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Medicare will require hospitals to post prices online (msn.com)
1015 points by DoreenMichele 5 months ago | hide | past | web | favorite | 544 comments



I really like this push towards transparency but hopefully people who use the data / develop will make sure to understand the system and the data they're dealing with. Like list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts

I'd imagine hospitals hate this. Many of them are paranoid at what will happen if there is more transparency -- there's a union fighting Stanford hospital now and playing radio ads about high infection rates at Stanford. Other hospitals are worried about whether similar things could happen to them -- and hold their data tight to make sure no one has ammunition to do similar things. Hospitals in many cases market based on brand value rather than quality. In a closed world, hospitals can define quality any way they want. Everyone is #1 in something. If there's an objective standard for quality based on integrated data from hospitals nationwide, many brands will be tarnished. I'd be interested to see how hospitals respond to this push towards openness


How this isn't already mandated by law is baffling. We like to champion the "free market" but then completely fail to implement policies that make that even remotely possible.

When people talk about the free market and today's healthcare in the US I'm always like, "What are you even talking about?" You've got a situation where there is typically no competition and little or no information available to the consumer. Free market economics simply don't apply.

One of the reasons I like Kaiser is because the price for just about everything is posted. I know an CT scan of stomach area, with dye is $608. Every healthcare provider should be required by law to give you an estimate price on the spot. If it's too complicated because of multiple insurance providers and their contracts they should be forced to renegotiate in a way that make this possible. "It depends" or "we can't tell you until after we bill you" is not acceptable. Can you imagine any other market working that way? How much is this car? Can you imagine if the response was, "Well, it depends. We can't tell until after you agree to take possession. It's somewhere between $40 and $40,000. But it might actually be free if you submit form X, but you have to go back in time and submit it before you walked in the door and get it approved."

If the option was universal healthcare vs a free market system there would at least be a discussion. Instead it's universal healthcare vs the roll-of-the-dice healthcare system we have now.


I'm glad to see someone else shares this view. I've been saying for years that both a single payer health system and an actual free market system would be preferable to the heavily-yet-poorly-regulated mess of a "market" we have now.

If we don't go the single payer route, it seems one of the #1 things we could do is to help move "insurance" back to being actual insurance (i.e., we'll keep you from being bankrupted by your medical bills) rather than a system that highly subsidizes your regular medical care but then may not actually be there for you when the bills really pile up... If consumers had to actually shop for procedures (as opposed to knowing the out-of-pocket is $250 and who knows what happens beyond that), I think you'd start to see people screaming for transparency, and medical providers would have to get their acts together.

Only one of many problems, I know.


Resetting the expectation that insurance is for unusual procedures, not for yearly checkups and the common cold would be a great start. It's also necessary to focus on the supply side. Just two examples: the AMA limits the number of doctors and new hospitals can't be opened without the approval of the existing hospitals in the area. There is far from a free market in health care in the US.

http://reason.com/archives/2017/10/25/this-one-weird-trick-c...


I don't think that making sure that insurance doesn't cover checkups and preventative care would have a very desirable effect. Putting people (and their young children) on high deductible plans has the very predictable effect of discouraging treatment or even 'well baby' checks. That is part of what leads to such an abysmal (third world) infant mortality in the US.

You can argue that hospitals and ERs in particular are not a good place for checkups, but discouraging them is likely to be more costly (in $ and human lives) than not.


Come to Norway. Every visit to a doctor or hospital involving any of our children is completely without cost to us as parents - there is no deductible. We just walk right out the doors from the doctor's office or hospital, and there is no bill.

It makes so much sense: If your father had to decide between a beer and you getting that wound checked, kids would die.


Yes, I'm wondering how would that work in Norway without the petrodollar economy behind it.

(For clarification, I'm all in for universal free healthcare, but comparisons need to be fair, and comparing the US to the nordics, is not fair)


Yea, I think that those things are highly desirable FOR the insurance company, because yearly checkups reduce the chance that the insurance company has to make a big payout. So you would either see insurance rate refunds/reductions for a yearly checkup or you would see them covered.


We tried that, for, well, the whole history of health insurance in the US prior to the ACA, and that's not what happened. Preventive care improves outcomes but doesn't reduce aggregate costs.


Is there data that backs up this assertion?


Not sure about data, but medical costs are for the most part inelastic, and concentrated on a small number of patients with expensive conditions.

What I DO know from working in insurance is that lifetime medical costs are concentrated in the last 2 years of life (I worked on credit card insurance and life insurance).

That's where you could make huge costs savings (but is an ethical landmine, not to mention economic interests)

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....

https://www.nihcm.org/categories/publications/the-concentrat...


I understand your sentiment, but it is absolutely incorrect that the AMA limits the number of doctors.

I presume you really mean 'residency slots' when you say doctors. In this case, the relevant administrative body is the ACGME... who sets the limits based on appropriations from Congress.

The trope of doctors restricting entry to enrich themselves does not explain reported physician shortages.


Practicing medicine without a license is illegal in all 50 states. The AMA is a major gatekeeper of this process. It's one thing to prosecute people for falsely passing themselves off as being licensed, quite another not letting them perform procedures on consenting patients.


That was tried before and resulted in horrible levels of death and suffering. Which is exactly why we now have the AMA and laws against the unlicensed practice of medicine. No one who understands the history of medicine wants to go back.


The AMA lobbies to limit the type of work nurse practitioners can do and they are licensed.

http://articles.baltimoresun.com/1994-06-14/news/1994165047_...


That's a false dichotomy, no one said anything about going back.

Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments occurred, also with work performed by licensed physicians.

Just that the bureaucracy has resulted in an industry that fails patients. Heart surgeons refuse difficult surgeries to juke the stats. Good for their mortality ratings (not that anybody could blame individuals doctors)[1], not so great for patients.

Even just the notion of specialties hurts the patient - it makes perfect sense that the deep knowledge involved means that an orthopedic doctor can't (and shouldn't!) treat issues that should be seen by a podiatrist. But at the end of the day, the patient is in chronic pain, and has such a low quality of life, that to them, the risks of street heroin are acceptable. This isn't a moral failing by the patient's, nor is it a lack of intelligence, this life being too much to bear otherwise, and if you've never considered suicide as an option, be grateful.

Dr. David Casarett's talk[2] takes a closer look at an alternate, but accepted medical practice, and gives some thoughts about how our medical bureaucrats have resulted in worse patient care.

[1] https://www.telegraph.co.uk/science/2016/06/03/one-in-three-... [2] https://www.ted.com/talks/david_casarett_a_doctor_s_case_for...


I am not repeating this to be pedantic - this is simply a common misunderstanding in the public:

> Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments

The AMA has no role in licensing physicians, a task which is left to the states.

> Heart surgeons refuse difficult surgeries to juke[sic] the stats.

This is far more complicated than it seems. For example, consider that the sickest/most difficult patients are the most likely to die, irrespective of an intervention. At a certain point, the harm inherent to surgery outweighs any potential for benefit that the surgery might yield.


The Heart surgeon thing is likely referring specifically to a UK press article recently featured on HN that was about surgeons in the UK reacting to a policy change that means their stats are shown to the general public. A large minority of those surveyed said that as a result they now refuse to do surgeries they think will be very bad for their stats, even if clinically the surgery might be appropriate and within their competence. A majority said they knew a surgeon who had made such choices.

As a patient in that system (the NHS) I would prefer my surgeons not to make decisions based on trying to game the statistics. If I need heart surgery, I want whoever is competent and available. So if these stats block that, I'd rather we don't have the stats.

Frankly it's weird anyway because surgery is a team activity, not solo. Nothing serious is done by one bloke in a surgical gown, there's a team. I had a relatively minor operation and the named surgeon will have spent most of that operation _talking_ not operating. All the sewing and some of the cutting will be the nice younger doctors I met, a woman who'd been doing this a few years and was well on her way to being an actual surgeon, and a new bloke who seemed like he'd probably graduated just a couple of years ago. The old bloke with the paperwork saying he's allowed to cut people open is mostly there to watch over them both and step in if things go to shit. The woman is doing most of the work, showing the noob what she's doing and maybe overseeing while he stitches me back up at the end. There's some Eastern European doctor lady making sure I neither die nor wake up, and two or three nurses making sure everybody has what they need, and counting things to make sure nothing is left inside me that shouldn't be there. But if I'd died (very unlikely for minor surgery) it would count against my named surgeon and not the rest of the team.


Medical licensing is performed at the state level. The AMA, a non-governmental organization, does not perform the function of ensuring physicians' qualifications.

The AMA even explains this process: https://www.ama-assn.org/education/obtaining-medical-license


I'm aware. I was careful with my language about saying they are a gatekeeper, not that they set the law. But your info is appreciated.


I'm not aware of how the AMA acts as a gatekeeper to the medical profession - what did you have in mind?


In the broad sense that they are an influential industry group that has taken a number of political positions that impact laws. Chiropractors and osteopaths have in particular felt discrediting hostility from them, as I read. Now to be clear, I for one do not personally hold either of those two fields in as much esteem as much of the American public might, so I don't meant to be partisan, but to simply say that the AMA has used it's influence to maintain the standards of what should or should not be licensed medical practice. They are free to maintain their own standards, which I do much respect.


You've made good arguments in this thread, but you lose a lot of credibility when you imply that a DO is not as good as an MD.


I guess they aren't referring to DOs with that remark, there's a field quite like chiropractic that is called "Osteopathy", in the US such practitioners wouldn't be DOs.


People suffer real harm at the hands of unlicensed doctors.

For example, this guy was prescribing powerful meds with severe side effects.

http://www.chicagotribune.com/suburbs/daily-southtown/crime/...


While that's certainly true, people also suffer great harm at the hands of licensed doctors.

But more to the point, almost everyone suffers harm because of the way our medical system is set up.

Maybe some ailments don't need 8 year degrees to cure. Just throwing out ideas here.

But anyhow, more transparency is almost always good. Particularly in the morass that is the American medical system. I keep wondering how ever let something so important get like this.


Requiring doctors to get a 4-year-degree before medical school also adds to the cost. The degree can be in anything: film crit, classics, Japanese history. those are valuable things to know, but they clearly aren't necessary to medical school or else you'd disqualify the people who couldn't give a solid explaination of how Miazaki was influenced by Heian literature. The cost of a $200,000 degree plus interest on a loan that doesn't start getting paid back until after med school shouldn't be dumped on the medical system.


The degree might be in anything, but there are many pre-reqs before you can apply, such as organic chemistry.


It would make more sense to add a year to medical education to cover the prerequisites rather than requiring a bachelors degree to apply to medical school.


That's also an absurdity I never understood in the US Medical school system. Why not do like other countries, and allow 18 years old to directly chose Medical School after high school?


The Certificate of Need process also applies to anyone wanting to install a MRI machine. Rather than letting a doctor take the risk of buying an expensive machine for their business, the certificate process forces patients to travel to the nearest machine, possibly in the next town, instead of just walking down the hall to it.

The knock-on effect of there being fewer machines built keeps the price high. The first photocopier (the Xerox 914) cost the equivalent of $220,000 in 1965, yet there are very few businesses without a copier today because the price is so reasonable (5% of the 914's cost), and they do much much more.


Insurance is for unusual procedures

In healthcare you'd not only like to even out expenses over time, you'd also like to spread expenses over a group, else people with chronic conditions are still screwed.


The Accountable Care Act (Obamacare) specifically mandated that routine preventative care be covered by private insurance plans at no cost to the patient. That way patients won't skip preventative care to "save" money and problems can be detected early before they become serious.

https://www.kff.org/health-reform/fact-sheet/preventive-serv...

What you propose would work fine if humans were fully rational and not living paycheck to paycheck. Unfortunately that's not reality.


> The Accountable Care Act (Obamacare)

The law that got the nickname “Obamacare” is not the Accountable Care Act, it is the Patient Protection and Affordable Care Act.


Except checkups and preventative care are usually far, far more effective than emergency care. So it would be to the benefit of all for insurance to cover it.


This is intuitive, but turns out to be false.

That is, for any one particular patient who's found to have a disease down the road - say, cancer - it would have been cheaper for him if that problem had been found very early, so for his individual case the checkups and tests would have been a big savings.

But when you account for all the people that do not turn out to have the problem at all, and the cost of checkups and tests, and then especially the costs of the followups due to false positives that are a risk in every test, the overall cost of test and prevention is actually worse.


Your statement is poorly thought out on several fronts.

Firstly putting a bullet in the head of anyone with non trivial cancer would probably be a financial savings for the insurer but the real equation is the human/societal benefit of treatment vs costs to best make use of a finite resource.

A simple cost of treatment analysis even misses out on the income that a person would have earned had they not died and the money that could have been paid in taxes and used to fund more treatment.

Drilling down into just the cost of treatment your statement isn't even wrong its a category error like saying that adding 2 integers always yields a number greater than 42.

For any given test and set of circumstances under which it is administered there can be a cost benefit analysis.

