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Bringing transparency to ER prices, one hospital bill at a time (cjr.org)
227 points by smacktoward on Oct 24, 2018 | hide | past | web | favorite | 115 comments



Kliff's approach to covering healthcare is nothing short of miraculous. She's killing it on all fronts—dominating the beat as far as traditional reporting techniques, innovating new ways (like this) to unearth information, and on top of it, communicating an intricate and sometimes abstract area of public policy in a way that anyone can understand and relate to.

In general, I think vox.com is underrated. But Kliff in particular stands out.


I love vox.com's depth (which their clickbaity headlines belie). Their podcast, The Weeds (where they get into, of course, the weeds of policy topics) is among my favorites. They are a little too liberal for my tastes, sometimes. I mean, I'm at least that liberal myself, but I sometimes feel I'm just getting the side of the story that caters to my existing beliefs from Vox.

Sarah Kliff's reporting, specifically, though, has always stood out as unusually excellent to me. It doesn't seem to suffer from that problem as much as some other Vox reporters I like (eg Matthew Yglesias). Her healthcare coverage, of course, is supurb, but there's also great stuff like her piece[0] on the wage gap.

[0] https://www.vox.com/2017/9/8/16268362/gender-wage-gap-explai...


While Kliff's work seems good, the title has the "Helping X, one Y at a time" problem.

The actually state of affairs is that arbitrary hospital bills are a problem that won't be solved one hospital at a time but rather are going require regulation, not just on all hospitals but of health care broadly.


The one Y at a time approach brings _transparency_ as mentioned in the title. Once there's transparency the conversation is more likely to be about the facts because that's what everybody can see.

When you don't have transparency what happens is that everybody can bring their own anecdotes, maybe baseless, and you can watch as a group "wins the argument" based on claims _you_ know are spurious, because even though their position is unsupportable on the facts, nobody had those facts.

So, you're right that Kliff's work doesn't itself fix the problem, but what it does is document the problem unmistakeably so that this thread has fewer people saying "I don't think that can be right, my friend's sister knew someone who worked in an ER and they never charge that much".

Back in technology the Certificate Transparency system doesn't itself solve any problems per se. But it delivers transparency, and that has allowed clean-ups to happen in years that would undoubtedly have taken decades to complete without transparency.

It still requires a Will in the right place to solve the problem, for example CT's effectiveness is in good part dependant on Mozilla. Would Google step up to the plate and do the same job if Mozilla didn't exist? Maybe, or maybe for political reasons as a for-profit they would fail. Certainly Symantec's leadership believed that going over our heads to Google management would get them what they wanted, but unless what they wanted was "Get out of this business" that does not seem to have worked.

But the good news is that for healthcare Americans can vote to put that Will in place in your country.


I moved to the US about a year ago.

Went to ER for the first time ~3 months ago. I was charged about $4000 for:

- Cleaning a wound (with water/desinfectant).

- Some antibiotics.

- A band-aid and gauze.

I get how, with labor cost and all, that might cost $200. Maybe $300? I have no idea how this can cost $4000.


I got an abdominal ultrassound, because some of my bloodwork was off and the doctor wanted to confirmed my liver was ok. Very routine. So I agreed. 15 minutes from the time I got to the reception desk to the time I was out of the door.

Hospital billed $6000 (already negotiated down with insurance). Insurance paid around $4000. They wanted me to pony up 2k. Told no. Went to collections, negotiated to just under 1000. According to the line items, doctor took ~$100.

I have no clue why this was so high. My wife did pelvic ultras-sounds at another hospital (so not exactly the same procedure), but was billed $300.

The only reason I can think of is the 'name' of the hospital. It's in the Bay Area and shares the name of a well known university.

Had I known, I would never have gone there. That incident caused me to ditch my plan and go with Kaiser. It's been ok so far. No ultra-sounds, but I got a sleep apnea exam and a cpap for about 150 - and that was disclosed upfront.


Ultrasound is a quick and relatively simple procedure. They could get a few in the ER and a few technicians on staff. Then doctors are encouraged to say bloodwork is off let's do an ultrasound and there you have it - $4k / 25 minutes. Bill the insurance and keep raking in the money.

