
Greg Knauss's 10-year-old son's $23,800 bug bite - anu_gupta
http://www.eod.com/blog/2012/09/bugged/
======
_delirium
Even though I've been researching with interest, so far I haven't run across
much in the American healthcare system that makes me question my decision (as
an American) to move to Denmark. My taxes are higher, but my costs are very
predictable, and by design cannot ever bankrupt me: I pay a flat 8% of my
income to support the national healthcare system. I won't end up with a charge
equal to 20% or 50% or 500% of my income in _any_ circumstance, not even if I
get cancer or find myself unemployed. So it's guaranteed that I will always be
able to pay my healthcare costs without great hardship.

I do hope someday to move back to the USA (mix of language / "feels like
home"), and am mildly hopeful that PPACA will make it feasible, by 2014, for
an individual to buy private health insurance without worrying about
preexisting conditions and rescissions and whatnot. But we'll see. For now,
Danish is growing on me. :P

Incidentally, this kind of emergency care would be free _even for a tourist_
in Denmark. Regular use of the national health system is only available to
legal residents, but acute emergency care is considered a basic service not
subject to billing, like police and fire response.

~~~
forrestthewoods
8% sounds great. US currently spends around 16% of GDP on health care every
year. I think the majority of Americans would support a universal health care
system that provides far more coverage at half the cost. Instead our total
spend is expected to double by 2020.

Source:
[http://money.cnn.com/2011/07/28/news/economy/healthcare_spen...](http://money.cnn.com/2011/07/28/news/economy/healthcare_spending_forecast/index.htm)

~~~
tptacek
Worth noting that the US leads Europe in outcomes for serious illnesses
(particularly cancer), and the US provides access to specialists in days where
other countries often have multi-week or even multi-month delays.

~~~
tzs
Careful--the US does more early cancer screening than is typically done in
Europe. This boosts the US score on 5 year survival rates, but it doesn't
necessarily mean we actually get better outcomes. E.g., if an American and a
European each get a cancer that will eventually kill them in 7 years, and the
American finds out in 1 year and the European doesn't find out for 3 years,
then the American will show up in the 5 year survivor statistics, and the
European will not.

We do gain some outcome advantage from earlier screening, in that it means we
will catch some cancers early enough to treat that Europeans would miss, but
the outcome differences aren't nearly as big as the 5 year survival stats lead
some people to believe.

As far as seeing specialists goes, the US does do well, although I believe
Germany and maybe Japan have us beat--showing that universal affordable
coverage can be achieved without having to give up reasonable wait times to
see specialists.

The thing that makes me sad about the US system is this. Take the top, say, 10
non-US systems. They have quite a diverse range of approaches, ranging from
straight up socialized medicine to highly capitalistic market-based systems.
All they have in common is that in most areas they have equal or better
outcomes than the US, with universal or near universal coverage, for a lot
less cost per patient or as a percent of GDP. Based on the evidence, it
doesn't appear hard to design a good healthcare system for a first world
country. Only the US seems to be able to botch this. WTF!?

~~~
tptacek
By what measure do European countries have better health outcomes than the US?
We're seeing in this thread why the most obvious metrics don't work well:

* Cancer survival rates, because of the 5 year survival heuristic, capture people who's illness is detected early but isn't actually cured.

* Life expectancy captures the fact that people drive more and faster in the US, that the US has more violent crime, and that more people in the US kill themselves

Intuitively, "high cost" plus "shortest wait time to specialist" plus
"problematic overprescription" (a problem common to all first-world health
systems) plus "earliest cancer detection" just doesn't add up to "worse
outcomes than Europe".

But, it does make sense that despite the money we pay, our outcomes are not
_different enough_ to justify the expense.

I strongly agree: the way we finance health care in the US, primarily through
a system of employer-provided health insurance policies that give way to a
single-payer socialized system that kicks in right when patients are most
engaged with the health care system, all without giving patients control or a
stake in the cost of their care --- this system makes no sense.

------
jellicle
If he's still in the hospital and thinks the bill is $23K he's got a surprise
coming. The bills will keep coming for months. Many items may be billed
multiple times. Writer is going to have to invest several man-weeks in dealing
with this, minimum.