Example if you spend a thousand dollars on each false positive result and save 10k for each and have a 1% false positive rate and test a million people with a 1 in a million true positive rate. You will find one true positive saving 10k unfortunately you will also find 10k false positives and waste 10 million dollars.

In actuality you wouldn't do this you would test people whose symptoms or circumstances suggest they are likely to have it.

It seems fantastic to suggest that preventative medicine is always financially negative when people who actually study health care say otherwise.


Still, you've got your facts wrong. Consider:

Mr. Gruber [yes, it's THAT Jonathan Gruber] found that when retirees in California began visiting their doctor less often and filling fewer prescriptions, overall medical spending fell. People did get sick more often, but treating their illnesses was still less costly than widespread basic care — in the form of doctors visits and drugs. ... As Dr. Mark R. Chassin, a former New York state health commissioner, says, preventive care “reduces costs, yes, for the individual who didn’t get sick.” [1]

You go on to state that the additional productivity of the person we saved also nets us additional savings. But the same article contradicts this notion as well:

The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.

You go on to suggest that medical professionals would not be wasting money on doing too many tests: "For any given test and set of circumstances under which it is administered there can be a cost benefit analysis."

That seems logical, but it's not how the real world works. People get emotional about the potential risks, and demand the tests even when there's not a clear indication. You might remember the hubbub a couple of years ago when it was suggested, based on historical evidence, that regular mammograms should be delayed a few years later than was currently the practice. But women's health advocacy groups raised such a hue and cry that the actual medical guidelines were not changed to follow the evidence.

[1] https://www.nytimes.com/2007/08/08/business/08leonhardt.html


I think that it is very hard to do a proper accounting. It is difficult to forsee all the consequences of an intervention; if a parent is sick, they do not work. The other parent may need to stay home too to help out. A double whammy on productivity. The firm employing them takes a hit too, as well as the municipalities and other levels of government depending on tax revenue. Such hits can lead to declines in necessary investment. And this doesn't even account for possible epidemiological effects, which can be highly nonlinear, as infection Cascades can be frequency dependant.


It seems like a mistake to extend preventative health care inferences for senior citizens to the general public. They are the largest cohort receiving medical testing and treatment. Also, fee for service encourages over-testing and treatment.


> Except checkups and preventative care are usually far, far more effective than emergency care.

This may be true in terms of outcomes, but it turns out not to be true in terms of aggregate costs.

(If you encourage smoking and discourage screenings and preventive care, you'll probably do a lot to reduce aggregate health costs, but at the expense of outcomes; the efficiencies you really want are ones that reduce cost while preserving outocomes, or improve outcomes without increasing costs. When outcomes and costs are in tension, though, desirability can be more ambiguous.)


Forcing insurers to pay for “oil changes” drives up premium costs and depletes funds that patients could otherwise use to pay for preventive care.


It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters.

More importantly it leads to less people dying of preventable matters. What you seem to be implying is that its a net negative to which I say citation needed.


> It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters.

Doing that could also drive up the price of oil changes such that they're no longer affordable without the use of insurance. If you could get an oil change for $50, then most people could afford it by paying for it outright. If that oil change now costs $500, then most people would have to go through insurance, and get the "discounted" price of $100 (which either has to be paid if the deductible has not been met, or you end up paying 10 to 30% of it).


> It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters

It also catches things that require long expensive treatment early enough for them to be treated, rather than treatment be pointless, and, even if attempted, of shorter duration (on average) than if the conditions were found earlier, which is why preventive care doesn't seem to reduce aggregate costs.

The best way to reduce aggregate healthcare costs, if you have no other priorities, is to just make people less likely to seek care. No care = no costs.


Your reasoning holds water. How does it play out in the real world? Do “free” checkups result in more frequent well visits?

Goods and services are allocated by price or by time. Take out the price component and assume that people will go to doctor more often, obtaining an appointment will take longer. How do time and hassle required to see a doctor disincentivize well visits?


> If consumers had to actually shop for procedures

You'd have even more people avoiding easily treatable conditions due to cost.


If it worked like normal insurance, people with chronic illnesses would still go bankrupt.


I want to tell you not to waste your breath.

Frankly, no one wants to talk about chronic ailments. ADHD (the so-called fake disease) for example.

Nevermind that they are a real part of why premiums are likely as high as they are.

Nevermind that it is essentially a life-long tax for the patient.

Nevermind that the law deprives those who suffer from a case for which narcotic therapies work and CBT doesn't into profit slaves to drug manufacturer's and their 'attending' prescription writer.

They have a solution to the problem (that generally works out better for the supply chain than the patient)! How dare you suggest it isn't the best approach! What are you, some communist? /s

But alas, if we don't say it no one will listen.

So...

As the parent said...

"If it worked like normal insurance, people with chronic illnesses would still go bankrupt."


I agree with this, and I would also like to see more welfare programs separate from the insurance role. Insurance companies like to trick you into thinking you're getting a better deal because of them. That's not what insurance means. Keep those roles separate and straightforward.


Yes! Political chicanery and tribalism is exploited to make sure that the leeches stay in place, with neither side realizing that what we have now is just the worst of all worlds for everyone else.

I'm pretty conservative and I'd love to see a solution to the healthcare marketplace that doesn't amount to nationalization, but at this point, the market is so distorted and fundamentally unworkable that even a nationalized healthcare industry would be preferable.

There is no definition that fits better than "FUBAR" [0]. The only solution is going to be tear down the industry that we have and build something more sustainable in its place, whether that new thing is a nationalized health system or just very serious regulations to ensure healthy and functioning competition and free-market ideals (Obamacare does the opposite of this, literally making it illegal to not pay a health insurer; good policy would make non-catastrophic medical coverage illegal). Whatever the answer is, there's going to be a lot of people who are unhappy about it, but we have to fix this.

That other conservatives are just slamming their heads into the sand and saying "free market" when it's impossible to know how much a given medical procedure will actually cost until 3-6 months after the fact is just utterly and fundamentally embarrassing for everyone. Pricing is the most fundamental element in a functioning market. You can't pretend to be making rational choices if you can't even find out the cost. The whole thing shows how very little anyone is paying attention to anything other than virtue signaling.

The government is a big bad powerful thing, but it exists for a reason, and reducing every argument down to "just let those nice men in the Hamptons handle it, they wouldn't be rich if they weren't real smart" gets really tiresome.

[0] https://www.urbandictionary.com/define.php?term=fubar


Bronze ACA plans are pretty much catastrophic coverage. $7300 individual, $14,500 family deductibles.

There's plenty of people that could afford higher deductibles than that (and would prefer the accompanying lower premiums), but not really the majority of people.

Cutting the basic benefits out of them wouldn't even really save that much money (because insurance negotiates reasonable prices for basic office visits...).


Insurance certainly costs far too much money, but that's missing the forest for the trees. Insurance is the reason that the market is non-functional and broken. The misdirection inherent in an insurance-centric pricing regime is what's made it impossible for anyone to ever know the actual out-of-pocket cost of anything, and getting that is the first part of getting a functioning market established.

We need to stop looking at the individual level and "What can we eek out of people who don't qualify for Medicaid?", and look to the macro-scale effects. Insurance is the wrong model for routine services (indeed, insurance usually functions as a discount program rather than true insurance) and people shouldn't be able to sell it for that purpose due to the debilitating effects it has on the marketplace.

Docs and pharamacies should be up front about their real prices. Today, even people who are "posting prices" can't be up front about it because posted prices function as high anchors for insurance negotiations. This is why you can often get a massive "cash discount" if you call about a bill that you're going to self-pay. That's what they'd really like to charge you, but if they don't start out charging the sticker price they quoted the insurer, they're in big trouble.

For a market to work, there must be a real pricing dynamic where the consumer can be reasonably well informed about the actual total cost and vote with their feet. Hyperinflated 300% prices, necessitated by insurer demands for large discounts, don't count, they're still not real numbers. Markets simply cannot work without meaningful and accessible pricing information.

The medical system will remain a disaster until we can break this dynamic around pricing, and the only way to do that is to fundamentally change the way that medical insurance works, either by nationalizing insurance and/or medicine so that the government writes all the checks and price becomes only indirectly relevant to the public anyway, or by imposing law that mandates price transparency and seriously limits what "medical insurance" and "discount programs" can do, so that we don't immediately descend back into this.

IMO this is a textbook case of a market screaming for good regulation. Ideally we would identify the malicious actors (primarily insurers), develop rules and systems that minimize their ability to operate, and allow the free flow of commerce to handle everything else. "Nationalize it" is a clear power grab, but lacking any willingness to do anything else about such a breathtakingly large economic and humanitarian issue, even that would be better than "let's just keep crossing our fingers".

It's so sad that the level of conservative dialogue is not "let's find a good minimalist intervention that will get this market working again" but rather "Did someone say 'MURICA wasn't the best at something?!"


Yep. There's a book that does a good job outlining the main problems in the healthcare industry: "Catastrophic Care" by David Goldhill.

https://www.amazon.com/dp/034580273X/ref=cm_sw_r_tw_dp_U_x_-...

The big issue, as you mention, is health insurance companies themselves. They aren't actual insurance companies—they are payers, like others in this thread have called out. Real insurance exists when unlikely but disastrous events occur, like a house fire or a car accident.

Payers act more like surrogates—they bargain and make purchasing decisions on behalf of users like us. This is the fundamental problem in healthcare because surrogates cannot make financial decisions as well as a free market can.

Goldhill’s proposal for changing the industry is to eliminate the role of surrogates and replace it with a version of a health savings account that everybody would be required to contribute into and carry indefinitely, and require everybody to have a very high deductible catastrophic insurance plan. For example, all healthcare payments under $30k would be paid for directly by the patient and come out of the savings account. When something truly big and expensive occurs in a patient’s health (e.g., a cancer diagnosis) is when catastrophic health insurance would kick in and cover it.

This would allow for patients to make active decisions about which type of care to choose, and would force providers to become more competitive to earn the business of actual customers.


Why doesn't Germany have this problem? Their system is insurance-based. Why can't Blue Cross Blue Shield (a nonprofit) avoid this cost problem but a Krankenkassen can?


Because a tiny minority of the overall population profits from current inefficiency and if we revamped the whole thing even to massive public benefit some currently wealthy people would inevitably lose out.

In America we are happy to burn a dollar as long as a rich person somewhere can make an extra penny.

As a nation we have no notion of public ethics and haven't for decades. We believe in every man for himself and rather than resignation we feel pride. Venerating not caring about our fellow man as if it was self reliance.

We believe in the dysfunction of the public sphere as an article of faith, implacable as gravity, instead of it being the result of our collective failure to build a system that works.

We feel pride in ourselves when we ought to feel shame for all of us.


> if we revamped the whole thing even to massive public benefit

But this doesn't answer the question: what is the revamping that would be done to solve the problem? I get that "We believe in the dysfunction of the public sphere as an article of faith" is true and the answer to my next question "okay cool, so why haven't we implemented that", but I'd first like to know what "that" is.

(not that you're on the hook for the time to educate me on a complex public policy issue)


Taking away the employer tax deduction for health insurance would do a lot more than banning coverage for flu shots.


Do I need coverage from my food insurance every time I take a trip to Trader Joe's, Chipotle, or even Walmart? There is every reason for flu shots to be cheap enough that they don't require a special mechanism of payment. Yes, vaccine is delicate and it must be handled with care ... but the same is true for most foods and many other necessities that we somehow manage to buy and sell without an insurer butting in.

The goal has to be making medicine work like everything else we buy, including the daily non-negotiables like food, water, clothing, and energy resources. There's no reason medicine shouldn't or can't work that way in the general case.

But as long as we make it about moving numbers around so that Group X is slightly less inconvenienced by this farce, we're playing their game. We need to be talking about how to break their stranglehold, and I don't think just "move it into the government so we can get installed as bureaucrats, who are even harder to get rid than executives!" is necessarily a great macro-scale response (though I continue to believe it's better than doing nothing).

I don't suggest taking anything from anyone who is actually involved in the thing here. The only people I want to take out of the equation are the pencil-pushers leeching gargantuan quantities of otherwise-useful time and money away from the public.

That so many people find it so difficult to conceive of routine medical care without an insurance carrier of some type is a testament to the work we have ahead of us.


Isn’t choice also a fundamental part of a free market? I can choose to buy a certain product and decide not to buy if the market prices are above what I’m willing to spend. How does that apply to medical procedures?


Most medical issues are not emergencies. For most problems, there is plenty of time to comparison shop, consider the urgency and/or optionality of specific care, and so forth.

We do this just fine with other usually-non-emergent necessities of life like food, clothing, and housing. We didn't need to nationalize land ownership or food distribution to create vibrant economies for these, despite the fact that people can't really just "choose not to buy them".