Normally I'd say that's far fetched but after having relatives advised to get unnecessary surgery I wouldn't be surprised.


I'm not sure what you mean by the doctors being encouraged but unless the doctor ordering the U/S is getting a cut then there is no direct incentive. But I don't know how your system works so I might be wrong.


In some emergency departments, the physicians participate in profit sharing. I know of a few EDs where they add up all the revenue, subtract all the costs, and divide the rest into each doctor's paycheck based on how much that doctor billed each month.


Do you not understand that doctors have levels of management above them? Their incentive could be "Boss wants me to encourage them for X reasons"


This is basically the reason I have Kaiser and have stuck with them for over a decade. The quality of service is shaky sometimes, and there is doctor turnover, and sometimes I have to travel relatively far to see a specialist - but if a KP physician refers me for something, I get scheduled to see someone, then I get it done, and I pay a reasonable copay that I know about immediately. I've never had to haggle with insurance or been surprised with fees later, even for relatively complex surgeries.


I left Kaiser. As far as I can tell, they don't have any doctors. I've been told that if I yell at them repeatedly, they could get me one, but I don't have time for those shenanigans. I went there for a GI issue. They poked my belly and said, "It's a virus". Had I not figured out the issue on my own, it could have become life threatening. Several coworkers know people that have been misdiagnosed and lost loved ones because of Kaiser. It seems to me that Kaiser is an entry level place for new doctors to get some experience. The offices are tiny and everything is rushed.

Yet, I've heard on HN so many people love that place. I can't fathom how that is the case. Even military clinics are decades ahead of Kaiser.

The only positive thing I have seen about Kaiser is that they are an amazing drug company. Each campus has 2 to 4 pharmacies. That must be a very lucrative business.


Goddamn, are you me? I have the exact same story. Minor blood test anomaly, liver ultrasound, 30 minutes, surprise $6,000 bill. Pretty sure it's the same hospital too.


The only thing that would make it weirder is if the initial bloodwork happened to have been also ordered and checked by a doctor from your company's 'health center'.


My wife is scheduled for ultrasound #4 because of pregnancy irregularities. The fact that it's covered by universal healthcare gives me peace of mind in a few ways: I don't have to worry about affording it, I can just worry about keeping my family healthy. I don't have to doubt if the medical experts have my family's interests at heart or if it's just a cash grab.

First pregnancy we had a scare about genetic issues. Instead of wondering where the money would come from, I was able to take time off work and be there for my wife between the phone call and the battery of tests done 45 mins away. Another hour long ultrasound and a sit down with a geneticist in the afternoon. No bills, invoices, anything.

There's simply no reason for capitalism in healthcare to directly involved the patient. At least I believe that to be true.


  There's simply no room for capitalism in healthcare
Yet the very technologies you specifically required in both cases (ultrasound and genetic screening) are direct results of capitalism in healthcare.


Medical Ultrasound was pioneered by a UK university in conjunction with the NHS. Are you giving "capitalism" broad credit for everything in modern society or is there some more specific claim you're making here?


Medical is in bed with the government

https://www.opensecrets.org/lobby/top.php?indexType=s

Heck, if you want to know why something in the US sucks, just look at that list.

Massive government corruption from legal bribery.


This is amazing. The list reads like a "who's who" of the most insufferable sectors of American life. I was surprised not to see auto manufacturers and agriculture in the top twenty, but medicine and telecom have definitely got them beat.


What makes auto bad?


The same kind of regulatory capture dynamics occurring with telecom and medicine. In the case of auto, preventing startup competition by mandating the old and needless system of dealer middlemen.


Not just ER. We went to urgent care with a bean stuck up my sons nose. The doctor spent about 30 seconds getting it out. We were in and out in 10 minutes or so. The bill was $2000.


Should have planted that bean. Maybe it would have grown an entire stalk of $2,000 beans.

In all seriousness, that they are able to charge that much with no upfront warning is pretty insulting. But then again they know they have you hostage, its not like you are going to change your mind and tell the doctor to just leave it in there.


> But then again they know they have you hostage, its not like you are going to change your mind and tell the doctor to just leave it in there.

