year.

Fear of Zika has spread to pregnant mothers around my neighborhood. People are
literally choosing not to get pregnant because of the fear of this new
mosquito in the area.

The amount of fear caused by these new mosquitos has been extreme. They are
very hard to control, I think this new invasive species can only be eradicate
with government intervention. There are no cost effective trapping solutions.

Nets and Deet aren't 100 percent effective and is not something we should
settle for being the new normal when government intervention is possible.

The sooner it's dealt with the more realistic it can be fixed.

I would literally vote for any local politician if this were a primary policy
issue for them.

~~~
Accujack
Hmmm, interesting. I wonder to what level this is an actual threat vs.
something the media came up with? It being such a hot button for people in
that region would seem to also make it a potent way for politicians to gain
support.

------
simonblack
Health-care costs can only be slashed by somebody missing out on their current
income.

Would there be strong resistance to that?? You bet!

There are too many middle-men leeching away within the US health-care system.
Many poorer nations can afford single-payer health-care which covers all
citizens. Why not the US too? It's just a matter of determination, and
removing the 'I must have my share at the trough' mindset.

------
lcall
Trying various proposed solutions sounds good to me, if and only if the US
federal government is not the one doing it. States could be good laboratories
to try things if and as those people want to, and learn from each other etc
(and not make the _federal_ budget problems even worse while trying to solve
everyone's _personal_ problems). If there are people in need: join nonprofits
or help them personally, or at the state or local level: there are many good
efforts! But charity by federal force leads to too much control over our lives
and huge, controlling, wasteful bureaucracies that are hard to live with,
multiply laws and consume resources so limiting ability to try anything
different.

(edit: I know enough about history to know what happens when the government
tries to solve every problem. We definitely do not want that.)

In fact, we fought a war in the 1770's, partly because of faraway people
having too much involvement and control in our lives. Then wrote a
constitution that limited federal power, because of those problems. The
principles in the Declaration of Independence and US Constitution really are
important.

Helping people is important! There are other, better ways to do it than
increasing federal control and distracting it from its core missions.

To avoid going on and on about this, I posted more thoughts including personal
experiences (with even more that I haven't posted, but can, given interest),
at:
[http://lukecall.net/e-9223372036854586100.html](http://lukecall.net/e-9223372036854586100.html)
There is an email address in the footer for honest feedback.

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dudul
I don't understand how people can be liable to pay a bill they have no
knowledge of upfront, like not even a rough estimate. Even a plumber will tell
you "well, I bill $150/hr and I _think_ it will take 2 hours, but who knows".

Is there any other example of an industry that operates like that?

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gigatexal
From an economists perspective knowing the prices could have profound effects
on things as people will likely substitute either going to the doctor at all
or shopping around within or without their state for treatments until a fair
market price for a procedure is found. At least that’s the theory anyway.

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fuqmachine
Why look at Singapore, a tiny country akin to San Francisco and try to apply
it to all of US, which is infinitely larger and more rural. Why not look at
Sweden, UK, France etc. like the Dem. nominees are correctly doing?

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smileysteve
The vision vs knee surgery on price comparison falls flat on my ears.

The current HSA deductible limits are $1350-$6750.

So, how does knowing a knee surgery is $20k instead of $60k make the consumer,
who is out of pocket $6750 (that they still can't afford) either way, price
discriminate?

~~~
cheald
Expecting price transparency to fix things without actually changing anything
else doesn't solve anything, sure. The point isn't that prices aren't
transparent, it's that prices are artificially high because they're opaque.
Fixing the transparency and encouraging people to shop around should, in
theory, help fix that inflation.

Currently, insurance premiums cost the average American family $19.5k/year[0]
(yes, this includes employer contribution, and yes, the actual incidence falls
nearly entirely on the employee[1]). Much of the point is that if pricing
transparency were in place, costs of both care and premiums would plummet,
resulting in more money in consumers' pockets to spend how they choose. What
kind of medical care might you elect for if you had an extra $15k/year?