I talked to a friend of mine who received some treatment recently. He made
sure the hospital was "in network", but apparently someone who came in to give
a shot was "out of network" - personally, for herself only - so he received a
huge out of network bill for the services of one nurse in giving one shot. He
asked the insurer if he was supposed to quiz each medical person in the
hospital about whether they were in a particular insurance network before
allowing them to provide treatment. The insurer's answer was "yes", with no
irony.

~~~
russell
Anesthesiologists are the worst offenders. My experience is that none of them
are in network. You think you have everything covered and along comes this
bill that is as big as everything else.

Woe to you if you are uninsured. I had minor heart surgery nearly two decades
ago. The bill was something over $80K. The insurance company disallowed most
of it, bringing it down to $20K of which I had to pay $2K. Except for the
Anesthesiologist.

~~~
ysopex
Why is it that you can't go to a medical facility and tell the intake nurse or
admin person you're not agreeing to any procedure that's not covered by your
insurance. Wouldn't that put the onus back on them? Anything not covered
instantly becomes a freebie or a lawsuit?

Why do hospitals and clinic get away with this crap when auto mechanics and
plumbers can't?

~~~
eli
What makes you think anyone else would take on the liability of vetting your
care for you? And for free?

~~~
rdtsc
If a law was passed that they have to that's what. If a law was passed that
any hospital billing mistake in favor of the hospital should be fined by a 10x
fine of the amount on the first offence and a much higher one on subsequent
offences. That kind of stuff, stuff that would protect individual citizens
when they get sick and are most vulnerable. In a normal country that's what
would happen.

~~~
eli
The hospital didn't make a mistake in this case; they were indeed covered
under the plan. The specialist who is not under the plan is probably not an
employee of the hospital. So basically you're saying we should overhaul the
way medical billing works. I totally agree, but I don't think that is
accomplished by passing a law that levies fines on hospitals.

------
abtinf
For complex reasons, I was without insurance for a couple days last week.

I happened to have an appointment schedule. I went into the clinic and, since
it was my first time there, I filled out a stack of paperwork. And then they
told me my insurance was inactive.

So I figured, whatever, I'll pay it out of pocket and file for reimbursement.
I asked how much the specific service I was requesting would cost. And they
had no idea. They refused to tell me, other than to say "well, we charge a
hundred dollars up front and then you pay the rest of the bill after you are
done".

I ask to see their cash price list, because every sane facility I've ever been
to has a cash price list with prices that are 1/2 to 1/4 of the insurance
price. And they don't have one.

So I ended up leaving. It's amazing just how perverse health insurance has
become, that it can so affect the delivery of medical care that the facility
cant/wont give an up front estimate.

I wasnt even there for anything complex - just a standard glucose diabetes
test. They probably do ten a day.

~~~
tptacek
Last year, my daughter caught a stomach bug and for a few days woke up each
morning nauseous. We took her to her pediatrician and were surprised to find
out that "waking up nauseous" is a Big Deal; it can be a neurological symptom.
We were pretty sure that wasn't it (there were... other symptoms...
corroborating our "stomach bug" hypothesis) but the doctor was adamant: if she
kept waking up and puking, she'd need to get imaged.

She got better and we cleared her to go on vacation with her grandparents, and
were just about to get on a plane to go give a talk at Black Hat, when we got
a call from our parents in Michigan telling us she was puking again. We called
the doctor, who demanded we retrieve her and scheduled a CAT scan.

We are at this point freaked out for a variety of reasons, some of them
logistical (trip to conference, driving back/forth to Michigan, &c) but also
from the fact that our doctor knew what an epic inconvenience all was and was
absolutely clear "daughter needs CAT scan" --- so in the back of our heads
there's gnawing "something could really be wrong" (Adia had seizures when she
was 4, which, by the way, GUESS WHAT DING DING DING UNINSURABLE ON PRIVATE
MARKET NOW, and now 7 years later I still can't even hear she has a headache
without taking an inventory of all other possible symptoms.)

So anyways, we want that CAT scan done now now now yesterday now. We get to
the hospital for our appointment and: problem with our insurance card. No big
deal, we'll just resched--- _fuck that, I'm paying cash_.