Things are that way in part because there is a controlled regulatory regime in there, not trying to nationalize everything but also acknowledging the duty to protect the market from bad actors. Food, clothing, and housing aren't perfect analogs because medicine is a professional service, but this suffices to show that necessities aren't necessarily exempt from market forces just by virtue of their non-optionality.

Medicine needs a middle ground between "nationalize it" and "ignore it", but in this case, if those are the only two options, "ignore it" is clearly the worse one.

My wife and kids had 0 medical emergencies last year and we still paid over $10k in doctor and dentist bills just from deductibles, copays, and coinsurance. That's after having nearly $1k per month deducted from my paychecks for insurance premiums, not to mention the part that my employer contributed on top of that. It makes me sick to add those figures up, so I'll just leave that as an exercise. You can bet that if there were any actual optionality here, we'd spend a few days trying to sort out the most efficient way to handle this stuff.

Let's also not forget that insurance imposes a significant amount of rationing too. Our policy only covered up to 40 "habilitative care" visits per year, despite the fact that every therapist and doctor we saw recommended about 3x that. These are relatively mild speech and occupational therapy visits -- 40 visits is combined, every speech and pt/ot visit counts against it. "You need insurance because you'll have to buy medical care or you'll die" doesn't always play out that way.


Every medical procedure I've ever seen anyone forgo has been to their gross detriment. People really don't choose not to by like its a new car or chinese food. They suffer or die because they can't afford to do otherwise.


> Can you imagine any other market working that way? How much is this car? Can you imagine if the response was, "Well, it depends. We can't tell until after you agree to take possession.

I was livid when I couldn't find out how much it would cost for a medical procedure for my wife. All I got were excuses about how they couldn't do it. So many of us have high deductible insurance now. How can they not be setup to do this yet? How is it that we're not all demanding it?

Let's be clear: there's no real problem that couldn't possibly be solved here. All the other industries do it, medicine is no different. If unpredictable problems cause new expenses, then you can either disclaim those from upfront quotes and/or try to predict likely events that would cause additional charges.


There's a business called ZoomCare where I live that posts their prices for uninsured patients. I am quite annoyed that I, someone who has private insurance with ZoomCare as an in-network provider, was charged almost twice as much as the posted price. That money comes out of my pocket because I have one of these high deductible plans. So even places that are decent enough to post prices pull some b.s. when insurance is involved.


It's a bit of a gray area, but theoretically the provider has a contractual obligation to your insurer, to charge what your insurer requires. Also, they have to do more work for you than for an uninsured patient. By bringing your insurer into this, you've also made more work for them. You could have made it easier for everyone by simply telling the provider that you are uninsured.


I got some fancy new experimental equipment when I was recovering from a broken arm. I had to sign a paper that if I lost it I could be responsible so I asked how much it was and no one could answer and I was the first to ask.

In the end I signed and was never asked to return the item.


Two things complicate the realization of a free market in this sector:

1) It's standard practice to proclaim one's love for free markets when one is trying to enter a market. "Competition is good!" (for me) But then as soon as one's company is entrenched in said market, one mysteriously starts doing everything possible to make it less free. "Competition is bad!" (for me) The one consistent part here is, of course, the "for me" part.

2) In most of the healthcare industry you are not the customer; your insurance company is. So the incentives are perverted accordingly. Higher prices for providers means more revenue for them, obviously; that part is straightforward. Higher prices paid by insurers, you would think, means it's harder for them, but just like any business, they adjust their prices (premiums, rates) accordingly, so they can pass costs on to the consumer and still make a profit. So higher prices from providers just means the insurer is essentially insuring a higher "volume" of claim dollars and collecting a higher volume of premiums; in other words they're doing more business and making proportionately more profit.


In practice that's not really how it works any more. Most "insurance" companies don't provide much actual insurance. Instead they act as third-party administrators for self-insured employers and other group buyers. Those customers are very price sensitive, so insurers have a lot of incentive to drive down provider prices in order to maintain market share.

What's increasingly breaking the free market is provider consolidation. In many areas most of the small medical practices have been bought up by larger organizations. So those large providers control so much of the market that insurers have to pay whatever they charge. For example, in Northern California if an insurer (other than Kaiser Permanente) doesn't have Sutter Health in their network then their plans aren't viable.


I used to work in health insurance business, and actually a lot of this information is available via CMS: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

It's mandated in a sense because all Medicare data has to be sent to and aggregated by CMS and then reported on. So I think this already happens.

California also has some mandates about hospital "chargemaster" data, and the data is publicly available here: https://www.oshpd.ca.gov/chargemaster/


> We like to champion the "free market" but then completely fail to implement policies that make that even remotely possible

We like to talk about free markets, but we don't really want them, at least our elected representatives don't. This is the reason why Medicare is _legally prohibited_ from negotiating drug prices (something that blows the mind of pretty much everyone the first time they hear it).


Saying Medicare can't negotiate drug prices is an over simplification.

For physician administered drugs, the gov't has said "we will pay an average of what everyone else pays". No negotiation, just defacto proclamation of what Medicare will pay.

For prescription drugs, Medicare pushes negotiation to private insurers who actually provide the coverage. They do negotiate with drug companies, often getting very steep discounts. Also, Medicare has said to drug companies "once a patient hit the donut hole, you need to give a 50% discount". Again, no negotiation, just a "if you want to do business with Medicare, deal with it".

So yes, they don't negotiate drug prices, they just tell the drug companies what they are willing to pay.


The word 'free' ... like the words 'nature','organic','improved','good', and 'god' ... means what you want it to. You may, of course, try to convince people that you mean something else entirely.

Of all such words, the word 'democracy' is possibly the most-abused.


> "It depends" or "we can't tell you until after we bill you" is not acceptable. Can you imagine any other market working that way?

Auto repair. Computer repair. Probably most kinds of repair. Even when prices are posted, there's always a ton of wiggle room, and by the time you find out the work is already done.


> Auto repair.

I walk in and sign a form that states I agree to pay diagnosis fee not to exceed ~$120. Diagnosis happens, I get an estimate of the work required to execute the repair. I can't recall a time when I paid anything other than precisely the amount of the quote offered ahead of time. Maybe it happens but it's vanishingly rare.

Best part is that the repair center will triage and rank the problems and often offer more than one treatment which will vary on endurance/cost/etc. Would that medicine could offer the same!


But can you then pick up your phone and do a quick price comparison with nearby shops without taking your car to each one and potentially paying a diagnosis fee at each one?


Yes.


How if they don't publishing pricing information?


At least in auto repair you have a pretty good idea how much repair is going to cost you, and when you've been in a major wreck you get one bill that you can turn in to your insurance, not ten from the tow truck, the body shop, the paint shop, the several master mechanics &c, and none of them is out of network for insurance purposes.

And the bill is usually honest. The pregnancy test for males isn't a joke, it really happened to a physician colleague of mine.


Terrible examples. Any kind of repair gives you a quote before work starts. If you don't like it you can take it someplace else. Does the quote always match reality? No, but it give you an idea.

In most healthcare scenarios of consequence you have no such choice.


But it's not an order of magnitude difference (or more).


I like to think about it less as free market vs universal healthcare, and more in terms of incentives of incumbents and political power of incumbents to protect those incentives through regulation. If your regulatory regime doesn't adequately deal with incentives, then the companies you regulate will just find a new way to abuse the system to suit their needs

Right now, lack of public understanding of healthcare quality and lack of transparency is a big weapon for providers. Providers have a lot of political clout, as hospitals are huge employers at local levels and thus have lots of local political influence, plus they are powerful on a national scale bc its a huge industry.

There could theoretically be a large scale political movement against hospitals, though it would probably have to be grassroots, as again, hospitals have lots of control over the political incumbency because hospitals employ so many people and are important to communities.

However, it is hard for grassroots movements to propose effective policy recommendations. Healthcare is complicated, and presenting simplistic solutions that sound good but probably won't work gets more grassroots support than complex solutions that may be more effective (i personally think that single payer is one of those solutions that sounds good but prob wont work, but i know thats controversial). In many cases, its probably possible for hospitals to push legislation that sounds like it is decreasing costs, but actually helps powerful hospitals make more money (one could argue that ACOs and ACA in general are an example of this). Making the issue worse is that hospitals control data, so they are able to cherry pick data that makes them look good and get public support based on these factors, but grassroots organizations cant access data to counter those claims

So hospitals have tons of political cover to protect their interests through 1) control of information and 2) influence on politicians through their roles as large employers


> You've got a situation where there is typically no competition and little or no information available to the consumer. Free market economics simply don't apply.

I think a bigger issue is that during an emergency, even in the case where you are conscious and cogent, you will often have no ability to determine if you should get treatment at that hospital, or another.

I think it's utterly insane that life-critical procedures could result in someone being in massive debt (or bankrupted) through no fault of their own.

This insanity is one reason why when people ask "Would you be interested in working in the US?" my immediate answer is "hell no".

Even if employers were offering gold-plated top of the line insurance (doubtful), the insurers have so much wiggle room with bullshit about lifetime limits and whether they will cover X treatments, and whether specific hospitals are covered.


"How this isn't already mandated by law is baffling."

Cause people get in a huff about mandating things by law, complaining about "freedom".


lol, the free market doesn't mean free as in money. Not that I agree with this, but in a free market, information is a good to be purchased just like everything else. In other words, no matter how nervous hospitals are about transparency, there is some dollar amount that would make them willingly provide all of their pricing data. A company could buy all the data, analyze it and create a paid service that ranked hospitals by affordability, quality, etc. They could then sell access to governments, universities, and insurance companies who would then be able to make informed decisions about society, career-planning, and coverage networks.


free market health care is innately impossible (simple example: you can't pick your hospital if you are knocked unconscious in an accident) , all the first world countries save one have figured that out, and get better health for less money because of it.


I've been saying this for years. Try asking your dentist or doctor how much something will cost. Most of the time they just tell you well we bill your insurance and then your insurance figures out your cost. Once in a while I can get a cost within 10 minutes, but that makes it impossible to shop around. It should take them a few moments 90% of the time to give me a quote with only exotic procedures being the exception.

Is it so hard to provide a real-time cost? It might not be easy now, but we have the damn technology. System is broken. Mandate this, give them a deadline to implement. They have deep pockets, the engineers and tech exists, delivering it within 3 years should be mandated. Let me shop around cuz capitalism...

You want to cut healthcare costs? This is something 100% of congress can back, even with a hefty lobby against it. Cruz and Sanders could co-sponsor this for Christ-sake, thats how non-partisan this is.


> System is broken. Mandate this, give them a deadline to implement. They have deep pockets, the engineers and tech exists, delivering it within 3 years should be mandated.

Have you ever looked at the language specs for MUMPS? That's what a lot of medical software started out in, or is still written in. Compared to anything but Intercal, it's amazing that it works at all...

3 years indeed.


Good point, a free market requires a transparent market.


There is something quite interesting in this - you claim that “free markets” are inhibited by a lack of information.

I’m not sure information is requisite in “free markets”; is it? I like the idea that a free market requires some information liquidity but I’m unfamiliar with any economic theories / philosophy on the subject.

Anyone here have some information that can be explored alongside that idea?


Yes, it is. This is literally an economics 101 thing. Pick up any text book and before you even get to supply and demand you will go through the "assumptions" that must be true in order for a free market to function.

They are usually listed as:

Perfect information

Perfect competition

Mobility of capital and labor

Firms maximize profits

Consumers maximize utility

A lot of people (most?) who champion free market economics have no idea what they are talking about. They could not pass the first quiz in an Econ 101 class.

In healthcare, at least in the decisions of consequence, you typically have no information and no choice.


Well, you're right that it's an econ 101 thing - because it's not a grad-level econ thing. Real economists understand that the real world differs from those simplistic models, and have (or are working on) other approaches that better model the real world.

It's just like in Physics 101 you're dealing with point masses on a frictionless surface. Later on you learn abut friction and inertia, and still later you get into relativity.

We frequently start with that simplified view of the world, but there aren't any real professionals who believe that's the end of the story. Markets do exist, despite the fact that your assumptions don't hold true to varying degrees.


You got me. I haven’t formally studied Econ, and maybe I would be one of those chumps you would mock for failing the first Econ 101 test.

Anyway, that’s all somewhat irrelevant. I asked a question wanting to know more about “free markets” as is commonly used in discussion, and not the theoretical concept which apparently does require complete information and is incompatible with the common / non-theoretical construct.

My curiosity remains, so I’ll ask if you know of any approachable resource that discusses the taxonomy of market models and their levers?

(In the past I have’nt found Amazon’s ranking of books to be useful as they’re written for entertainment, not exploration).


> I’m not sure information is requisite in “free markets”; is it?

No, but information (specifically perfect information about cost and all benefits, to an infinite time horizon, of economic decisions among all market participants) is a (but not the only important) central assumption in the theory underpinning the conclusion that free markets are optimal in terms of economic efficiency.

You can have a free market where this isn't even approximately true, of course, but the farther it is from true—ceteris paribus—the weaker the argument for the desirability of free markets is.