I hear people make this argument about patients who are bleeding out, and that's one thing. You're not going to suffer any extra harm from leaving a bean in your nose for a week. The nose just dumps out into the back of your throat. Why wouldn't you shop around in that case?


How would you shop around?


Is that what you had to pay out of pocket? With or without insurance?


Unfortunately we thought that urgent care clinic was in-network, but it wasn't. Insurance covered a little bit, but we were left with the majority of the bill. We complained about the high cost and asked for a discount to no avail.


That's an easy one.

- (1) With an admirable humanitarian intention, the government forces hospitals to treat patients whose life is immediately in danger, and figure out later whether they'll be able to pay. If 1/10 people have the means to pay for the treatment they receive, then you're paying for your treatment, plus the expensive life-saving treatment of nine other destitute people who couldn't pay.

- (2) It's a monopoly. If your choice is letting your daughter possibly lose a finger, or taking her to the hospital, you'll take her to the hospital. Because you don't really have a satisfactory alternative.

- (3) It's opaque. You have no idea what treatment she'll need or how much it'll cost going in. They're loth to make promises about this up-front ahead of a diagnosis.

- (4) Because they can. Why would they ever charge $400 when they could charge $4000? The only surprise here is that it's not $40,000 or $400,000 or $40,000,000.


In Japan or Korea, that would've been $50-$100 tops without insurance.

And almost all hospitals are walk-in without appointments, and many big ones have night coverage.

ER? sure, it's there. But only if you have rebar sticking out of your torso.


Part of it is because consumers are completely detached from the price aspect of medical care. Getting an estimate, shopping around? Forget it. It’s a black box.

And, frankly, part of it is because hospitals can’t refuse care to anyone and if they can’t pay, someone else has to.


"And, frankly, part of it is because hospitals can’t refuse care to anyone and if they can’t pay, someone else has to. "

I think that's a cheap excuse they have to rip off everybody else. I would like to see the actual numbers of people who aren't paying and what losses they incur.


It's substantial but doesn't come anywhere near explaining prices. The PDF here has some numbers:

https://www.aha.org/data-insights/2018-01-03-uncompensated-h...

Somewhere in the ballpark of $40 billion dollars a year vs total revenues in the ballpark of $3 trillion. Various aspects of Obamacare had the effect of leveling them off.

There is likely additional underpayment due to Medicaid and Medicare (to the extent those programs are underfunded and operate by mandating care, they are a hidden tax).


That's what mandatory insurance is for. Everyone pays what they can, and gets what they need. Doesn't work perfectly, but allows me to go to a hospital anytime without being broke after.

There's benefit for everybody, which is risk reduction. You actually blame poor people for going to the ER in case of emergency.


It's crazy because the initial idea was, insurers would be more educated buyers and thus better able to negotiate with medical providers. As it turns out, with no skin in the game, they hardly seem to care to negotiate prices at all!


They do negotiate - the prices they’re charged are vastly less than what you would be as an individual.

As far as I can tell the problem is really the big HMOs seem to be essentially managing another companies money, rather than their own, and they essentially get a cut of money going in and out of them.


And the worst thing is that there’s no way to predict the cost. Even if you go to an ER that’s in network (good luck with that in an emergency), you might be assigned an out of network doctor and be charged out of network prices


We've had 2 children in the last 4 years and this concept was foreign to me. Our 2nd child we were billed for an out of network anesthesiologist at an in network hospital. Several thousand dollars in total, I called the insurance after reading online a bit about it. Eventually they said they would "resubmit" the claim for reconsideration. A few weeks later we got an EOB showing we didn't have to pay any of it. The whole experience we shocking to me, I can't imagine dealing with this sort of thing on a regular basis.

Even worse is receiving bills from various providers up to a year later. How are these people still in business?


Anesthesiology is a particularly pathological case, so to speak. You don't choose your anesthesiologist; it's the medical equivalent of a (very important and highly-paid) back-office function. So you've chosen an in-network hospital and an in-network surgeon? Surprise! You may also discover, months later, that your chart was read, while you were sleeping, by an out-of-network physician on call. Surprise!

The American system is literally (literally literally) unsustainable.