Head scratching ensues, long story short, very large hospital in Chicago
doesn't have any price list for a CAT scan at all. Not even an insurance cost
to pass on to me, let alone a cash-basis discounted price. Getting imaging
done at a top hospital in Chicago without insurance: unheard of. They ended up
just making up a price on the spot; $1000.

~~~
ScottBurson
Wow.

I have on a few occasions floated the idea of making it illegal to insure more
than 90% (say) of procedure costs -- there would _always_ be a mandatory 10%
copayment. No one I mentioned this to ever seemed to understand the point. I
don't know that the proposal is actually workable, but I think you can see
where I'm coming from. If patients had to know all the prices because they had
to pay some fraction of them, the whole system would look very different.

------
tptacek
A young coworker had an ATV accident. It was ugly, but not so bad that they
weren't on IM within days talking about work.

Total bill: just shy of $100,000.

A friend's son had appendicitis. Uneventful appendicitis.

Total bill: neighborhood of $35,000.

Add to this: tens of millions of people are, despite any debilitating medical
conditions or even better-than-even likelihood of incurring anomalous medical
expenses at all, _actuarially precluded_ from getting insurance on the private
market. There are very long lists of widespread health conditions, most of
them "chronic", most of them minor, that will land you on automatic exclusion
lists (not "we will cover you but not for this condition", but, "we will not
issue a policy for you at all"). Particularly if you are a woman with a
functioning reproductive system.

Once again I say: I cannot understand how anybody who runs a software business
or who aspires to run a software business could possibly oppose guaranteed-
issue health insurance. I dealt with many dramatic problems during the
operation of the company I cofounded in 2005, but the only one that was almost
intractable was trying to obtain private coverage for my family. Fortunately,
my wife Erin got a tech job with group health coverage and we dodged the
bullet until Matasano got its own group plan.

Employer-sponsored group health insurance is a terrible system. It increases
costs on new businesses and adds uncertainty to their financial planning,
while at the same time retarding labor mobility. It introduces a
principal/agent problem between the people selecting plans and the people who
use them. Because this idiotic scheme is tax-advantaged, it incentivizes the
creation of a bizarre slush fund with warped, collusive prices. At the same
time, because users of health care never directly pay for it, it encourages
people to make dumb decisions about their own care.

People should buy their own insurance. Insurance companies should be forbidden
to decline applicants, or to constructively deter them with shady pricing
schemes. People should not be allowed to exploit that requirement by waiting
until they get sick to apply for coverage. The requirement should be
nationwide, so that states that offer sane insurance regulations don't get
sabotaged sick refugees from other states without sane insurance regs.

Minus the Medicaid expansion, which I'm ambivalent about, this is what we
worked out in 2010.

~~~
clarky07
Just because the system is broken, doesn't mean we need socialism, and it
doesn't mean that a software developer should support anything in particular.
I personally, won't support anything that makes me pay for your health
insurance. I pay plenty for mine, I have no desire to pay for yours. We can
work to fix the broken system, but keeping everything the same and then taxing
us more to have the government foot the bill WILL NOT FIX THE PROBLEM. The
government getting involved isn't the solution.

Just think, emergency rooms that function with the efficiency of the DMV. Woo
Hoo

~~~
Niten
It's hard to take comments like this seriously when the private American
health care system has worse outcomes and more than double the cost of
numerous socialized systems.

You can blindly chant "government isn't the solution" all you want, but it
doesn't change the fact that it undeniably is the solution in a large number
of countries with functional health systems.

~~~
clarky07
Functional does not in any way mean better. I do not want to wait on a list
for my health care. As I noted in another comment -
<http://news.ycombinator.com/item?id=4466161> \- this doesn't just have to be
"current shitty system" versus "socialism". I never said that the current
system is great. All I said is that I'd rather have it than socialism. So many
things we can fix easily about our system without going to socialism. And
Obamacare is the worst of all worlds. Halfway socialism while still keeping
insurance companies. Please tell me how that makes sense.

------
theoj
Hospitals often bill 5x-10x actual costs to make up for the "discounts" that
insurance companies force upon them. If you're uninsured and get hit by a huge
bill, you need to negotiate with the hospital to bring the amount down. Doubly
so, because hospitals have lax tracking of costs, and no one really knows how
much your visit really cost. More about this from an actual MD:
<http://truecostofhealthcare.org/hospital_billing>

~~~
TheAmazingIdiot
I'd be more for using informed consent laws to argue that you would not have
proceeded with treatment had you known how much it cost, or the costs related
to failure of procedure.

Our medical system is the worst of capitalism, and the worst of socialism.
Tell me again: Where are the prices?

------
rkischuk
This is putting things exactly backwards. The argument is roughly "Treating a
minor condition cost $24k, which could wipe people out financially, therefore
PPACA is important."

Where is the outrage over this price? What part of PPACA does ANYTHING to
reduce this cost? PPACA does essentially 2 things: 1) It makes insurance
"affordable" for people who previously couldn't obtain it at all. 2)
Drastically increases demand for health care, without adding to supply or
controlling costs any other way.

Insurance is simply a distribution of cost over a risk pool. If relatively
mundane life happenings cost $24k, and nothing is being done to fix that,
we're in real trouble, and I think we are.

Nothing done to increase the pool of doctors. Nothing done to control medical
lawsuit costs, which transfer money from the insurance pool to individuals.
Nothing done to control the cost of drugs (and in some cases, aggravated by
making more expensive drugs "free").

Bring the cost down to $2,400 and "wiping people out" isn't as big a concern.