> You can have a free market where this isn't even approximately true, of course, but the farther it is from true, the weaker the argument for the desirability of free markets is.

That's debatable. In some markets (Veblen/Giffen goods, goods with a price elasticity that approaches zero, etc.) you could say that information doesn't matter because price is irrelevant, but I personally would say that you don't have a free market or any approximation of such without at least reasonable information. Which, you know, is up for interpretation.


I think there is a semantic issue where some people use free markets to mean markets run by mutual exchange by agreement between participants, and see the conditions that make such markets efficient as separate factors which may or may not be present, and other who use “free market” to include the combination of voluntary exchange with some or all of the conditions that make such exchange efficient.


Access to information is a pretty big requirement to a free market. In fact models of the free market assume "perfect information".

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


Those aren't free market models, those are 'perfect competition' models. They're not the same thing.


They are. A free market model typically has five basic assumptions built into it. See my comment above.


No.

>Pick up any text book and before you even get to supply and demand you will go through the "assumptions" that must be true in order for a free market to function.

You will go through the assumptions that must be true in order for a market to be in a state of perfect competition. Most econ books should be pretty good about this lanugage. 'Free market' is actually more about political philosophy than economics although it's usually cloaked in the language of normative economics.


Perfect competition is typically listed as an assumption of a free market. I mean, at least when I was a TA.


I can’t find anything on there that supports the idea that free markets are modeled on “perfect information”.

I wouldn’t think that’s the case, anyway. Because marketing/advertising/awareness is a cost with diminishing returns, meaning it’s be prohibitively expensive to inform everyone of your product in the market, much less make accessible ALL products in a category for comparison shopping for any customer at any given time (aside from a singularity event).

I do think markets require some information liquidity to be maintainable, and I generally understand free markets to be free of coercion.

This sounds more like an “transparent market” though I’m not sure that’s a defined concept.


So after some light reading, theoretical free markets are predicated on complete information, and known to be impossible to achieve for the reason I mentioned. Interesting.


We assume "perfect information" because that's what lets us create simply supply and demand functions. Obviously in the real world you rarely (if ever) have perfect information—and we have models to deal with that—but healthcare has almost zero information. You either can't make a choice because you literally can't (only one provider in your area) or you can't make a choice because you don't have pricing information. So you can't maximize your own utility, because you don't know what options lead to that outcome.

Just about the ONLY assumption that holds true in healthcare is that firms maximize profits. And, in a twist of irony, the only healthcare provider to provide information on pricing is Kaiser Permanente—which is a non-profit. Yeah, they still do maximize profits, but not for shareholders. So you could make the argument that healthcare as a whole meets exactly zero of the assumptions necessary for any kind of free market model to apply.


The benefit of a free market is that businesses must compete by providing better service or better prices to consumers. That is entirely pointless unless consumers can actually choose the better service or price.


If information is not a requisite, then how do you actually know what you're paying for? Or know that you're getting what you're charged for?


> How this isn't already mandated by law is baffling.

It's not baffling if you look at the way the medical billing system actually works. In short, Medicare is able to use existing laws (the requirement that Medicare receive the lowest price, along with the lack of mandate to reimburse COGS) to force providers to use funds from privately-insured patients to cover the costs of treating Medicare patients. From a financial point of view, the biggest adversary of price transparency (for privately-insured patients) is Medicare itself.

In that light, it's not surprising that an administration which has been very clear it wants to defund Medicare (without actually admitting as much in those words) is establishing rules that will essentially restrict the effective operating budget that Medicare will work with, long-term.


> Like list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts.

Exactly this. The numbers that hospitals bill are largely fictitious compared to cost of care. What a lot of people don't realize is that hospitals use inflated billing from paying patients to cover the costs of uninsured patients that the hospital is required by law to treat in the ER.

A lot of people against socialized healthcare don't realize that the system still takes extra money from those that pay and gives it to those that can't--just through hospital billing.


>> A lot of people against socialized healthcare don't realize that the system still takes extra money from those that pay and gives it to those that can't

A lot of people against socialized healthcare are perfectly aware of this cost shifting.


Is there a reasonable alternative? I'm not trolling, but letting people die of treatable maladies doesn't seem like the right move.


> Is there a reasonable alternative?

What most other countries are doing: Fund healthcare from tax money.

The middle class will anyway pay for the healthcare of those who can't pay for themselves. In other countries they pay in taxes, in the US they pay for it in their own higher medical bills.

This is a matter of an opinion of course. But most Europeans would opine that the American model is the unreasonable alternative.


The American health care system also costs double as a percent of GDP vs every other modern country's health care system so spending more money on it is not going to fix things. Arguing about who pays is easy.


Paying for more preventative care, instead of the care required in the ER after the health issue became too serious, should help bring costs down.


Possibly. There was a study on this in Oregon, and the data suggested that people who use the ER for their primary medical care keep doing so even after they're insured: https://www.npr.org/sections/health-shots/2016/10/19/4985261...


"People who self selected to apply for free medical care used it", study finds. More at 11.

People who self selected for free medical care didn't have much better health outcome than others who were not selected, except that they didn't go bankrupt.

So, the group that didn't get paid for didn't go to the ER, while the group that did get paid for went to the ER but didn't have better health outcomes than those that didn't. Surely that says something about the private, for profit institutions that run the ER business.


Insurance has co-pays, does it not? People who use ER as their primary medical care would avoid that if possible.


> What most other countries are doing: Fund healthcare from tax money.

Then why do people in those same countries purchase additional insurance from the private sector?

> In other countries they pay in taxes, in the US they pay for it in their own higher medical bills.

Surely you have heard of Medicaid and Medicare before. Yes?


> Then why do people in those same countries purchase additional insurance from the private sector?

Same reason some people upgrade their coach-class airline tickets - they can afford a nicer, more personalized level of service.


I don't understand why you're getting downvoted. The way the system works right now, I don't think the hospitals really have a choice. I'm hoping this new cost-transparency will raise more awareness at the patient-level which will in turn push for more discussion.

There ARE a lot of alternatives to the current system. Canada, France, the Netherlands, and Singapore are good examples to look at--very different systems, all far more cost-effective than ours.


All first world and many second world systems are more cost effective than the US healthcare system...


If we're looking for good examples, let's keep France and toss Canada. I maintain that Canada's system is one of the main reasons the US doesn't go single-payer. We're close enough to see how bad it is, and people assume all single-payer systems are like that. I'd rather have single-payer than the mess we have now, but not if we end up like Canada. Three months wait for an MRI? No prescription coverage? No mental health coverage? No thank you.


And the US system is one of the main reasons there's resistance to loosening single-payer in Canada. Wait times for MRIs (and other procedures) depends on need -- low priority cases will get bumped for more immediate issues. Psychiatrists _are_ covered under MSP (with a referral), although psychologists & counselors are (generally) not. But non-government insurance plans will often cover them as well as prescriptions and other non covered services. Such extended medical plans are often a work benefit (like in the US).


If there's some social good the government is pursuing it should, as much as possible, be done through taxation and spending rather than rules that the government hopes will accomplish the same thing in a way where they hope voters don't notice the indirect costs.


Make every hospital into two separate corporations, one a for-profit and the other a not-for-profit. Budget their revenue and expenses entirely separately. Intake government-enforced "charity cases" only to the not-for-profit.

And then, don't allow the for-profit to loan or grant or shift any resources over to the not-for-profit. In fact, ensure they're not owned by the same parent corporation or even the same shareholders.

Keep the logistics consolidated—everything flows through the for-profit's buyer—but then, have the for-profit rent its facilities and machinery, and provide its pre-acquired drugs and materials, to the not-for-profit at market price.

And have the for-profit and not-for-profit hire the same employees and split their shifts; or perhaps, have the for-profit hire them, with the option to volunteer as many hours as they wish to the not-for-profit. (This would lower the expenses of the not-for-profit considerably.)

In other words, leave the not-for-profit "twisting in the wind", where it's still running but nobody's paying for it, so it's just running at more and more of a loss each year. Try to minimize its costs—in fact, have people working for the not-for-profit entirely dedicated to trying to minimize its costs (successful strategies for which can be rolled back into the for-profit.)

But also, treat the not-for-profit as a thing which needs to raise money, rather than just making revenue. A thing like a University, which has entire departments dedicated to getting funding from its alumni. Maybe even work with other not-for-profit hospitals in a Public Advocacy Coalition to build a social norm that if one of these not-for-profit hospitals saved your life, and you went on to great [monetary] success, you should donate to that hospital (and it will, in turn, privilege your family while pretending not to, just like Universities do.)

A fun effect of this is that the not-for-profit will now be a large, visible advocate for cost-minimization in the for-profit's purchasing—since those costs will be passed on to them (so they'll be incentivized to lower them), but they can't just lower them by buying cheaper themselves (because they don't have their own purchasing/facilities management/IT/etc. departments), they'll instead have to figure out how the hospital as a whole can lower costs, in order for them to save any money.

Essentially, this is doing the same thing that creating municipal vote districts along income lines does: the rich voters and the poor voters each get their own voices in how the city should be run, and so the poor voters (through their representative) get the chance to argue against proposals that would benefit the rich voters but hurt them. Right now, hospitals don't have any such representative for their "poor voters."

---

(Yes, I know that a lot of hospitals are already not-for-profits. They're still run on a model that tries to maximize revenue, though, because they need that money. If you split the unprofitable patients out, suddenly the for-profit hospital can lower its prices, while the not-for-profit is forced to lower its costs.)


Finding a way to just give needy people money, and then have them participate in the same system as everyone else, seems much simpler than trying to build 2 systems in 1. Granted there are plenty of problems in getting for-profit medicine to work for people with average income, but assuming you could wave a magic wand and solve those problems...


The problem as it stands is that no agent in the system sees an incentive to do so, because the people having problems are invisible to their preference functions.

Consider the aphorism "the squeaky wheel gets the grease." Why is this an aphorism? Because squeaky wheels are annoying. If the people who use the wheels have to hear them squeak, they'll soon oil them. So if you hear a squeaky wheel (for example, on a shopping cart), that's usually because the people with the oil don't ever have to get close enough to hear that squeak.

Proposals like Basic Income, or even welfare, basically translate to "greasing all the wheels on a regular schedule, whether you've heard them squeak or not"—i.e., fixing problems that aren't actually bothering you personally. It's nearly impossible to incentivize anyone to do that.

My proposal here is more in terms of "ensuring when manufacturing wheels that they will squeak as loudly as possible when they've begun failing." You want to solve the shopping-cart case, where the person with the oil isn't the person who has to use the cart. And the best way to do that is to ensure that the customers will be too irritated by the squeaking to actually use the carts; and therefore the carts will go disused; and therefore the customers will complain to the cashiers that there are no carts, and people will buy less than they would with a cart, and revenue will go down, and some stakeholder will notice, and gather information, and figure out that it's that all the carts are squeaking horribly, and so oil them.

Or, in other words, you want the squeak of "people not getting treated because they don't have the money" to be loud enough to actually make it all the way up to the hospital's CFO, where the squeaking will cause cost-cutting; and even further, to the city surrounding the hospital, where the squeaking will cause donating.

In fact, if you oil the carts regularly, you might not realize that your wheels are badly-made and are rusting prematurely; or that your parking lot needs a regular dust-blower-ing; or whatever else. Sensitive components—canaries in coal mines, or people with no money in poor health—show you where your system is weakest. If you eliminate them (by just providing UBI, or even just public healthcare), you eliminate the chance to observe where your system fails. In a country with more money than it knows what to do with, this is probably a sensible approach—it has fewer people suffer over the short term, after all, at the expense of a bloated, bureaucratic medical system. But if you're trying to figure out how to cut those costs, you need the squeaking.


> (Yes, I know that a lot of hospitals are already not-for-profits. They're still run on a model that tries to maximize revenue, though, because they need that money. If you split the unprofitable patients out, suddenly the for-profit hospital can lower its prices, while the not-for-profit is forced to lower its costs.)

Bawawahahaha. No. Non-profit is just a tax status that allows them not to pay income taxes or property taxes on enormous assets and enormous income.


How do you think this would play out? My intuition is that the not-for-profits wouldn't even be close to sustainable (even with cost cutting). Are you anticipating a huge influx of funding for them or do you think they could cut costs that drastically?


A non-profit hospital is extremely unlikely to start a for-profit venture out of principle.


Are grocery stores required to give free food to the hungry?


No, but most grocery stores do take EBT (for those outside the U.S., it's food assistance).


1) It's coming https://www.theguardian.com/world/2016/feb/04/french-law-for...

2) Many shops in UK (especially London), run by Muslim or Seikh owners, have been feeding hungry people for years.


Most American grocery stores (at least in California, which is what I know of) run by anyone give their food away for free, as it approaches expiry. Choosing to do so is a lot different than being mandated to.


Most grocery stores aren't non-profits that are exempt from taxes. Many hospitals are.


Would you rather the market or the government make that choice for you?