How could they go out of business? Any time they need money they can just go through patient records and charge for anything they feel like with very little statute of limitations. Its a license to print money at the expense of those that can least afford it.


Yep...I got an email last week for something for my daughter's birth...which 2 years ago. It was charged to an insurance I no longer have. I met deductible that year so everything was covered and it says I'm paying $0. They could lie about the some missing cost and I wouldn't know where to begin disputing it. If I don't successfully dispute it, it goes to collections and hurts my credit. Is my time worth disputing a $500 bill (it I had to pay it?).

It's a lose lose situation.


Regulatory capture.


Worse - you can get a bill in the mail later for some out of network doctor who looked at a chart without ever interacting with you, in addition to the hospitals charge.


Yup, or a bill from an out of network doctor that consulted while you were under or generally unaware [0]

[0] https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-sur...


My favorite is that the hospital will use the external consultation to charge more for the visit.


Recruitment fee for the out of network you didn’t ask for!


Urgent care or walk-in clinics will likely cost much less. If it's a simple wound, a CVS clinic will work too.

Some urgent care clinics post wait time online so you can find out how to see a doctor the fastest way.


> Some urgent care clinics post wait time online so you can find out how to see a doctor the fastest way.

These are often misleading, though - the clinics that market this way essentially perform triage with docs instead of nurses, so you're technically seen by a doc quickly. Time-to-discharge would be a far more useful data point.

They're also often marketing like this because they're standalone clinics that are out-of-network for major insurers in the area. https://khn.org/news/surprise-that-urgent-care-center-may-se...


For the past three weeks I’ve been going through a flare up of an autoimmune neurological condition. It’s been terribly painful. The treatment is high dose IVIG or plasmapheresis. Unfortunately my insurer doesn’t want to pay. I’m told if I had almost any other insurer they would. This has left me trying to find out just how much I’d have to pay out of pocket for either of these services. But absolutely no one knows and no one will work it out for me. All I know is it will be somewhere between $30k and $60k from various guesses that have been offered.

Pricing in the US health system needs regulation. The best option would be all providers must charge the same rate to all customers. Then I could look up the price and know it’s been prenegotiated by big insurance companies.


I get IVIG 3x / week for a primary immune deficiency I’ve had since birth. For my dosage, it’s billed weekly at a rate of ~$32K of which my insurance company pays around ~$3K.

I hit my max out of pocket the first month of each year and the rest of the year is “free.”

I know that all the IVIG pharmaceutical companies offer a “I can’t afford this” option if you’re going out of pocket.

Good luck, it’s stressful to get but it’s a miracle blood product for those who need it.


"The best option would be all providers must charge the same rate to all customers. Then I could look up the price and know it’s been prenegotiated by big insurance companies. "

This should be number one.


What would justify such a law, in a free country like the USA? Even socialised medicine countries can't force private providers to charge constant rates to their private clients.


The practices espoused here confuse me quite a bit (essentially, variants of not being quoted a price before a thing happens).

In the UK it's common to, say, go to a pub and buy a pint. It's not usual to ask for the price first. It's possible a bar could decide to quote me 500 quid after pouring. I'd obviously decline and walk out.

How is it any different in the healthcare case? If you've made an honest effort to determine a price, been told it'll be about X, and then receive a bill for 10x, it sounds like a scam that cannot be enforceable.


You forgot the part about forcing you to sign paperwork saying you'll pay everything insurance doesn't before you see anyone.

That's how I went from being told I was only getting charged $100ish and wound up being forced to pay $600.


Heh, funny they brought up the rabies vaccine anecdote. I was jogging and had a bat fly into my eye one night. This was during a period in my early 20's when I didn't have health insurance. My bill was around $14k for the immunoglobulin and vaccine series.

I paid somewhere around $2k out of pocket for ER fees. There was a program through Sanofi Pasteur and the CDC to pay for it for people under a certain income threshold. Seems it's bad press if Americans catch symptoms of rabies and die, since prevention is straightforward... and it is such a deadly disease.

The kicker was, around a year after this... the hospital reported me to collections for nonpayment of the full amount. I begged the guy that I submitted the application to, to provide me with a record of being covered under this program. Thankfully he violated HIPAA law and did it. Provided me with a complete report of everyone paid under the program that month.