~~~
tptacek
We also need to increase the pool of doctors.

We probably don't so much need to deal with malpractice insurance, since that
fix doesn't (to employ a congenial metaphor) change the exponent in the Big-O
cost of health care.

We need to make it simpler to get drugs on the market, but we also need to
walk the tightrope of doing that while regulating pharma marketing,
particularly to medical practices.

We need to restructure care in the US. We recognize that the E.R. is a
terrible provider-of-first-resort and that non-emergency E.R. visits are
damaging the system. We need to start realizing that M.D. doctors are _also_
poor providers of first resort, and get a nationwide system of low-cost
clinics deployed. That's already starting to happen at places like Walgreens.

We very much need to figure out how to start exploiting the Internet to
provide some level of routine care for patients.

These are all things that do need to happen. But they don't have much to do
with the problem that insurance problems are randomly bankrupting large
numbers of Americans. We need to fix that problem _first_. Face it: the most
expensive cohort of patients in the US, accounting for by far the majority of
our exposure to rising medical costs, have had socialized single-payer health
care for decades. Access to private insurance and the "cost curve" of health
care are simply orthogonal problems.

~~~
ScottBurson
I think we really would do best to attack the cost explosion problem at the
same time we attack the coverage problem. Fixing the coverage problem is
mostly a matter of political will (granted that the opposition has been
bitter). Getting costs under control requires far-reaching changes to the
health care system itself and will take years at best.

------
dollar
The question no one ever asks is "why is the bill $23,000?". The only question
that ever gets asked is "who should pay this $23,000 bill?". I charge $200/hr
for my time at a minimum. Did this child really receive an equivalent of 2.8
weeks of my time in services? Or did an unecessary middle man negotiate
ridiculous prices with the provider, leaving the consumer out of the equation
but responsible for the bill? And yet people seem to think that _more_
unnecessary middlemen will make the situation better.

~~~
kdsudac
You can figure try to figure out the "why" for specific cases but it's tedious
work and comes down to subjective opinions that can't be generalized to other
cases. The theoretical worth of the shadowy middlemen (whether they gov't or
insurance companies) and where the blame lies can be debated. All these
arguments rely upon theoretical simplifications of very complex systems--
meaning they are almost impossible to model.

What's more important is the "what" as in what are our alternatives. Luckily,
we have tons of empirical data from other countries and they all tell the same
story: America pays more money, with poorer results.

So why not just copy the models of other countries?

~~~
tylee78
After 15min ER due to a strained wrist the bill was $4100 dollars. We demanded
detailed itemized bills and send letters to the doctor (billed separately) and
the hospital. The doctor dropped his bill from ridiculous $900 dollars (for
saying everything was alright and taking 5 mins to open a tiff file on his
computer) to $200 after our complaint. His bill and the hospital had up-coded
our visit and tried to hide the costs of their ill-managed hospital by billing
a piece of cloth (made in Guatemala) with $500, the price of an iPad.

------
kefs
As a Canadian, I couldn't imagine having to decide between money and
healthcare. I don't know how you guys do it...

Relevant reading: [http://www.rhrealitycheck.org/article/2012/07/12/how-i-
lost-...](http://www.rhrealitycheck.org/article/2012/07/12/how-i-lost-my-fear-
universal-health-care)

~~~
throwaway87654
I'm a Canadian who owes tens of thousands because I had an emergency operation
in a different province (BC) from where I have my health card (Ontario).

~~~
pgrote
Curious. It seems either Canadian healthcare isn't the panacea we Americans
think it is or there a number of Canadians who post here that don't know about
their plans.

My thought is the situation is analogous to each US state and their safety net
medical programs. Means based? Is this correct?

