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Your New Medical Credit Score Could Deny You Care (thetoolsweneed.com)
337 points by kaxline on Feb 6, 2020 | hide | past | favorite | 387 comments

To give a real-world example of why this is problematic: my wife recently had surgery, and they had a follow-up a month later to remove a stent. Even though she was insured, a slew of wholly unintelligible bills from various departments at the hospital followed. When she showed up to have her stent removed, the director of the hospital's billing department told her that all past bills must be payed before they are able to remove the stent: this was a blatant lie, and the doctor overrode the decision in about 30min. Now after speaking with the nurses about this, one reveals that the collections department has a whiteboard game going on in the office where they write up their names and have an ongoing competition over who can extract the most money from patients. The hospital and its services are under no obligation to provide accurate pricing until ipso facto, and the pricing can often be changed because it doesn't stand up when placed under scrutiny. Does anyone believe a system like this is capable of producing an accurate "score"?

I just learned, to my surprise, that pricing and transparency changes may go into effect next year.

Forcing hospitals to disclose prices:


Though the hospital industry is fighting it, so we'll have to see if the rule survives.

I'm completely onboard with price transparency, but am skeptical as to the utility of it to the consumer. I suspect a lot of people will get "oh, we thought it'd be X, but it turned out to be Y, which is 3x the price" sort of scenarios.

I'm sure "colonoscopy, clear" and "colonoscopy, with removal of polyp and pathology on it" will have different prices, but you won't know which it is until after the procedure.

The pricing game in the medical field is not that though, it's just a ridiculous tradition. They give hugely inflated prices then accept a fraction of that from insurance companies because it was their real price anyway. If any uninsured individual (e.g. with good credit they want to protect) gets ensnared by this and ends up paying their 3x number it's totally unfair.

when they are selling similar procedures for elective or cosmetic surgery, like plastic surgery patients, the prices they ask are much more competitive.

i wonder if they inflate the prices to inflate their write offs come tax time.

No they can only write off actual costs.

I'm pretty sure a good accountant can drive semi-truck full of large bills through that.

I dunno, the reality is that we have mark to market accounting https://en.m.wikipedia.org/wiki/Mark-to-market_accounting

Some how automotive repair, general contracting, and many other industries have been able to solve this problem.

It's baffling how medicine can't produce accurate estimates. Sure, there are edge cases and differences between patients. However, every surgeon has a rough idea of how they're planning to do a procedure. They've been trained and practiced on it many, many times.

I have a torn meniscus. The doctor can happily tell me how easy it is to clean up and exactly what he'll do to fix it. He certainly knows what the risks are and potential complications.

Why he can't document that prior to surgery, I have no clue.

Shit... my vet can do that. They saw my cat, estimated the surgery necessary, the length of care in an ideal and not-ideal situation, cost of potential extras based on possible complications or additional needs such as full sedation.

I was given three estimated prices that ranged from $800 to almost $1800, with an expected final cost of $1000 being the most likely outcome. Surgery came out to $975.

And this is with a non-communicative and uncooperative animal, not a human.

Not to belittle what a doctor does, but I totally agree that a doctor should be able to estimate the most likely and most extreme situations and gauge the range.

When one of my pets had surgery a few years ago, the surgeon's office actually sent us back a bit over $500 a few weeks afterward since it went smoother than expected.

The extremes are much wider in human medicine, though.

No one's going to spend a million bucks on a severely premature puppy, but we will for a human, regularly.

"This might be $500, or $250,000" isn't super helpful.

True, but it should be possible to say the average cost is $10,000 according to the last N similar operations. In the event of something abnormal occurring, you might require an extra $25,000 for this and that, and if the shit hits the fan, expect $250,000 for extreme lifesaving effort.

That's why private healthcare makes no sense. You just cannot attach a price tag to human life no matter if it's premature birth or a child with leukemia or routine surgery like an appendicitis. The only sensible way to run healthcare is by socializing it.

Socializing healthcare doesn't eliminate the cost calculus, it just shifts it to a different group of deciders. It feels icky to attach a price tag to human life, but in a world where resources are not infinite, and healthcare requires resources, those decisions have to be made somehow.

Most countries with socialized healthcare and comparable (sometimes lower) GDP per capita to the US have higher life expectancy, lower expenditures for both the state and the citizens, and a better relationship between healthcare and the citizens. It's a fact. No, death panels aren't a thing. You die when your heart stops beating, period.