The hospital's response was to tell me to immediately destroy the document, citing privacy law, and to tell them where I got it from. I explained that I would not be doing that, and that I would go public with the situation to as many sources as possible. The next day the hospital had a meeting with their vice president and the head of their pharmacy department. Within the week, I had collections removed from my credit reports.


Anecdotal story, a few years ago my dad had a heart attack. He was self employed, living the american dream so no insurance. He had to stay 2 nights plus ambulance ride. Total bill ~80k. I kid you not, 3 days after he got out my mom shattered her wrist and was taken to emergency surgery. ~40K. They wracked up a bill slightly less than their mortgage in under a week.

Of course they could not pay and the hospital dropped it down to something affordable over a long period of time. How could the hospital expect anyone to pay either of the bills? Don't get me wrong, hospitals and doctors do amazing things and deserve to get paid well, but their has to be some sort of reality applied to the billing process or they are just breaking people.


  living the american dream so no insurance
Since when does "living the dream" mean choosing to go uninsured?


Living the american dream as in being self employed and attempting to make your mark. America reveres the self starter and the entrepreneur. Unfortunately for small business owners that can often mean not being able to afford insurance. They did not choose to have no insurance, they were poor. Perhaps life choices led them to being poor but to suggest it was a cognizant choice is a little disingenuous.


"living the american dream" has indeed started to be used rather sarcastically in foreign parts, for exactly this reason.

Your dream, everybody else´s nightmare.


A similar motivation got a friend and me started with pricepain.com - but the ACA made us take a step back and see if anything changed / got better... apparently not. Though some of these state bills that try to force more transparency have since pushed the topic a bit further. Still so far from a market place.


Checked out the site, very cool concept. Obviously needs some polish but the idea could be very monetizable if you can get traffic. Nice work.


That’s easy - medical debt isn’t written off by bankruptcy. So they’re pretty much guaranteed unending money.


Source?

“Medical debt can be completely discharged if you qualify for Chapter 7 bankruptcy or you can pay it over three to five years through a Chapter 13 repayment plan”

https://www.thebalance.com/tactics-to-deal-with-medical-debt...


Ok - I’d swear when I moved here I was told that it was excluded from bankruptcy proceedings (much like student loans) - maybe I misunderstood?

Anyway, I’d directly correct my comment but it’s been too long for edits apparently :-/

Upvote the replies :)


At least in the USA, this isn’t true. Medical debt can be discharged in bankruptcy.


Parents were US based so Bankruptcy was an option. In the US to the best of my knowledge the only thing not discharged in a Ch. 7 is student loans and debt obtained fraudulently.


Just nationalize the whole damn thing already.


...and make it 15 times as expensive, unfortunately.


This is the exact opposite of the truth. The US spends a disproportionately high amount on health care compared to other industrialized nations, and receives worse outcomes from that expenditure to boot. See https://www.healthsystemtracker.org/chart-collection/health-... for details.


I consider myself a "pragmatic libertarian", and by "pragmatic", I mean I'm in favor of legislative intervention when the free market often goes awry. Examples of this would be combating monopolies (since I don't want feudal system 2.0) , preventing immoral practices (like child labor), and controlling prices when there is no competition at work, such as utilities. It seems that with hospitals, there effectively is no competition-driven pricing pressure due to unpublished pricing. This seems like a place ripe for legislative intervention... but perhaps the medical industry is so bad that it would be better to just nationalize it.


The US government has put in place extremely heavy barriers to open a medical care facility. If we were to allow people to open facilities that compete with hospitals, we would very quickly see advertised prices and dramatic price drops. The medical cartel and all its bizarre non-market activities are a result of the existing legislation in place.


  The US government has put in place extremely heavy barriers to open a medical care facility
That's not true at all. The federal government wouldn't gave any reason to intervene unless you end up falsely billing a Federal program like Midicare, Medicaid, or VA.

The reason for consolidation in ERs is cost -- uf you run an ER, you are obligated to treat anybody who cones in without regard to ability to pay. It's a money pit in many urban areas.