~~~
_delirium
As far as I can tell (some reading, some 2nd-hand stories) Canadian healthcare
is not a good model at all. It may be better than the US, but that's faint
praise. I'd look to the French, Swiss, or Scandinavian systems for better
models.

------
ojiikun
Every time a healthcare discussion comes up and everyone gets derailed on
whether (or how much) to socialize things, I wonder the following:

from a technology, taxation, and moral standpoint, what the hell led to a
system where some heavy-duty antibiotics cost about 10-15X what they should?
More importantly, why do generally intellegent audiences get caught up in
arguments over socialism rather than correcting the cost issue _first_? Is it
sue-happy lawyers, is is an anti-competitive marketplace, or is it the pushing
of the very concept of insurance that has given us such an unsustainable
system?

I truly want to put out a call to geeks: for every healthcare dollar you
spend, grill your provider. Haggle them down, and make them justify the price,
or we're all screwed, no matter who is paying for things.

~~~
abtinf
The reason is simple. Many folks, myself included, hold the view that it is
government intervention that has led to the insane system currently in place.
Eliminating the perverse healthcare system forced on us by current policy IS
the way to control the cost issue.

~~~
cma
Most other industrialized countries have heavy government involvement and pay
half what we do with the same outcomes. We just have a hybrid system with
capitalism applied in the stupidest way..

~~~
bhb916
This statement sounds totally odd to me on both ends.

First, the US pays more in a lot of markets. By and large, that's because we
can.

Second, capitalism isn't applied. That sounds like it's some sort of
regulatory tool that just isn't being used correctly. Capitalism is the
absence of government force in an economic market with the notable exception
of enforcing private property rights. You can say a lot about the US
healthcare situation, but "applied capitalism" it is not.

~~~
tylee78
...which goes to show that socialized health-care can even be worse.

------
T_S_
Reminds me of my kid's $6000 bump on the head. Or the time I had and knee
operation and they took five minutes extra to clean out something they spotted
and added $3500 to the bill. Or the eye operation where they took fifteen
minutes extra because there was a detached retina adding $9000 to the bill.
(Insurance wouldn't pay that one. They never said why either.)

You are not exactly going to negotiate at moments like these.

~~~
TheAmazingIdiot
Insurance companies make more money if they refuse payment.

I've always liked the old Chinese medicine system. You find a doctor who is
willing to take you as a client. You pay the doctor money per month when you
are well. If you are sick, you do not pay. Of course, refusing treatment is
acceptable to get you disqualified, as are a few other things.

~~~
tylee78
nice system! sounds like it has a market principle built into it...

~~~
brazzy
Except it breaks down completely when there are expensive drugs and
procedures.

------
api
The US healthcare system combines everything that is bad about a state-run
socialized system with everything that is bad about privately funded care.

To add insult to injury, we do not pay substantially less taxes than, say,
Canadians. If we paid Costa Rican taxes I'd be fine with it, but we don't.

~~~
jerf
This is why I think even if you are in favor of socialized health care, you
really ought to be against the PPAFA. It's not "socialized health care", the
glorious ideal you have in your head where everybody takes care of everybody
and it's all smiles everywhere. It's an ungodly abomination of a thousand
pages of hastily thrown together legislation with a bajillion moving parts,
dozens of newly created agencies, what is basically gibberish in terms of who
is paying for what driven more by what voters needed to hear than any
resemblance to reality, and then after all of that, was brutally beaten by the
legislative process until it could barely assemble a coalition to drag it
across the finish line in a horrifically compromised state.

Trying to explain why this is a good idea and trying to explain why socialized
health care is a good idea are two things that should not be done at the same
time. If you think it's bizarre how many people aren't buying into the whole
nothing-but-smiles theme now, wait until after a few years of experience with
this turd.