[0] [https://www.kff.org/other/state-indicator/family-
coverage/?c...](https://www.kff.org/other/state-indicator/family-
coverage/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D)

[1] [https://www.nber.org/papers/w3557](https://www.nber.org/papers/w3557)

------
oliwarner
This comparison between LASIK and _actual healthcare_ is puerile. Healthcare
providers make bank off the fact you can't afford to shop around. That you
need that cancer operating on. That you need that chemo. That transplant. That
stay in hospital. And that they —and all like them— can charge whatever the
hell they like because your only alternative is a painful death.

So no, pretending that you can fix this by listing pricing things because an
entirely optional industry does it, doesn't just not fix this, it's noise that
confuses people.

Healthcare in the US can only be fixed by hard laws on price gouging (codified
limits, etc) or astronomically altruistic competition that comes in at cost,
and drives everybody else out of business.

And I don't see either of those happening in the US because _everybody_
involved in US healthcare is making obscene money from the status quo.

------
didibus
Couldn't you do both? Provide HSA deductible Medicare for all. And force price
tags on everything? Then you get government offered health care. Negotiating
power of a big single bulk payer. And competition from patients trying to keep
some of the insurance money to themselves by avoiding unnecessary care or
hunting for a better deal.

------
Ericson2314
I don't get how anyone. An draw conclusions from elective treatment like
Lazik, when, until we get better about proactive medicine, most treatment is
reactive and fairly dire.

I don't think in our current state of poor health and disfunction ("deferred
maintenance") is a market appropriate at all. The Oregon experiment makes
sense. We need to get a few good years of people taking care of themselves in
ways they never did before. It might mean more visits. (A side benefit is we
can recalibrate all our statics with more healthier people visiting.) Only
then could we experiment with some quasi market tricks.

America is too stupid unhealthy and disfunctional for some clever market
tricks to work. We need some simple stupid public healthcare and only then
could try some German/Swiss/Japanese/Indianan tricks. Capitalism works best
when the stakes are low, as a game for rich (or healthy in this case) people.
The improvished or dying will just get screwed over without aggregate benefits
for the rest.

------
partiallypro
This would definitely help, but the 75% number is just pulled out of the air.

~~~
npongratz
It may have been in reference to Singapore's results, per TFA:

> With Singapore’s citizenry empowered by deductible security and price tags,
> competition has worked its magic, forcing providers to constantly figure out
> ways to lower costs and improve quality. The result is not only 77% less
> spending than the United States but also, as Bloomberg Businessweek reports,
> one of the healthiest populations in the world.

~~~
ska
It is mostly pulled out of a backside though, because without much evidence it
attributes that 77% decrease in spending to a couple of cherry picked
difference between the systems.

Overall it would plausibly help, but it's a pretty strong claim that these are
the only important differences.

~~~
adventured
It ignores the 30 point gap in obesity - 6% for Singapore, 36% for the US -
which is obviously a big contributor to the US healthcare cost problem. 36%
obesity is an extreme elephant on the table for costs. I would be surprised if
the US couldn't shave 1/5 off its healthcare costs with a 22% obesity rate
(comparable to Germany, Brazil, Poland, France, Sweden, Netherlands, Finland,
Norway, Austria, Spain, Russia, etc).

Singapore vs Japan and South Korea is a more interesting comparison (similarly
very low obesity rates) between costs in developed health care systems, if you
wanted to see which worked better. Japan for example has a spiraling
healthcare cost problem related to its aging population.

------
Goronmon
_But the annual gifts do more than ensure that participants are financially
secure; they give people skin in the game. Participants spend prudently
because they know that any unspent HSA balances are theirs to keep. The
result? Massively lower health-care spending without any decrement to health
outcomes._

HSA also discourage you from doing any preventative care because that's money
you can probably find a use for in other ways. Thus inflating long-term
healthcare costs as people only go to the doctor when it's an emergency.

Anyone who supports HSA accounts is either an idiot or has suspect motives.

Those may be a strong opinion, but it's one I stand by in this particular
case.