Hospitals in the US not only benefit from unpublished pricing, they also benefit from the situation of customers.

A lot of their customers will be unable to compare multiple hospitals and "shop around", so to speak. Either because their conditions is life threatening, they're actively dying or they're no longer responsive. The ambulance, in any rational scenario, will drive you to the closest hospital in terms of time-spent-driving

So from a corporate perspective it's perfect; the customer arrives and you're legally obligated to start spending money while they are likely unable to object and then you can bill them for it.


The medical profession's billing practices make used car dealers look reputable.


I love that Kliff gives a shout out to Kaiser Health News’ Bill-of-the-Month feature (https://khn.org/news/tag/bill-of-the-month/), which is a really similar project. I wonder if these two projects were independently inspired? Either way, totally a good thing to get more public visibility into medical billing.


Standardize the bill format across all providers, and provide EDI billing option, or a digital copy, and then we have something very easy to parse and store and make comparisons. Barring that, develop OCR parser. There's probably just a few programs that hospitals use that generate the bill paper so most formats could be profiled.


> If you are bitten by a raccoon, you can’t really decide not to get the rabies vaccine. It’s literally a life-or-death situation. But the price is incredibly high. We had a bill from someone who had gotten a rabies vaccine at an emergency room

What the... I'm pretty sure vaccines only work to prevent illnesses and are very much useless to treat them. I mean they're supposed to be small quantities of the virus or bacteria that causes a given illness to train the immune system to defend itself. Why would you add more of the rabies virus when you might potentially already have more than you can handle after being bitten? I thought she was just giving a bad imaginary example, but she says she "had a bill from someone who had gotten a rabies vaccine at an emergency room". Could she have misinterpreted why the vaccine was administered? but why would anyone need a vaccine in an emergency?


This is referring to postexposure rabies prophylaxis (PRP); see https://www.cdc.gov/rabies/medical_care/ under "Postexposure Vaccinations":

> Rabies postexposure prophylaxis consists of a dose of human rabies immune globulin and rabies vaccine given on the day of the exposure, and then a dose of vaccine given again on days 3, 7, and 14.


Rabies is a slow moving infection that hides from the immune system and usually doesn't become lethal until it hits the central nervous system. The vaccine stimulates immunity before the infection becomes serious.

Modern treatment also includes antibodies that will immediately work against the virus.


The rabies vaccine is usually only given post-bite, unless you’re unusually likely to be bitten (e.g. veterinarian).

If you don’t get the rabies vaccine shortly after being infected, you will almost certainly die.


No, that's how rabies vaccines are typically used. You get them after (potential) exposure but before the disease kicks in. You can also get it in advance -- they last about 10 years -- but this isn't typically done, presumably because most people don't expect to get bitten by wild animals very often.


> If you are bitten by a raccoon, you can’t really decide not to get the rabies vaccine. It’s literally a life-or-death situation. But the price is incredibly high.

This, to me, is a perfect example of why healthcare should be subsidized by the government (either directly or through a government-backed insurance plan that you receive as a fallback).

Health isn't a good or service you choose to purchase. Demand is perfectly inelastic and everyone is subject to emergencies no matter how healthy their habits are.


I've moved to the US from Australia, and the medical system here is pretty terrifying. People are always discussing "how to fix the homeless situation" here in San Francisco, but as I wander the streets I can't help but wonder how many of these people were bankrupted by a medical emergency.


> This, to me, is a perfect example of why healthcare should be subsidized by the government (either directly or through a government-backed insurance plan that you receive as a fallback).

Nah, this doesn't really work in the US. All it does is to funnel money into the coffers of the companies that are creating the problem in the first place.

There has to be some more regulation – companies need to be forced to be more transparent in their pricing, as well as to limit the markup they can add so they can 'negotiate' down.

And then, there has to be some competition, as in many places people have no alternatives. That competition could even be with the government itself, in the form of government-run clinics or hospitals. This works in Brazil – you don't have to carry any form of insurance whatsoever if you don't want to. For major issues, you are covered just fine – trauma surgeons in the public network are among the best (at least in big population centers), and are often the same doctors that practice in private hospitals. My mother also got top notch cancer treatment for free. The last one is more location-dependent though.