The whole "Oh, the monstrous heartless conservatives just want to throw granny
over the cliff so they can save a buck" is just a propaganda smokescreen put
up so you don't look too much at the actual product you're pitching beyond the
catchphrase level. Personally I feel some people are being pretty careless
about what will actually happen to real people while they are moving abstract
political footballs labelled "socialized healthcare" around without caring
what's behind the abstraction. I know the abstract progress may feel good
today, but the reality isn't going to stay behind the abstraction boundary.

~~~
_delirium
I don't really support the outcome (I want real socialized healthcare), but as
far as I can tell PPACA is at least better than the status quo. It seems like
it'll make it possible to buy individual health insurance, which will actually
cover healthcare, and won't be jacked up when you get sick. That's at least
one improvement over the current system, which is completely broken unless
you're in a quasi-socialized health-coverage pool, like those provided by
large corporations' group plans.

------
Stratoscope
> We’ve got a strategy for dealing with the COBRA expiration, but it’s
> complicated and requires a lot of hoop jumping and is more than a little
> silly.

Whatever the author's strategy is, it sounds like he's quite misinformed.
There are no hoops required to get HIPAA guaranteed issue coverage when COBRA
runs out. All insurers are required to offer it regardless of preexisting
conditions. It will cost more, but coverage is automatic with no medical
information required.

The usual procedure is to simultaneously apply for underwritten coverage and
guaranteed issue. If the underwritten policy is declined, the guaranteed issue
takes effect. If you know you'll be declined, you can skip the medical history
on the application and apply for guaranteed issue only. You have 60 days after
COBRA runs out to apply.

You are also eligible if your insurance ends because the company goes out of
business without making COBRA available.

Any insurance company or agent can give you more information, or search for:

California HIPAA guaranteed issue

~~~
rdtsc
To someone from a country with a sane health care policy this whole procedure
sounds ridiculous.

------
clarky07
I don't think kidney stones are really going to get someone denied for
insurance. There is no reason I should have to pay for your healthcare. I pay
for my healthcare. You pay for your own damn healthcare. (note that I am self
employed and had no problems getting a high deductible health plan).

Now if when you say you are short and stout (or however you worded it) you
actually mean you are 500 pounds and obese, then get on treadmill. Absolutely
no reason I should have to pay for your healthcare because of your poor life
decisions.

------
petercooper
Naïve European who'd pay nothing for this here (ok, taxes, but supposedly we
still pay fewer % of our GDP overall) with a question:

 _I’ll have to have to pay less than 6% of that, because I’m lucky enough to
still have insurance._

Why? If you have insurance, shouldn't that cover the whole expense? Or is it a
bit like an excess on a car insurance policy? Can you get insurance that
covers everything?

~~~
smsm42
Did you ever have car insurance or any other kind of insurance? Most
insurances have deductibles, and the point of that is that insurance is to
prevent catastrophic loss, not every expense. There can be insurance that
covers 100% of expenses, but it will be very expensive, especially for health,
as it won't be insurance at all.

Imagine that 1000 people pay each $100 into insurance pool. Then if somebody
has a problem there's $100000 available for him, and if the chance of this
problem is 1/1000, then this works. Now imagine each of these people has $50
in regular expenses that they want to be paid from the same pool. Then to get
the same coverage one needs either to pay additional $50 into the pool (which
then is not insurance but just a very expensive savings account) or accept
that his coverage dropped by half. And that's not counting insurance company's
cut, which makes it worse.

~~~
petercooper
_Did you ever have car insurance or any other kind of insurance?_

Yes. I go with the largest excess possible (what I assume is also called a
deductible) because the chance of making a claim is low. But it's only 10-20%
more to have no excess at all.