We have lots of examples of governments doing this with ranges from poor to fair to good results. To my knowledge, the US is the only widescale attempt at market-based health care, with results of 2x the OECD average of health care cost per capita [1].

[1] https://read.oecd-ilibrary.org/social-issues-migration-healt...


But it’s hardly a market-based system with the third party payers. Consumers aren’t making informed decisions about what they buy, have little ability to comparison shop, and state-level regulations intentionally limit the number of providers in a market. With those attributes, the poor outcome of the “market” system is entirely predictable. We need to go in one direction or the other, but having the worst elements of centrally managed care and the worst elements of a market solution makes for rotten outcomes.


How do I make an informed decision when I'm bleeding out in the back of an ambulance?


Lots of ER visits aren't that dire. There are three hospitals within range if I broke my arm. I'd totally comparison shop if it were even remotely possible to call each up and ask how much. But getting even an estimated price for x-ray and bone set over the phone? Hahahahaha.


In which country in the world do patients regularly call up 3 hospitals to inquire about the price of setting your broken bone?


A lot of the regulations are there to protect existing players in the market as well. It seems that the market-based approach degrades when it comes into contact with democracy, probably because the equilibrium the market is trying to achieve is incompatible with our values.


The US is required to treat all critical condition patients under EMTALA since 1986. So the market does not currently decide in the current setting.


What would you propose as being a "market-decides" approach to health care, beyond abolishing any-party insurers and revert to a 19th-century model?


19th century healthcare was relatively affordable, or at least the costs were streamlined and transparent.

Perhaps keep 3rd party insurance but ban it as an employment perk, that would incentivize the market to play to the greater public instead of just white collar salaried employees.


The market would just let them die, so if those are the only two options then I'd go with the government.


Would I rather this market decide if I die from a treatable illness? No way.


The evidence overwhelmingly suggests that the market fails to make this choice, and governments - for the most part - have done a good job.


It it’s erroneous to call the American system a market-based system. It commonly is referred to as that - I know - but it doesn’t operate as such. Gov. regulation artificially and intentionally limits supply, supply shortage limits competition, limited competition inflates cost. Third party payer systems abstract the consumer from the supplier. Their buying decision is based on proximity of service center, not cost, because they often just see a $10 co-pay. So they aren’t making informed comparisons. If there’s a market there, it’s certainly not a free market, or anything close.


Definitely the government.

People with severe disabilities may not be profitable, but I'd still like them to have the option to live.


This. What good is advanced technology if profitability calculations stop it from being used for all but those that can pay full price.


To hell with profitability. I'm infinitely glad my son's right to live wasn't an option or a choice. Today he's an healthy 7 normal years old Canadian who had the top infant cardiac surgeons in the world for multiple surgeries.

So, yes, the government. It may not be monetarily profitable but money shouldn't matter to build a humane society.


Single payer system still make financial decisions about who gets care and who doesn't.

"It's crazy that I live in Canada, but now I'm looking at having to sell my house for coverage of my medication."[1]

[1]http://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-f...


That doesn't seem to be the issue:

> Helen Anderson, provincial lead for systemic therapy for the BC Cancer Agency, said that Ibrance is currently under active review for coverage in B.C.


Does help her much right now, does it?

There are several expensive medications that the Canadian health system has elected not to cover.

Here is another example where if the husband didn't have drug coverage through his employer, he would have been on the hook for the entire cost. Eventually he had to shell out $3,000 per month.[1]

At first, he says, his company insurance covered the price of the drug. But years later – Gary’s employer changed insurers and he was now on the hook to pay more than $3,000 a month.

[1]https://globalnews.ca/news/1654757/canadian-patients-struggl...


> Does help her much right now, does it?

No, but if that's the standard, I'm fairly certain we can find a lot more "no insurance, couldn't get treatment at all" stories in the US than we can "Canadian needs unusual, not-yet-approved medication" ones.

> There are several expensive medications that the Canadian health system has elected not to cover.

You'll find the American medical system does the same.

https://www.mercurynews.com/2007/12/21/teen-dies-hours-after...

https://www.today.com/news/man-battles-health-insurer-drug-c...

All medical systems will have rules and timelines for approval of drugs and procedures. Sometimes they'll lead to unfortunate situations.

In the US, though, approval's just the first step. You might then have to scrape together the $6k deductible for your family's bronze plan. You might have to wait until next year to switch insurers to one who covers that particular med.


Commercial insurers in the US cover far more new and experimental treatments than the Canadian system does. The drug mentioned in the CBC article? Full coverage in the US, from the day of approval.

Covered in Canada? Maybe never. And that's one of the best drugs out there to treat that type of cancer.

I'm not arguing the US system is better than Canada's. Just calling out there are trade offs with single payer systems. If American's think they can move to a single payer system and keep all the bells and whistles they have now, they will be deeply disappointed.

And your 2nd link actually proves my point. The drug in the article is not covered in many Canadian provinces at all. The guy in the article is being denied the drug because it's not approved for his mutation. Most people with the correct mutation do get coverage for that drug (again, a new, state of the art drug).


> Covered in Canada? Maybe never.

Sure, but that's true in the US here, too.

No insurance? No med. ERs aren't gonna give you it.

Can't make your $6k bronze plan deductible? No med. Maybe you'll qualify for a patient assistance program from the drug company, maybe not.

> If American's think they can move to a single payer system and keep all the bells and whistles they have now, they will be deeply disappointed.

It's entirely possible to have a supplemental private health insurance system for the experimental or unapproved stuff. You can get private coverage for stuff like IVF in Australia, for example.

A lot of America's bells and whistles are already inaccessible to a large portion of the population.

> And your 2nd link actually proves my point. The drug in the article is not covered in many Canadian provinces at all. The guy in the article is being denied the drug because it's not approved for his mutation. Most people with the correct mutation do get coverage for that drug (again, a new, state of the art drug).

As the article mentions, the insurer approved their sibling with the same mutation for the same medication. Private insurance can be just as capricious as a single-payer's approval system.


When cost-cutting needs to happen... and it's inevitable, the people with severe disabilities will be the first ones to get cut.

Government-funded health care suffers from all the same economic problems that privately financed health care suffers from, and the government is just as corrupt as any private organization, plus there tends to be little incentive for efficiency, so government programs tend to be extremely inefficient and wasteful.

I appreciate (and agree with) your concern for the disabled, but letting the government be in charge is a recipe for making everything worse.


Government-funded health care suffers from all the same economic problems that privately financed health care suffers from

Except the biggest one: the need to maximize the extraction and distribution of profit to shareholders, while funding the cheapest and least amount of care possible without jeopardizing that imperative.


> I appreciate (and agree with) your concern for the disabled, but letting the government be in charge is a recipe for making everything worse.

Except we have pretty much the entire developed world's healthcare systems to debunk that claim. They have similar life expectancies, medical outcomes, infant mortality, access to care, wait times, etc. for half the cost.


Similar, sure, but US is ranked:

* 31st for Life Expectancy [1]

* 32nd in infant mortality [2]

* 5th for colorectal cancer survival [3]

* 1st for breast cancer survival [3]

* 19th for cervical cancer survival [3]

* 7th for heart attack mortality [3]

The actual numbers are reasonably close, but the cost is also about 25% more per captia [4] than the second highest-spending country.

[1] https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

[2] https://en.wikipedia.org/wiki/List_of_countries_by_infant_an...

[3] https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...

[4] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...


Yes, I remember some right wing US rag saying the following in 2009:

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

Forgive me while I laugh uncontrollably


Yup. Investor's Business Daily.

https://en.wikipedia.org/wiki/Investor%27s_Business_Daily#Er...

> In July 2009, an editorial in Investor's Business Daily claimed that physicist Stephen Hawking "wouldn't have a chance in the U.K., where the [British] National Health Service (NHS) would say the life of this brilliant man, because of his physical handicaps, is essentially worthless." Hawking has always lived in the United Kingdom and receives his medical care from the NHS.


I want somebody who benefits from me being healthy on a long term to choose for me.


False dichotomy. Please try to avoid logical fallacies when posting.


People seem awfully confused about who pays for healthcare in the US so let's be clear: either the government or the market (consumers) pays for healthcare, or they do it in tandem.

I don't have a view on who should pay for it, but there are only 3 categories of payers in healthcare: 1 government and 2 private (insurance and self-pay). The compensation is funded by one of those sources.


People also seem awfully confused about how much the government currently spends on healthcare: the US government currently spends roughly as much per-capita on healthcare as socialized systems that cover the entire cost of healthcare for their citizens, and have better measured outcomes.

The crippling healthcare costs borne by individuals entirely consist of rent-seeking. It's also important to say that a lot of that money comes back out in salaries for the massive workforce required for the unnecessary administrative overhead, adding to the economy, and of course in non-imported luxury goods purchased by the rent-seekers themselves.


So, to summarize, the person you replied to above asked what is the reasonable alternative to socialized healthcare that does not include people dying in the streets of treatable maladies. And through your explanation it appears as though you replied with a tautological statement that had no bearing on the question being asked.

So, what is it that you are actually trying to say?


They did not ask 'what', they asked 'if' an alternative exists, invoking the classic 'dying in the streets' motif.

>Is there a reasonable alternative? I'm not trolling, but letting people die of treatable maladies doesn't seem like the right move.

I answered a tautological statement with a tautological question based on the logic the poster omitted.

Can you tell me who besides the government or the market (ie consumers) will prevent people from 'dying in the streets'? Perhaps by kidnapping another country's doctors and compelling them to provide care...

>I'm not trolling


I'm a little offended that you'd assume my question to be tautological, by which I in turn assume you mean rhetorical. Seems to have generated some good discussion.


I feel like even that confuses the issue. The government can only pay for something with money it takes from consumers.


That's inappropriately anthropomorphizing the market. The market doesn't choose anything. I choose, and the market determines my constraints in choice. Since I'm well employed and not poor, my constraints are to my liking. My question regarding those who don't share that set of constraints. For some people, they go to the emergency room in cardiac arrest, having no insurance or ability to pay for critical treatment. Currently, they are treated, and costs are passed on to other consumers. Under single payer, those cost distributions would be made explicit. So besides doubling down on socialism, it accepting the status quo, are there reasonable alternative?


My half-baked opinion is that there should be a two tier system like US education.

Free primary and preventative care along with dental and vision, and have a government subsidized insurance program for hospital/long term illness coverage akin to the public university system (along with the in-state discounts).

And allow for a parallel private system to exist for those who want to pay more and get allegedly better treatment.


Australia works on this model.


So how NHS works in the UK?


No. If you have a private system, the public system gets abandoned; it's the first thing to be cut when budgets are constrained because no one making the decisions knows anyone who uses it. See US public schools.


I mean, there's a separate private system in the UK.


Public school funding per child increased 33% from 1995-2015.

EDIT: This does appear to be inflation adjusted. Here’s a federal source which is definitely inflation adjusted showing funding increasing in real terms by 27% from 1995-2013. [2]

[1] - http://apps.urban.org/features/education-funding-trends/

[2] - https://nces.ed.gov/programs/digest/d16/tables/dt16_235.10.a...


If it had been tracking inflation, it would have increased 55% in that time [0]

[0] http://www.in2013dollars.com/1995-dollars-in-2015?amount=100


That's a 14% decrease adjusted for inflation.


For all the justified complaints about the US education system, it does a fairly impressive job moving the bulk of the country's children through a complex system to navigate.

Many of the country's best schools are public, especially at the college-level.


The NHS has survived for 70 years, as has BUPA, so your argument rather falls flat.


The choice on whether or not people should die because they can't afford healthcare?


The government. Thanks for asking.


As long as markets decide who dies there is still hope. When a government decides who does it is absolutely final.


I've attempted to fight insurance denials. They're pretty final, too.


It’s a matter of finding a way to raise the funds, insurance is only one way.

If the government will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.


> If the government will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.

If insurance will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.

Side note: private health insurance, private healthcare facilities, and paying out of your own pocket are all possible in countries with socialized healthcare.


Parent poster is talking about the Alfie Evans case.

Alfie is going to die. He has no brain. He was being kept "alive" on life support. The hospital want to end this life support because it's in his best intersts to do so - there's no hope of treatment, and keeping him alive is likely to be keeping him in pain. The parents disagreed with this, and so it had to go to court.

This means there is legal representation for the hospital; for the parents; and independent representation for the child. This is because the child is a human and has rights and his best interests need to be kept in mind.

The parents have rejected the findings of the court, and have made many appeals. They've gone to appeal court several times, the supreme court several times, and ECHR[1] a couple of times.

All the courts agree: it's in Alfie's best interests to let him die, rather than rpolong his suffering when there's no hope of treatment.

Also, all the courts agree that Alfie's parents (and latterly his father) have been given terrible legal advice.

This is causing some consternation in US right-wing nutjobs.

Here are some, but not all, of the court hearings. I might have got the ordering wrong.

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA/...