Really, reading all the stories on this thread is insane when I think my wife and I could just walk into a hospital and get out three days later with a baby without having to worry about paying a buck. Same when my father went to the ER and came out over a month later after an emergency heart surgery, a week in the ICU and two weeks of physiotherapy.

If a govt decides to restrict the amount of MRI scanners hospitals can have in a region for budgetary reasons, forcing patients to wait longer or only get them when the risk is higher, an economic decision has been made regarding the value of your life. A well-known stat that was already true decades ago was that Orange county california has more MRI scanners than Canada (population difference about 10x). And it isn't just a gimmick, far more imaging is done in the US than other countries. The US probably puts a higher value on life than any other country, which is part of the cost problem.

And considering that 90 percent of costs are borne in the last year of life by dying patients, it's naive to think there won't be something like death panels in some form, whether it's that explicit or not. Simple economics says price fixing creates shortages.

It’s naive to think the USA doesn’t already have death panels. People die after unsuccessfully fighting their insurers for coverage already.

The USA doesn’t put more value on life. We put more costs on it, but our outcomes aren’t meaningfully better.

I don't see that your case has been made. I see more willingness to perform costly interventions as a clear example of how more value is being placed on lives. As for outcomes, you can argue a CYA approach where they try everything they possibly can isn't necessarily more effective, but I disagree that you can dismiss it as proving less value has been placed on life. I also distrust stats about outcomes given how politically charged the topic is. The most obese country in the developed world comes in with a bias towards worse outcomes already.

By the way the vast majority of people who die in the US are an a socialized medicine system at the time (e.g., medicare).

Either way though, yes, of course there's "death panel" behavior or other cost-controls which effectively lead to the same result (e.g. doing harm through inaction rather than direct action), in any system.

I agree. I would say the only reason providers are not cost estimating is because they don't need to in order to get business.

For automotive I'm typically getting a problem diagnosed first, then after diagnosis, I'm agreeing to a price for a fix. This is the norm for that industry.

For a walk in appointment for a rash, I'm agreeing to a fixed visit fee, PLUS signing that I agree to pay any charges my insurance does not agree to pay. The true costs can (and should) be computed by the provider, so the only true unknown in that equation is what Insurance will cover. THEN the provider (wanting to cover their bases) is putting that risk of not getting paid by insurance, back onto the patient.

I like to think we're 1 killer app away from a shift in consumer behavior here to change the expectations

I'm in the Kaiser Permanente system in California where the hospital and insurance are one entity. Since everything is pre-negotiated, most times its just the copay. So under my plan, for example $20 for primary physician visit, $40 for specialist visit, $20 for blood test visit and $100 for emergency visit. Having one entity involved simplifies things.

Kaiser utilizes the Experian program.

They can totally do it. It's only a problem because they want it to be a problem.

I worked in Australia for a little and had a couple of doctors visits (mole removal, fractured rib). They were able to tell me, on the phone, cost for a consult, removal, xray, check-up, etc. I was able to pay for the mole removal + biopsy with cash...

I'd love to see something like this in the US:

"Assuming a standard hernia surgery, you're looking at $3000 base for the procedure, with another $300-900 for consumables. 91% of surgeries are at or under $3500, 99% are under $4100. Though patients can go home the same day, 24 hour of hospital bed are covered under the fee; additional days in hospital beds are available at [X] rate. In the event of serious complications, consumables, beds, and misc. are billed at [Y]."

The very existence of insurance allows this insane inflation to occur. It completely obscures the need to to price things accurately.

Not really, insurance must exist because healthcare expenses aree simply too unpredictable. And anyway places with single-payer healthcare spend much less than the US even though they are effectively a state-run insurance. Heck, the same applies to Medicare.

Only in the US, in India, every medical procedure has a cost attached. 90% of the transactions are cash, and it would not work otherwise.

While I understand your healthy skepticism, I would be a bit more bullish given this example from 2013:


One thing is for sure, any improvement to price transparency is a boon to competition.

> Some Hospital administrators accuse the surgery center of cherry-picking the healthiest and wealthiest patients.

You probably won’t see this place put a fixed cost on a 26 week preemie like my twins.

>I'm sure "colonoscopy, clear" and "colonoscopy, with removal of polyp and pathology on it" will have different prices, but you won't know which it is until after the procedure.