The logic in your second paragraph makes sense on the surface, but the lack of
a deductible in many European-style health systems doesn't seem to result in a
larger share of GDP being spent on health (which is notoriously high in the
US) _or_ the healthcare being of a lower quality.

~~~
smsm42
The difference between medical & car insurance is certainity of small
expenses. If your insurance covered regular maintenance of the car, it would
be substantially more expensive.

------
clarky07
This thread has a lot of socialism vs free-market talk, but the real problem
with American health care is the lack of transparency, and the middle-man, be
it government or insurance doesn't change that. We have so many pointless
things done, and the prices are not known ahead of time. Unless we are talking
about life and death, the cost of the procedure you are doing to me should be
known before I decide whether I want it or not. The number on the bill also
isn't ever really the bill. The insurance company or government negotiating
says no I won't pay that amount, this is the real amount you should be
charging so we are going to pay this. Doctors and hospitals charge X because
that is what insurance companies and government decided they would pay.

If you were negotiating this care for yourself, you could almost certainly get
it cheaper (as you have a much bigger vested interest in your savings account
than the government etc does), and we would not get nearly as many unneeded
procedures done. Most of the time it's not even a question, and it should be.
They don't say, we think maybe you should have this done and this is why. They
say, we're going to do a X. Maybe they tell you why, if you ask them,
otherwise it's just assumed that since I'm sick I should do what they say.

I broke my arm a few years ago playing softball. I had an extra 90 degree
angle in my arm. People in the bleachers heard it snap. It was 100% broken no
question about it. The hospital wouldn't give me any pain killers until they
had an x-ray to see if it was broken or not. Now I suspect getting an x-ray is
useful for the guy doing the surgery to fix it, and he did several as well,
but there was 0 reason for the x-ray in the emergency room. It cost me (and
the insurance company) money, it wasted valuable time for the nurses/doctors
who could have been onto the next patient sooner, and most important it made
me absolutely miserable for another hour waiting on it when all i needed was
some pain killers and nice splint until I could have the surgery.

Socialism doesn't solve this problem. It just makes you pay for my x-ray.

------
anonymoushn
The bill would be much higher if he paid with cash than if he paid with
insurance. I'm curious to know how much. I expect would be at least 3x the
amount the insurance company must pay.

------
wavesounds
Im interested how people feel about hacking the ER. I personally have never
had to do it but I know quite a few people who will give fake names and social
security numbers to avoid such situations. Obviously this makes it more
expensive for everyone else and one could argue the Affordable Care Act is a
way to fix this security whole as much as anything. Morally if you're stuck
between lying to a doctor and losing your child's college fund what is the
best choice really?

------
SoftwareMaven
The people who think the US health care world is A-OK are the people who have
never been uninsured nor been uninsurable. As much as I want to build my own
company, my life and job revolve around my ability to get insurance because I
had the gaul to have surgery once upon a time.

People should not expect something for nothing, but there has to be a better
place than we are at now. Because this place _sucks_!

------
rdtsc
> an accident or a disease or any of a billion other random, faultless
> happenstances — isn’t going to send them to the poor house.

What is he talking about? It doesn't make sense. He complains about high
costs. Then he praises the health care act but I don't see how health care act
controls costs. Not having a single payer option, not having cost controls
make it a stupid and broken.

------
noonespecial
The (big) problem isn't really that there are people who may or may not have
insurance to protect them from 24 kilobuck bug bites, its that we've let so
much friction build up in our system that it has come to cost this much to
treat even simple maladies.

We're so busy worrying about _who_ should pay what we don't ask the big one:
why the hell does it cost so much in the first place?

------
joni123
Silly americans... in my country, it's obligatory to have health insurance and
if you cannot afford it, the government will pay your insurance, for god's
sake. Not even the most conservative and right-wing politicans who see our
freedom in danger when we can't keep fully automatic assault rifles at home
anymorehere question this system, because it just makes sense.

~~~
retillit
Can someone please explain to me the purpose of an insurance company when
participation in the pool is mandatory? A policy like this seems like it
creates a legislated middle-man that just wastes money.

~~~
tptacek
Participation in the automobile risk pool is mandatory in all 50 states, even
in states with no-fault accident laws. Nobody questions whether auto insurance
companies are really insurers. Similarly, while huge companies aren't
_required_ to insure their commercial activities, virtually all of them do.

Mandatory coverage is orthogonal to the question of whether health insurance
is a proper insurance scheme, or some kind of social safety net entitlement,
or a utility. The sole purpose of the mandate is to make free-riding on the
insurance market unlawful; it's a mitigation for an asymmetric information
problem.

~~~
dwwoelfel
_Participation in the automobile risk pool is mandatory in all 50 states_

Only if you own a car and drive it on public roads.

~~~
tptacek
Oh, so you mean, "only if you don't live and work in one of a prohibitively
small number of major metro areas in the US".

For all intents and purposes, auto insurance is effectively mandatory for most
Americans. It's for a similar reason that many states revoke driving
privileges for parents who don't comply with child support.

~~~
dwwoelfel
You have to own a car, though. The state makes you buy car insurance because
you can do a lot of damage to other people and their property with a car. They
own the roads, so they're responsible for making sure you can pay for that
damage.

Texas, for instance, doesn't actually make you buy insurance. You only have to
prove that you can be financially responsible for the damage you could cause
[1].

Why is this relevant? You made the claim that "The sole purpose of the mandate
is to make free-riding on the insurance market unlawful"

The medically uninsured only pose a financial threat to themselves. It's only
through laws that make taxpayers responsible for the medical costs of the
uninsured that they pose a threat to the rest of us. This mandate won't change
anything in that respect. It will just make the line from taxpayer money to
person who can't pay for his medical bills harder to follow.