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...

https://www.supremecourt.uk/docs/in-the-matter-of-alfie-evan...

http://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR/...

http://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR/...

An example of the terrible legal advice (from a non-lawyer too!)

---begin

On 12th April 2018 the father went to the hospital with some other people who included a foreign doctor and air ambulance staff. The father had a letter written to him by Mr Pavel Stroilov of the Christian Legal Centre which, we were told, is a campaigning organisation. In the letter Mr Stroilov, who we have been told is not a lawyer, purported to give the father legal advice. He said that it would be lawful for the father to remove Alfie from the hospital and take him to any other place he chose. The previous order made by Hayden J was said not to have circumvented "your parental rights".

The letter, which was disseminated on social media (presumably with the knowledge and consent of Mr Stroilov), stated that:

"as a matter of law it is your right to come to (the) hospital with a team of medical professionals with their own life-support equipment and move Alfie to such other place as you consider is best for him. You do not need any permission from (the) Hospital or the court to do so".

This letter was misleading to the extent of giving the father false advice. We have been told that it had the most regrettable consequences in that it led to a confrontation in which Alfie was involved. The Police had to be called. An application had to be made as a matter of urgency to Hayden J.

The letter gave false advice because the previous decisions made by the courts in this case have directly addressed whether the parents have the right to decide what should happen to Alfie. The clear answer which has been given is that the parents' wishes are not determinative. The court has also expressly decided that removing Alfie from the hospital as the parents wanted was "irreconcilable with (his) best interests" and that his treatment and care "shall" be given by this hospital. To act inconsistently with or contrary to the court's determination and order would be to act without lawful authority. This includes the hospital which would have been acting in breach of the court's order if they had permitted Alfie to be removed from the hospital.


There is no treatment for Alfie Evans.

All the doctors (even the Italian doctors) agree: Alfie Evans is going to die, and soon. What they're offering in Italy is exactly the same palliative end-of-life care that he'd get in the UK, but with the addition of a long painful trip.

Alfie Evans has had the benefit of world class medical treatment - in the US he'd have been killed by the insurance company a long time ago. He's also had the benefit of free legal representation to make sure his best interests (because in the UK and Europe the best interests of the child are what's important) are looked after.


Also, the government has literally nothing to do with the Alfie Evans case. The government isn't a party to any of the legal cases.

Here's a ranty English lawyer: https://twitter.com/BarristerSecret/status/98919501104352870...


In American English, "government" includes almost any public body. The hospital, the court, and the organization acting as the child's guardian all qualify.


The government. I don't trust the market to create a humane, compassionate system.

I don't even trust the market to create an efficient system.

I trust the market to be adjusted by the wealthy to further enrich themselves.

I also trust the government to be the one organized group of people that can restrain that market, to give the rest of us a chance.


Isn't this a great argument for socialized (single-payer) systems? There is no price shifting in such a system, we all just pay in according to our ability as defined by the tax code.


[removed]


> I’m just surprised their voice is so loud.

It's a voice backed with $3.7 trillion in total economic value per year (18.x% of the $20 trillion US economy). In terms of size, it would just about be the fourth largest economy on earth, comparable to Germany.

There are millions of very well paid hands in that pot of gold, from doctors & nurses to scientists and pharma sales reps, hospital admin and insurance industry employees. Consider for a moment that US drug costs - the most notorious example of abuse in US healthcare costs - are about 10-11% of the total US healthcare expenditure, and our per capita spending is about 2x what it should be: ie nearly everyone in healthcare is partaking in the plunder. That makes for a very loud voice.


GP is implying that it is those who would abuse such a system (or represent people who would abuse such a system) that are making those decisions.


I'll speak for myself. I meant what I wrote; putative opponents of 'socialized' healthcare are not, in fact, ignorant of the endemic cost shifting that occurs in medicine. My intent was to satisfy my probably foolish urge to disabuse people on the Internet of their cherished strawmen. Unfortunately I haven't the time today to indulge that compulsion further, so I'll bid you all adieu.


What's more telling is many countries such a Canada with full socialized healthcare spend less taxpayer money per person than the US does.

At this point socialized medicine could literally save US taxpayers money while also removing the need for health insurance.


It isn't actually about costs. The thing about Americans, culturally, is that we hate other Americans. As a society, we would gladly pay $5 more to ensure our neighbor doesn't get $1 we don't think they deserve. See: drug testing of welfare recipients.


Right, when you have a system working as more of a cohesive hole incentives are realigned such that preventative care, reasonable drug prices, and less middlemen, lobbying $$, etc, are part of the process.


> use inflated billing from paying patients

It's not even that. "Sticker price" is simply the opening of negotations, sam as with any big-ticket purchase like real estate and vehicles and school tuition, and to a lesser extent airfare and hotel rates.

As with any high-overhead business with room for high-marginal-profit on units, they simply seek to maximize total revenue or at least cover costs. They don't care which customers pay how much.


I think this captures the mismatch better than you intended.

My routine healthcare is not a big-ticket purchase and should not be the kind of thing I need to negotiate over. The total package between hospitals and insurers is, but my transaction is not.


The key point of prices being published in a machine accessible and machine readable format isn't the numbers.

What numbers are published can be haggled over in future laws.

But the requirement for some numbers to be published is a big win.

FWIW, the move to digital health records was basically realized through Medicare demanding it. Providers can't afford to go without Medicare payments; like Texas and California, so goes Medicare, so goes the market.


> A lot of people against socialized healthcare don't realize that the system still takes extra money from those that pay and gives it to those that can't--just through hospital billing.

It would be refreshing to have a conversation with someone who holds such a position that was willing to say that hospitals should turn uninsured and poor people away at ERs and let them die in the streets. Its at least more honest.


I have had this debate. The right has learned to be very slippery.

You won't ever hear them suggest people should die in the streets - why that'd be just unhospitable!

They'll instead say - "why don't they have insurance? Why don't they get a job so they have health insurance? Why should I have to pay for people that don't feel like working when I go to work every day without complaint?"

If you suggest all the myriad of reasons the trapped impoverished don't have a job, they'll counter with "those are obstacles to getting a job, sure, but it's not impossible."

If you point out that many people have jobs that don't offer health insurance, you'll either get a sarcastic reply about Obamacare, or the question "why don't they just get a better job? Why don't they go to night school and get a degree?"

Empathy has been replaced by the desire to be infallible in debate.


You're arguing against a far-right strawman.

Take a non-strawman like Paul Ryan, who is in every way a typical Republican, and his proposal is not to abandon Medicaid, but to make it into an Obamacare-like system whereby people are provided subsidized insurance.


If by "strawman" you mean my Trump-supporting friends back in Texas, sure. They are real, and I am paraphrasing from actual conversations I've had. I think it's insincere to claim "well actual republicans aren't like that" when republican propaganda seems aimed at creating a population exactly like that.

Ah, Paul Ryan.

>There’s nothing inherently wrong with high-risk pools, but they have to be adequately funded in order to work properly because the people in them are so expensive to care for. Many states had high-risk pools before Obamacare was enacted, but they charged much higher premiums than normal and excluded coverage for certain services. The federal government also had a high-risk pool temporarily, but it grew too expensive and had to cap enrollment. According to some estimates, the $10 billion a year allocated in the AHCA would still not be enough.

https://www.theatlantic.com/health/archive/2017/03/the-bigge...

> Unless the amount of the credit is linked to the cost of coverage comparable with what people received under the Affordable Care Act (and subject to indexing), it will represent a reduction in coverage (or higher costs if people want to "buy up"). If people will be reduced to buying catastrophic coverage, their deductibles may be larger, not smaller than they were under Obamacare policies. That's a step backward for many Americans, who complain that the deductibles are too high already. Moreover, depending on the differential between the credit for older and younger Americans, older people (who use more health care) may wind up paying more.

>Equally problematic is the use of health-care saving accounts in lieu of the subsidies available on the Obamacare exchanges. If working-class people do not have the extra income to contribute (albeit on a pre-tax basis), once again they will be worse off than they were previously.

> Without massive new taxes to pay for it, it's hard to deliver more coverage for less. In other words, Republicans promised more and are delivering arguably less than Obamacare does.

http://www.chicagotribune.com/news/opinion/commentary/ct-pau...


I blame identity politics. If you want to identify with your right wing group you must stick to those believes. Compliance with the group norms you identify with is more important than health care for abstract "poor people".


I'd argue that the desire to appear infallible in debate is a facade to shroud the overriding desire to pay less in taxes no matter the human cost, coupled with a lack of empathy.


I’ve been saying for a while that until and unless people start advocating for the repeal of EMTALA (the law which requires ERs to treat everyone), there isn’t any debate over whether we should have socialized medicine, merely over how.


I don't think that socialized medicine is certainly necessary. Compulsory private health insurance like Switzerland is workable.


My point isn’t about whether or not it’s necessary. It’s that we have it already, just in a weird and inefficient form. Our politicians pretend to debate over whether we should have it, when in fact we’ve had it for three decades and nobody serious is proposing to change that.


So who pays for the treatment of people who can't afford to pay for their own private health insurance?


If it can be simply made up for by the Swiss equivalent of SS I guess that'd be nice, seems like private health insurance wouldn't care either way.

Then again this goes against my theory that socialized aid should come directly in the form of the thing needed - voucher for healthcare, food (or very specific food vouchers), rent free housing or vouchers for housing, rather than cash which is a bit silly to give to someone the government failed to give good financial education to (speaking from experience here...)

There's a reason theres a huge market for under the table financial management among the trapped impoverished.


You're presuming that our only two options are requiring hospitals to admit everyone or let people die in the streets (and then calling people dishonest).

It's a bit like assuming grocery stores must give away food to anyone or people will starve in the streets. In fact, there's other ways to get food to those in need.


at least in the 80's a private hospital only had to bring a person to a certain degree of health. I had a gash and was taken to a private hospital where they cleaned and bandaged the wound but then told me to go to Bellevue for more work as I was not insured. Just came back from Thailand where I had a mountain bike accident where I spent 2 hours getting stitches in emergency room with next day followup and bunch of meds and total cost was US$400.00. That would have been more like US$4,000.00 in the U.S.


Or people who can't afford food get assistance from the government.

The difference is that healthcare costs are so outrageous, that the "people who can't afford healthcare" bucket includes families solidly in the middle and even upper-middle classes. Which includes most of the nation.


Propose an alternative.


People can die in the ER waiting room, without ever being treated?


I don't think this happens often, at least not due to the patient not getting attention in a reasonable amount of time. ERs triage patients based on severity of condition and if you are in more critical condition you get bumped up the line.

But there is an issue in certain areas of people using ERs like a GP because the ER can't legally turn people away due to EMTALA


The ER is only required to assess patients and if you come in uninsured, unable to pay and with a GP-level complaint (flu, whatever) you'll receive no further treatment other than the assessment.

A lot of people seem to think ERs are simply required to treat everyone, which is not even close to true.


Medicaid (free healthcare for the poor) and Obamacare (require insurance with subsidized rates for the poor) are examples of how to address this issue.


Medicaid is socialized healthcare so I think you and i spoke past each other.


Get rid of health insurance and watch prices come down.


There is no way to predict what would happen in a world with health insurance suddenly removed. This seems like a nonsequitor.


It would never happen. But if it did prices would stop going up at least.


There is no way to predict that. It's all guessing.


Maybe. But couldn't we at least ask the question and have the same studies done on eliminating health insurance that we did for the Affordable Care Act (ACA). Implementing the ACA did not exactly go as planned either.


1. Deregulation - reduce compliance and legal burdens. That would bring cash prices down, so instead of 1% perhaps 50% can afford them. That's a start.

2. Charities. You can start your own: give 5% of your income to underinsured. For example:

http://www.philanthropyroundtable.org/almanac/hall_of_fame/j...

At the urging of Frederick T. Gates, perhaps his most trusted philanthropic adviser, Rockefeller became increasingly devoted to medical research. In 1901, he funded the Rockefeller Medical Research Institute in New York City. Modeled on the Institut Pasteur in France and the Robert Koch Institute in Germany, it was the country’s first biomedical institute, soon on a par with its European models. The results were dramatic. Within a decade, it created a vaccine for cerebrospinal meningitis and had supported the work of America’s first winner of a Nobel Prize in medicine. Today, known as the Rockefeller University, it is one of the leading biomedical research centers in the world. Twenty-four Nobel Prize winners have served on its faculty.

But don't force charity on others who may be struggling.


Rockefeller University is an impressive research outfit, but not a) a pharmaceutical company or b) a treatment center. It deals more with moonshot basic research that most people won't benefit from for a few decades (e.g., Oswald Avery's early work on genetics) and doesn't directly affect the plight of the poor and underinsured.

Having worked in non-profits extensively, it's also disingenuous to claim that non-profits answer to anyone other than their primary donors, whose priorities are frequently not aligned with regular people.


> 2. Charities. You can start your own: give 5% of your income to underinsured. For example:

That's a shockingly high amount, especially if you don't get healthcare out of that.