Even as a foreigner, should you get in a car crash or something, you'll be patched up nicely and not pay anything.

Now, if you got a non life-threatening issue, then it can be a problem, as even the big hospitals may lack resources for everybody, so your appointment may be scheduled far in the future. To counter that, you can choose (and most middle class people do) to carry private insurance and not burden the public network. Private insurance is then cheaper that it would otherwise be because there is an upper limit on how much they can charge you – go too high and many people will drop insurance and private insurers (plus hospitals and clinics) would lose customers.

The government will also provide essential medication for free (diabetes, high blood pressure, etc). It doesn't matter how high your income is.

It is really not supposed to be rocket science. If a third world 'developing' economy can do it, with a much lower economic output, then the US could do it too. But not if it's a <whatever>care program that's allowing companies to continue charging $100 for a band-aid.


> This works in Brazil – you don't have to carry any form of insurance whatsoever if you don't want to. For major issues, you are covered just fine – trauma surgeons in the public network are among the best (at least in big population centers), and are often the same doctors that practice in private hospitals. My mother also got top notch cancer treatment for free. The last one is more location-dependent though.

As a Brazilian, this literally made me laugh out loud. Brazilian healthcare sucks balls. Even the US does a better job at it.

I'll just post this one article¹ about the guy who went to the ER in Rio to have one leg amputated and the doctors amputated the wrong one...

__________

1. https://extra.globo.com/noticias/rio/paciente-foi-preparado-...


Having a public option is the best way I think. In Australia, there is a private system and private insurance is fairly common, but when you can get generally as high or higher quality treatment free of charge in the public system, it makes it a lot harder for the private hospitals to charge crazy prices.

The only downside is that given underfunding there are waiting lists for a lot of ‘elective’ things so if you don’t have private insurance you might wait up to, say, a year for a hip replacement whereas you could get it done within a week or two privately. So I pay $1K a year for private insurance just in case.

But in our large cities the hospitals and emergency departments are as good as you’ll find anywhere so I always go to a public hospital in an emergency. You can even use your private insurance there so the state system gets some benefit.


Obamacare provides that, at least in states that have accepted Medicare expansion. The story in other states with state-sponsored high risk pools seems complicated and arguably doesn't meet your criteria.


That sounds great, but our US government has failed us for 30 years on healthcare.

Not sure why anyone thinks that tax dollars would make the problem better.


Because it works fine in other places. The US government isn’t uniquely incapable. We just have to stop electing people whose major goal is to make it fail.


Something like 40% of Americans already receive "government health care" in some form or other. Any government employees, military, police, teachers, fire fighters, and so on, receive health care. Anyone who qualifies for Medicare does.

Just push that number to 100%.


The funny thing is that a lot of Medicare recipients or soldiers are adamantly against "socialism" in the form of government healthcare.


Fox News is a dangerous drug.


No. Politicians favoring policies that deliberately exclude the poor have failed us for 30 years.

We have never been able to make extensive progress on healthcare because voters elect politicians that fight against government health insurance (even fighting against spending government money on insurance for the disabled and elderly).

Free market ideologues have failed us, not the government. This is painfully obvious if you've ever been in another civilized country (Taiwan, Canada, UK, etc.).


Let's see, Republicans are for denying healthcare to people who can't afford it (a free market). Democrats are for ensuring access to healthcare for everyone, including those who can't afford it (using taxes, so everyone who can pay pays and the rich cover the poor).

It's pretty fucking cut and dry at this point. We can dispense with the philosophical grandstanding.


I can really relate to this problem as it also exists in scientific chemicals and supplies.


While it wouldn’t be my first go to, I have to wonder if complete 100% deregulation would be better than what we have today.


Why would you even entertain that thought? When has anything even remotely the size of healthcare been 100% deregulated and successful?

Why go for such far out nonsense like this when there are perfectly good examples of successful healthcare models in other countries.


> When has anything even remotely the size of healthcare been 100% deregulated and successful

Plenty. The electronics market huge and barely regulated. The hardware for smartphones are cheap and amazing, televisions, etc. Automobiles are huge and relatively unregulated. It's not a great comparison, but your question was bad.