[1] <http://www.dmv.org/tx-texas/car-insurance.php>

_edited for clarity_

~~~
tptacek
The laws making the rest of us responsible for the uninsured aren't really
optional, so it's probably better to just reason about this problem as if the
uninsured were just intrinsically a financial risk to us.

------
amalag
I think we have to start with the American Medical Association. It is in their
interests to keep prices high and keep doctors in their McMansions. First
follow the money, who benefits from high prices? Insurance companies, medical
suppliers, and the American Medical Association gets to enforce the medical
monopoly.

------
nahname
Even with insurance it cost $1400 for a bug bite? I just had a baby (my wife)
and we paid $40 for a private room. This is pretty much why I will never live
in the USA. Which is unfortunate because I do like the country and could see
myself living there except for this.

------
useful
It costs $121/month for 100% coinsurance, no copay, and a 3000 yearly maximum
cost in network. Can no one spend <10% of their income on their health?

~~~
_delirium
Maybe if you're in your 20s and were lucky enough to have no childhood health
conditions. In the real world, that isn't the case for many people. How much
does individual health insurance cost if you were born with a congenital heart
defect? Or if you were diagnosed as a child with autism?

------
abtinf
This is an inappropriate article for HN.

~~~
fiatmoney
You know what's a huge barrier to entrepreneurship? Needing the insurance that
comes with a BigCo job, so you're not ruined financially when your kid gets
bit by a bug. I know many people who have this explicit rationale for not
founding or joining a startup.

~~~
abtinf
Then they are grossly misunderstanding relative risks and shouldn't be
launching their own startup.

And its terrible reasoning. Existing law already provides for cobra, giving
them an 18 month window of coverage in which they can retain your employer's
insurance (by paying the full premiums). That's more than enough time to
validate an idea and secure insurance in the new company, or fail and spend 6
months finding a new job. Or if you are an engineer, 1 month finding a new
job.

~~~
lsc
sure, if you are using the "build a prototype, get investment, move from
there" model... that's fine.

Personally, I think bootstrapping, taking no outside investment at all is also
a completely reasonable model (and often ends up with a more sustainable
business, and can be executed by people that lack the sales skills to get
investment)

If you are bootstrapping? 18 months is not a reasonable period of time to get
something to the point where you can get group coverage. (In most states, to
get group coverage, you need at least two employees on that insurance.)

also, I think it's quite valid to support yourself doing contract work. same
problem; if you don't want a body shop to take half your pay, well, you need
two employees before you can get group coverage.

~~~
bhb916
My company bootstrapped and we just initiated a group policy 13 months after
our doors opened. This is, of course, anecdotal, but I think it's very well in
the realm of possibility. Regardless, even in states like CA high-deductible
plans (i.e. catastrophic care plans) are very much attainable both by small
businesses and by individuals.

Contractors in the US get hit with a fairly sizable self-employment tax. This
tax would no doubt go up to fund any sort of universal health insurance.

Regardless, I don't see the need to 'scratch your entrepreneurial itch' as a
valid reason to stick you neighbor with your medical bills.

~~~
kdsudac
"we just initiated a group policy 13 months after our doors opened"

Doors opened means started development or launched? If after you started
development, how long were you in development?

"Regardless, I don't see the need to 'scratch your entrepreneurial itch' as a
valid reason to stick you neighbor with your medical bills."

What if you change your statement to:

\-->I don't see the need to 'educate children' as a valid reason to stick your
neighbor with your school bills.

\-->I don't see the need to 'protect your life' as a valid reason to stick
your neighbor with your police bills.

The reason the government provides these services is because it is in the
common interest.

I'm sure if you think a little while you can come up with some reasons why
having universal health care might be in our collective best interest.

------
davidf18
In the US there are many community health centers. NYC alone takes care of
450,000 people without any insurance at all through CHCs and other sources.
The very poorest generally have Medicaid in NY State, so the uninsured might
be people like waiters. At any rate, there are community health centers
throughout the country.

One issue that I have with the Obama Affordable Care Act is that they should
have put much, much more money into the CHCs.

------
michaelochurch
This country is still suffering from slavery and racism. We would have had
socialized healthcare in _1948_ were it not for the fucking asshole racists
who didn't want to desegregate the hospitals.

Our basketcase of a healthcare system kills 45,000 people per year. That's a
9/11 every 24 days. It's inexcusable.