16% of my taxes go to pay for my health care system, which covers the whole country. For someone on a median income that's 3% of their income. For someone on a top 10% income that's 4.15% of their income.

To spend 5% of your Gross Income on the NHS in the UK, you have to pay 31% in total taxes, that's an income of £75k, that's circa top 5% income.


What if even with the amazing price reductions achieved by deregulation, charities still can't cover for all uninsured patients?


Why should this matter? There will always be more things desired than money to pay for them.


The continued health and well-being of our fellow human beings take precedence over most other 'things'. If it's a choice between letting someone buy an extra boat and giving someone potentially life-saving preventative care, the choice is clear.


Deregulation might work if all market participants behaved like angels. But few people do, and so over time deregulation tends to result in cutthroat behavior, consolidation, and price increases.


Airline tickets are cheapest ever, and that's despite the fact that relative to biotech which is the fastest evolving field currently, airplane technology has been practically stagnant since the deregulation


It is much easier to compare airline tickets than hospitals/medical procedures. The worst case scenario for choosing wrong in the first case is a flight you're uncomfortable on and overpaid for.


Airlines are still heavily regulated on safety-related issues. (That might be the sweet spot.)


1. Regulation is not the cause of high healthcare costs in America. One could argue that the lack of regulation in certain areas could be responsible for price hikes[1] in healthcare.

2. Charity has had thousands of years to solve societal problems, yet it didn't. What you're describing is a pipe dream.

Within the span of a less than a century, countries around the world have addressed healthcare effectively such that care is available to most, if not all.

[1] https://en.wikipedia.org/wiki/Martin_Shkreli#Daraprim_price_...


It's a shame this is being downvoted. It's a valid point of view that has merit and should be part of the discussion.


I would argue that healthcare is not a right. But most of the comments here seems to leave only two choices: all or nothing. Just because someone is against socialized, universal, or free healthcare does not mean that they want people dying in the street. They just see the argument as a lot more complicated. As crazy as it sounds I think we should do away with health insurance in general. I think that would do more for cost control then any scheme the government could come up with.

I do believe that making hospitals publish their prices would be a good start. The first thing I think that would do is bring to light the difference in price between paying in cash versus using insurance. From there we could make arguments why the same service has a 10x to 100x difference in price depending on how or who pays for it.


How would you then hedge against unexpected high-cost procedures? Your assumption is that ridding the world of insurance would magically, dramatically lower the cost of every drug and procedure on the market.

Not everyone gets cancer, the medical insurance profit model is predicated on a bet that most people won't. The more people in the coverage pool, the less likely you will be paying out for every single person.

Socialized care is just the expansion of that model to encompass the entire country's citizen population. What would have been privately-captured profit from people that were healthy members of the pool can instead be used to reduce the premiums paid by all members of the pool.


I am arguing from the point of view that at current prices very few if anyone would be able to afford a high-cost procedure. When that happens prices would come down. This is partly why a bottle of snake venom antidote in Mexico can cost $100 but in the U.S. costs $10,000.

Another example is eye surgery. Originally the procedure was expensive but now it is more affordable because it is not covered by insurance. Comparatively, plastic surgery is relatively affordable because it is not normally covered by insurance.

Reducing or eliminating health insurance would also eliminate a lot of the medical administrators that provide zero care but due incur a cost due to their salaries.

As far as getting rid of the profit motivation but capturing the profits and giving it to those without health insurance I believe that you would also eliminate any reason to innovate and create new drugs.

I will admit that if you got rid of health insurance tomorrow that there would be a lot of short term pain. But I also believe that in the long run people would be better off because they would be able to afford there healthcare.

Using a different example look at the cost of college. I believe that we could fix that problem one of two ways. The first way would be to get rid of government loans and grants. The other way would be to allow people to file bankrupcy for student loans. The first way would attack the problem by getting rid of easy money. Because easy money makes things expensive. The second way could work by shifting the risks of the loans from the student to the banks. The problem with this solution would probably make it harder to pay for degrees that don't pay well.

To summarize my arguments, cheap money makes things expensive and is destroying almost everything is this country.

Edit: added the college example.


It's not all or nothing though. Many countries have hybridized private/public healthcare. Examples:

- Compulsory basic insurance (private or public) (Switzerland)

- Private insurance + equalization pool (Netherlands)

- Compulsory HSA + government price fixing (Singapore)

- Socialized general coverage + private supplementary coverage (France)


I don't think it would really work. Each of those countries developed their versions of healthcare based on the needs of the country at that time. It isn't like those countries were identical in size, population, gdp, etc. and then choose their healthcare scheme on a whime. The U.S. would have to design a plan that would work for the U.S. We are so polarized as a society right now we couldn't plan our way out of a paper bag if we needed to without getting into a fight.

I will admit that I have not read up on those countries healthcare plan but I think it is a lot more complicated than saying lets copy X countries plan. If you made a big change there would be a lot of second and third order effects that we would have to deal with and we may not like those out comes.


Maybe it would make more sense for each state to come up with a plan for healthcare as each one would have different needs.


I think it would be better but it still doesn't address the problem of easy money making everything expensive. The other problem I think could come from making each state a "walled garden" so to speak that prevents non-residents from using those services. At least with the states deciding you can vote with your feet.

I could see California residents arguing why they should pay for the medical expenses of tourist.


Having some domain specific knowledge of the financial flow through the industry, I tend to favor a more federated administration model like you suggest. Skeptical of federal level ability and historical competency, I favor outsourcing the initial transition wrt implementation and administration to Switzerland, Netherlands, Singapore, France, etc.


Now that I have thought about it for a little while longer I think I would be fine with each state deciding which model they wanted to follow. I falls in line with states rights and the 50 individual experiments concept. Which I also believe in. If one of the models work then great. If not they can look to see what is working.


The polarization is not as significant as imagined. On issues such as healthcare there is overwhelming support for universal coverage or a single payer type system, by around a 2:1 or higher margin. The problem is that our mainstream political parties are broken.


I am skeptical about that. I think that it is closer to 1:1. I could make the argument that everyone that I know is against single payer and universal healthcare. But I know that I would be biased. I think that that is called Comfirmation Biased but don't quote me on that.

We could point finger all day long about who is responsible but at the end of the day nothing changes. I think politics at this point is more about entertainment then anything.


> but I think it is a lot more complicated than saying lets copy X countries plan

I don't think anyone in the discussion thread is advocating carbon copying another country's healthcare.


Perhaps, but then there is no reason to bring up what other countries are doing except to say that they are doing something. But again we are back to trying to figure out how to make healthcare more affordable.

I think that both we and everyone in this discussion can agree that what we are doing now is not working and is unsustainable. We are just arguing over the best way to fix it. I personally believe that easy (cheap) money makes things unaffordable where is seems everyone else wants to spend or devote more tax dollars to an already broken system. I would just like to fix the root problem and not the symptoms.


> there is no reason to bring up what other countries are doing except to say that they are doing something

Are you suggesting that healthcare legislation should be drawn up in a vacuum? It's important to compare and contrast the benefits and pitfalls of other countries' systems. It's really all we have to go off of evidence-wise. It's also good to look at them for inspiration. There are a lot of different ways the public and private sector are being combined to make far more cost-effective healthcare systems than in the US. You are correct that some might not work in the US; that sort of reasoning needs to be weighed into whatever overhaul happens.

> I would just like to fix the root problem and not the symptoms

What are you suggesting as the root issue?


I have no problem with looking for good ideas from other countries. I just want to use realistic figures and study what the second and third order effects would be.

The main point to my arguments is that cheap money makes things expensive. Meaning is the government or somebody else subsides healthcare it will get more expensive. Because why not. Hospitals are trying to compete with other hospitals so they want the biggest budgets for paying the best doctors and newest equipment and technology. So why not charge just a little more then you need to get that. Then the next year comes around and the hospitals need more money so they charge just a little be more this year and it goes on and on.

You could probably start to fix things by making everyone publish their prices and charging the same price for cash as they would to insurance. From there things would start to unwind.


> I would argue that healthcare is not a right.

I would argue that rights are things that we declare by agreement as a group, not physical objects or measurable qualities. Of course healthcare is not currently a right; we haven't made it one. The question is: "Should healthcare be a right?"


Now here would be good forum post. But is pretty philosophical. What is the source of rights. If we agree that rights come from the state then we can't really complain when other countries do horrific things to their citizens. We also can't complain if our elected leaders decide that free speech, privacy, or any other pet social issue is removed. I think that we had it mostly right at the founding of this country.

Too much could be written about this argument but to me a right can't be provided by someone else's labor.

Now that I think about it, a right is also something that can't be taken away. No one should be able to prevent your free speech (1st Amendment), defend yourself (2nd Amendment), or violate your privacy (4th Amendment) without due process.

In this case no one is preventing someone from being able to care for themselves. We are just arguing over who pays for it. It is probably a bad example but everyone has the right to use the roads for transportation. We just don't have the right to the car, insurance, and gas.

Edit: Added more comments


What you're getting at is the difference between Negative Rights and Positive Rights. Negative Rights guarantee inaction, e.g. the government can't suppress your speech or take away your ability to defend yourself. Positive Rights guarantee action, e.g. the government will force someone to provide you healthcare.

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

You're also touching on the difference between Natural and Legal Rights.


Rights are expectations that you have from a just society. There's no real division into positive and negative rights. Due process, for instance, could be phrased either way but it is the same right nonetheless. One phrasing would emphasize freedom from extralegal persecution, the other would emphasize that all sorts of people (e.g. lawyers, juries, judges) are compelled to provide you certain services.

You can't have rights without guaranteeing action. My right not to be tortured requires all sorts of individual and societal interventions in order to fulfill. There's no classification of rights into positive/negative and certainly no difference in validity between the two.


I could not have said it better myself. I actually thought of that a little while after I wrote that.


Healthcare isn't a right. But as a wealthy society we have a moral obligation to provide essential healthcare to everyone at a price they can afford.


Now I am not wealthy by any stretch of the imagination but I do not have a moral obligation to force anyone rich or poor to provide essential healthcare. I could morally encourage people to donate time and money to hospitals as a charity but to force them as part of a government mandate to me is morally wrong.


If you think that taxing the wealthy to provide essential services to the poor is immoral then you've totally lost me. That's not the type of society I want to live in. Relying on voluntary donations leaves too many people to fall through the cracks.


The problem with using words like wealthy are that it is a moving target. Generally when someone says wealthy they mean anyone making more money than them. In a small town in south east U.S. 150k would make someone very well off. One might even say wealthy. In San Francisco someone making that amount of money might be homeless. So should the person living in California pay more?


Furthermore, even the capitalistic idealism of "multiple private insurance companies competing with each other will drive prices down" doesn't work. At the end of the day, Medicare decides what it's going to pay for a procedure, and the rest of the insurance companies base their compensation off that. The government is still in control of pricing, by and large.

Even the Singapore model (which looks capitalistic on the consumer end) relies on huge amounts of government price-fixing on the hospital side of things.


Or hospitals could have on site urgent care


In lots of places they do.

(I guess more so in areas where freestanding urgent care is a less interesting investment)

There's even hospitals that provide urgent care style care (and billing!) in their ERs, undermining the argument that this isn't viable.


> A lot of people against socialized healthcare don't realize that the system still takes extra money from those that pay and gives it to those that can't--just through hospital billing.

In fact it's really the opposite; it takes extra money from those who can't pay (the uninsured) and gives it to those who can (the insured), because it's the insurance companies that negotiate the lower rates.


It's more complicated than that. If you're uninsured, you can apply for aid. If your financial need is considered great enough, they might write off part or all of your bill. Hospitals set aside a certain amount of "charity" money to cover these cases (from the extra they get from other sources). In this case, the uninsured person is having their bill paid by others.

If you're uninsured and rich, well, you're paying sticker price and making the hospital very happy.

If you're uninsured and somewhere in the middle, you could be helped by the hospital, you could be screwed, really depends on the hospital.

Private insurance companies pay more than Medicare/Medicaid on basically all procedures. The price they negotiate is lower than the list price of a procedure, but remember, these sticker prices are hugely inflated. Hospitals will often raise the list price to renegotiate higher prices with insurers. In the end, I would suspect it is largely private insurance providing extra income for the hospitals (more common than cash patients, and they pay a greater % of the list price than Medicare).

Here's more info: https://www.nbcnews.com/health/health-care/hospitals-highest...


Both happen. I think the point OP was making is that the cost for anyone who pays (insured or not) is higher in order to compensate for the required care to people who never pay.


Obviously they aren't taking money from people who can't pay. They take money from people who can pay.


This could still lead to lower prices by giving consumers better information. I have always wanted to set up a site to allow people to compare prices for healthcare in different hospitals/areas in the USA but this information is not publically available on the scale that would make it feasible.