The size of the industry has nothing to do with whether or not it should be regulated.

The reason to entertain this thought it because deregulation is part of the solution to high health care costs.


> electronics market huge and barely regulated.

"Electronics market"?! That's like calling healthcare the "service industry".

> Automobiles are huge and relatively unregulated.

This is laughable. Air bags, seat belts, emissions, break lights, tires, and more. Cars are one of the most regulated industries out there. From how they're built to how they're sold (manufacturer can't own the dealerships).

> It's not a great comparison, but your question was bad.

Your attempt to add something meaningful failed.


We'd be bailing it out in 5 to 10 years, guaranteed. That's what happens when utilities that should be public, are privatized.


I've wondered the same thing. It seems like we have the worst of both systems.


As the person who submitted this story, I have a question: why was Sarah Kliff’s name removed from the headline?

I submitted it with the same title it carries at CJR, which includes her name. The story is a profile of her and her work, so removing it makes the headline less informative, not more. And she’s not a celebrity, so mentioning her by name doesn’t make the headline any more clickbaity than it would be without it.

Is there some reason HN believes she deserves to have her name struck out of the title of her own profile?


We often remove names from titles, because HN works better when the focus is on content rather than personalities.

https://hn.algolia.com/?query=by:dang%20content%20personalit...


But it's an interview with a specific person, focused entirely on her work. The entire content of the article is tied to who she is and what she does. Removing her name from the headline just obliterates the value of the headline as a way to determine what you're going to see when you land on the other side of the link.

This is a misguided policy and I hope you reconsider it.


Just want to note that I'm on the other side of this -- I think this is a great moderation policy for this specific forum.

Including names seems like a good way to:

- let people exercise their people-related biases

- encourage gaming of the system by appealing to authority

- encourage gossip-y headlines "X's techchruch interview whatever whatever"

> Removing her name from the headline just obliterates the value of the headline as a way to determine what you're going to see when you land on the other side of the link.

I'm not sure I agree with this at all... What she did is what's valuable right? When I clicked that headline, I expect to see something or some process that is actually bringing transparency to ER prices.

Also at the end of the day HN isn't a democracy :), but I think I happen to fall in the majority here (or at least in line with what was decided).


You forgot to remove the name from this post: https://news.ycombinator.com/item?id=18295942 ... or is Tesla not a name?


It's obviously not a personal name in this context. Nor is any moderation practice absolute. Please don't post frivolous nitpicks.


So if you talk about what a person does, you can't say their name, but if you talk about what a company does, you can? ok, got it. And if it's a known person, you can also say their name. How many exceptions to this "rule"?

ie: "Google paid Andy Rubin $90M while keeping silent about a misconduct claim"

A frivolous rule for lack of a better term...


Same thing happened to me, where the title was changed from "Java Creator James Gosling: Why I Quit Oracle" to "Why I Quit Oracle".

https://news.ycombinator.com/item?id=15163932

It doesn't make sense.


Your example (taken with this one) actually makes it make more sense though -- seems like they remove names from articles.

I don't know why the mods have chosen to do that (I'm not going to speculate because there could be lots of reasons), but at the very least they're doing it consistently.


well, it's a very different thing if the title is "Why I quit Oracle" or "Java Creator: Why I quit Oracle" and when it's all about removing name the consequence would have been a meaningless "Why I quit".


I find HN borderline propaganda.

Its the only educated place on the internet, but the front page and comments is what HN whales decide.


I would save the word propaganda for what it's meant to mean, and not for dissatisfaction in the bias of a platform.


You're not giving the community enough credit. We moderate the site, but we certainly don't determine it—and if we do something the community doesn't like, they are anything but shy in letting us know.


[flagged]


None of that is true.

Since you either can't or won't stop posting like this, we're not going to unban you after three months, because clearly this problem is just continuing. But if you can go three months without posting any abusive, off-topic, meta comments, we'll consider it. In the meantime, we're continuing to unkill good comments that you post, if the community hasn't vouched for them first.

We detached this comment from https://news.ycombinator.com/item?id=18289284 and marked it off-topic.




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