Here is a good example of a hospital that is doing it right. Granted I have not been there but I would really consider it if I needed surgery and I was in the area. Maybe domestic medical tourism.

https://surgerycenterok.com/

edit: forgot to add the link.


The inflated costs have very little to do with ER and uninsured patients. It is mostly about getting more money from insurance reimbursements. ER operations are subsidized by taxpayers in most of the US, and the ER is only a small part of the overall system. The reimbursement rates are loosely based on the inflated billing costs, with many insurance companies demanding a minimum discount of 50% being common.


-- Which amplifies the cost incredibly, through reactionary rather than preventative care. Sadly, it seems like most people I've had to inform of this perceive more than one bogeyman in more socialist systems.


> A lot of people against socialized healthcare don't realize that the system still takes extra money from those that pay and gives it to those that can't--just through hospital billing.

I don't know where you get this. In my experience nobody who advocates for socialized healthcare is under this impression. They know how the system works, just don't think it's an efficient way to run it (it isn't).

The way the incentives are structured on the American healthcare system now are beyond ridiculous and having public published prices is a way to start a much needed debate about the underlying issues, with data and facts instead of political viewpoints.

It's absurd that having a baby in an average facility in the US "costs" five times more than a private hospital in Switzerland. I put quote marks on cost because that's usually billed price and insurance tend to negotiate down, so in reality is more like twice the cost, but still absurd at any level.


> In my experience nobody who advocates for socialized healthcare is under this impression.

Did you misread? I said that many that are against socialized healthcare don't realize that wealth redistribution is already happening in the American system.


I'm sorry. I actually misread that, yes.


> Like list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts.

I just had $5k worth of bills from the birth of my last child (the amount wasn't surprising, pretty much exactly what the insurance estimated for standard pregnancy).

I called, credit card in hand, and asked if they have any discounts for paying on time. They gave me a 35% discount on the spot!

It still feels vaguely like insurance fraud because the $5k amount is what is going towards the deductibles...


Be careful. I did this exact thing with my first child, but they billed my insurance company for the 35% they discounted, anyway. After something like 50 phone calls and hours and hours on the phone with people who said they would "take care of it", I finally got taken to collections and ended up paying it to avoid damaging my credit.


I haven't looked at it in a couple of years, but medicare used to publish what they pay, and the random adjustments based on location and other factors i don't recall.

medicare doesn't negotiate. they just pay a fixed cost up front.


data is still on the CMS website: https://data.cms.gov


Think of it this way, if $3250 is going towards deductibles all the time, your deductibles and other insurance costs would also be lower by 35%.


You mean because insurance quotes your copays as % amounts, not $ amounts?


Yes I think that's what I mean. We have a $5k individual deductible. After a deductible is met, we pay 20% coinsurance. Before the deductible we pay 100%.

Making up some numbers, my wife had already spent $3k on the OB-GYN which counts toward the deductible. The hospital billed us $7500. So $2k we pay to finish meeting the deductible and then 20% of the remaining $5500 is $1500, so our portion of the hospital bill is $3500.

If the insurance company knew we'd get a discount on our portion of the final bill, that calculation for how much of the bill we'd only have to pay 20% of would be different.


> Like list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts

Which means that anyone those insurer contracts don't cover, is getting royally screwed. Thus, healthcare is simply unaffordable to someone who doesn't have those insurers acting as a payment intermediary.

This one of the dirty secrets of the whole US healthcare coverage problem that I never see politicians (or talking heads) on either side actually acknowledging.


It is extreme, but banning all insurance discounts would be a good first step.

This might concern people initially (because the discounts are currently so high) but for practical reasons after the ban is in effect the costs will go back to more or less pre-ban levels, but now simplify billing (reducing costs) and benefit people without insurance (no more absurd inflated bills).

Insurance discounts themselves are problematic, and also result in this silly "in-network" "out-of-network" system we have. In particular where you could go to an "in-network" hospital but get an "out-of-network" anesthesiologist or lab giving you care without warning.


Pulling people into the insurance system was the whole point of the ACA subsidies and Medicaid expansion. It's a pretty clear acknowledgement of the problem.

Whether full coverage should be something the government works on as policy and whether subsidized private insurance is the best way to get to full coverage are different questions, but the most talked about parts of the ACA directly address people in that insurance gap.


Right. Hospitals have to deal with a mess of insurance plans. If they Underbill they only get what they bill. If they overbill there is no penalty they just get paid the allowed amount. So they jack up the prices to ensure they are always over billing. This works for insurance patients but then people without insurance or high deductibles get screwed.


Hospital should not even deal with the mess of insurance plan by adjusting the price. They should not care what kind of insurance the patient has or whether the patient even has insurance. They should just set a price to what they deem reasonable and if somehow patient insurance provider doesn't pay enough, it still the patient responsibility to pay for it.


Insurance contracts with providers prohibit balance billing to patients. The provider can only bill a contractual maximum amount for each procedure. This helps to control costs and prevents patients from getting hit by unexpected charges.


> people without insurance or high deductibles get screwed.

I've used the high deductible plus HSA approach since it was an option. I don't know if this varies by state or plan, but all I ever pay is what the insurance company considers allowable.


> what the insurance company considers allowable

Why is this concept ever even deemed acceptable? Why do you get the privilege of "only paying what the insurance company deems allowable, minus what they cover", but someone else has to pay in full?

This puts you in a state where you basically require insurance to get care at a reasonable price. Where its cheaper to have coverage and pay out of pocket, than to pay out of pocket without coverage.


You can negotiate to settle your bill if you don't have insurance.


I dont walk into a Walmart or Target, load my cart up with stuff, have it scanned, walk out the door, and receive a bill 1-12 months later demanding all money paid in full in 30 days.

This "negotiation" you mention works 1. If you know the price up front 2. have the leverage to negotiate.

And guess what, you have neither of them. This law changes one of those, so that shopping around is at least possible.

Aside: I'm surprised a lawyer didn't sue a hospital over Informed Consent via no billing knowledge.


> This "negotiation" you mention works 1. If you know the price up front 2. have the leverage to negotiate.

In emergency situations this is hard to do, but I've done it numerous times when needing non-emergency health care. I even call around asking about prices and the cash discount. Oddly enough, a co-worker and I both had the same procedure (back issues ugh) last year at the same doctor. He used his insurance, and I asked about and went the cash route. I ended up paying less for the exact same thing because of how his deductibles worked.

It was the end of the year and I guessed I would not hit my yearly deductible so paying cash was the right move.


How complicated/extensive was this procedure? I have requested prices for many procedures and only once have I received that information (and like I said in another comment, I received a discount for paying it in full at the time of service). Every other time, every single person I talked to said "I can't give you that information" or "I honestly don't know".


Not too complicated I would imagine, but it was an MRI, doctor visits, and back injections. One place in town laughed when I called and ask for pricing, and when I said I wanted to pay cash they hung up. So it definitely takes some asking around.

When I had knee surgery years ago, and had good insurance at the time, I asked the doctor about the price just to see. He was quick to say if I wanted/needed to pay cash he could work something out.

So they are out there, but you might have to do some digging.

And again, emergency situations are a completely different beast.


Not really, there's another comment thread in this post alone which talks about getting a 35% discount just for paying on the spot. It's ridiculously easy to negotiate because the prices are already so inflated that the hospital isn't losing money by offering "discounts" like that.


Which is funny you mention that...

If you don't know the bill, they can't tell you the bill, and they have no way to get the bill until weeks later, how can they "negotiate" when nobody knows?

Frankly, that claim sounds like a pile of you-know-what. My bet is they take your money, and then bill you for the rest.


The negotiation happened when the bill came.


> politicians (or talking heads)

If you're serious about learning, stop listening to these people (seriously, it's a waste of your one precious life) and try taking a healthcare economics class or reading Paul Starr's Social Transformation of American Medicine.


The problem is that these people dominate the public conversation. We can't solve a problem if you have to read some special book or take some special class to even be able to correctly acknowledge it.


> I'd imagine hospitals hate this.

Not as much as you might think.

The biggest beneficiary of price opacity is, actually Medicare itself. Because prices are opaque, and because it's illegal to charge private insurers less than what you charge Medicare, and because Medicare has no legal mandate to reimburse COGS, Medicare is able to use the lack of price transparency to force providers to pass Medicare costs on to private insurers (which then gets passed on to privately-insured patients in the form of premiums).

A rather cynical - but wholly plausible - view of this news is that it's an attempt to undermine the long-term financial solvency of Medicare, by making it harder for them (in the long run) to pad their operating budget this way. Given that the press release heavily emphasizes the role of the current administration in making this change[0], and that the entire party has pretty consistently supported cutting funding for Medicare[2], it's a rather easy conclusion to come to.

[0] It's not exactly unusual to mention the President by name in a press release of this nature, but it's not exactly typical or standard practice either. Oftentimes, agencies will refer to themselves as if they were politically neutral and functioning somewhat independently of the executive branch[1], even though the leadership is obviously appointed by the executive.

[1] Because, to a large degree, they are - the people employed by these agencies have relatively low turnover, unlike the directors who are appointed fresh by each new administration.

[2] Not in their rhetoric, of course, but with their actions


> Like list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts

I had a "pleasure" to actually dig for some service (online) and after a while I got frustrated by this exact thing - all prices are always hidden, you HAVE TO contact 'sales' department and even if they show some prices upfront there are sooo many hidden costs and obligatory services and taxes that it's virtually impossible to quickly compare services.

In contrast - in majority of the European countries (I think it's an EU thing) all companies are obliged to display complete, total price for customer with all taxes included - this makes life so much easier…


What really needs to be published are the actual prices paid.


I would argue that there will be no push toward accurate cost of care unless some messy steps towards transparency are taken first. Union pushes infection rate data? Counter with your own data. Someone saying you’re too expensive? Counter with real dollar figures. More data!

Right now we kinda just have to take people’s word for it.

This transparency is the first step needed to move us toward smarter consumption of care. I don’t see any worthwhile brands getting tarnished by pricing data.

If consumers see a hospital as expensive, they might choose a cheaper hospital that provides the same standard of care without the frills. This is the kind of decision making that will bring down care costs over time and I’m stoked to see this move.


I totally agree, transparency has the power to really move the needle.

The issue I see though is that all parties that have data are incentivized to keep it to themselves. Many "leading" hospitals actually don't have super great quality compared to other, less well known hospitals. So powerful, well known but low quality hospitals will lose if there's more transparency. They know this, and they're fighting it

Large EMRs will also lose if there is more interoperability. Right now the fact that Epic and Cerner "own" a hospitals data gives them a lot of power. If anyone wants data, they have to go not just through the hospital, but through the EMR duopoly.

Insurers don't want to publish their rates, because they'd face backlash from all around when people realize how much variability there is in how much they pay for the same procedure at different hospitals


Under the 21st Century Cures act, the federal government has now started prohibiting information blocking by EMRs. There are still some obstacles and friction but generally Epic, Cerner, and their competitors are opening up and offering published APIs using standard protocols.


Basically, Medicare and Medicaid are tired of getting screwed. When those programs were established, they were intentionally hobbled in negotiating prices with drug companies, hospitals, physicians, etc. Because, you know, it wouldn't be fair to providers.

As a result, Medicare and Medicaid often pay more than private insurance. In part, that's because their ranges for negotiation are pegged to list prices. And so providers inflate those list prices. And nobody, except for a few clueless patients, actually pays list price.

Anyway, good for Medicare and Medicaid!


If you take Medicare, it is illegal to charge anyone else a lower price than what you charge Medicare. Therefore these prices will be the floor and nothing else.


Re: "list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts"

Would be great if they were required to provide list, min insurer price, max, and median.


> I really like this push towards transparency but hopefully people who use the data / develop will make sure to understand the system and the data they're dealing with.

They won't. Having clear, sinple, unambiguous per-procedure price information widely available while quality information (including on induced downstream needs and costs) is less clear will produce strong downward pressure on quality, while also not controlling aggregate cost. That's a pretty clear pattern in human behavior that is often leveraged both as a competitive tactic and to increase total revenue.


List prices are meaningless but Medicare prices are probably the most meaningful. Insurance prices are benchmarked off them.


Right, the real solution would be to have a listing of usual and customary costs per region.

This is what people who offer advocacy services to the uninsured do. It's similar to getting comps on real estate, those people have access to billing systems to find out what insurers actually pay and negotiate based on that pricing.


It's unfortunate that union actions against hospitals often try to scare the public -- the patient base -- into staying away. Such actions have been known to backfire. Where I live an electricians' union tried this, and it generated ill will towards the union and good will towards the hospital.


I just started a project for this: https://github.com/PraecantatioLabs/Asclepius

Pull requests for your local hospitals are welcomed!


"list prices are often incredibly far removed from the actual dollars paid, and the actual amount paid is all dependent on insurer contracts"

I think that fundamentally (or almost fundamentally) clashes with transparency.


But if you're uninsured the list price is what you will be billed, isn't it?


The uninsured pay much less, specially if you have no catastrophic claims

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