Considering that colonoscopies are not urgent you'll likely elect to have your butt probed at the clinic that doesn't have a massive price discrepancy between removing something and not.

I really hope the price transparency rule works as alleged. I'd be totally unsurprising if the entrenched industry finds some way to neuter it but I'm hopeful.

> Considering that colonoscopies are not urgent you'll likely elect to have your butt probed at the clinic that doesn't have a massive price discrepancy between removing something and not.

For most people they have insurance and for them to get any kind of help paying they need to be working with an in-network provider. There is no meaningful market here even for elective/non-acute procedures.

> am skeptical as to the utility of it to the consumer.

Yeah, me too. It definitely seems like more of a way to look like the industry is doing something without actually reducing costs to the end patient.

Our daughter went to the ER and was administered ibuprofen. We got an itemized invoice. Insurance paid $9 for one pill.

So going forward, I guess I'll be able to ask how much the pill will cost, then...haggle? Tell them not to give my daughter medicine?

Just seems like we're going backward...

> I'm sure "colonoscopy, clear" and "colonoscopy, with removal of polyp and pathology on it" will have different prices, but you won't know which it is until after the procedure.

Which is expected, and kinda ok. At least, if you do a colonoscopy and there's nothing else, no complications, it would be that price.

Hospitals are protected businesses in the U.S. To build one you need a "certificate of need" in most jurisdictions in the United States. I.e., they are government-granted monopolies. They behave like government-protected monopolists do: they rent-seek.

If you want to see affordable hospital care you have to see the protection removed and competition allowed and encouraged.

This is happening to some degree already. Nowadays we have unprotected, standalone ERs, urgent care clinics, and specialist clinics. But it's not really enough, not yet.

> Nowadays we have unprotected, standalone ERs, urgent care clinics, and specialist clinics.

In your example the tail wags the dog. Hospitals are mostly obsolete. You have outpatient surgery in strip malls because hospital beds are capped and reduced, and Medicare began refusing to pay for bad outcomes, which are more common in hospitals.

The government-allowed monopolies are the sprawling health networks the turn medicine into a sales funnel. They are labelled with hospital branding, but the monopolist actions are all about doctors. For example, in my region, 90% of renal doctors work for a single practice.

Urgent care is a whole other animal -- that's all about the reducing standards and addressing supply shortages of primary care doctors caused by restricted supply (there are caps) and higher salaries in specialities.

Depending on what you mean by "beds are capped and reduced", the opposite may be true: my understanding is that one of the major inefficiencies in US health care is that we have an unusually high vacancy rate in hospital beds. Addressing that problem is the central argument of Certificate Of Need laws.

Everyone fights hospital closures, so it's really hard to do. It's sort of like how everyone hates Congress, but loves their congressman. Certificate of Need addresses growth.

IIRC in New York, they closed something like 20 hospitals, with 10-12 in NYC. In my area (NY, but not NYC), there has lately there have been a bunch of hospital "mergers", where the lesser hospital gets converted into a sort of outpatient surgery site with urgent care, or an ER without longer term care.

I'm not even saying that CON laws are good; I have no idea. I'm just saying that the premise behind them appears to be accurate, and the argument that they are nationally responsible for lack of available hospital beds seems flawed (there are regions where there aren't enough vacant beds, but that doesn't seem to correspond to CON laws, and nationally the statistic is in the other direction).

> just saying that the premise behind them appears to be accurate

There's only one way to find out.

Indeed, we're finding out as we speak, because all those new ERs and urgent care clinics and specialist clinics and birthing centers, they did not need CONs, so they got built. And they got built by people who risked capital to do it. And it seems to be working out. I know I'm not going to any hospital's ER if something happens to me, and neither is anyone in my family -- we know the score on pricing and billing.

So the free market has found a way around the protectionist regulation of hospital construction. Is that even a surprise to anyone?

It's not working out. It obviously isn't. We pay multiples of what other countries do, and one factor in that is the inefficiency of how our health facilities are deployed.

> The government-allowed monopolies are the sprawling health networks the turn medicine into a sales funnel.

Crazy levels of regulation is one of the most sure-fire ways to make monopolies or oligopolies inevitable by creating huge economies of scale. The red tape burden is much easier for larger players than smaller ones. They can keep a staff of dedicated pencil-pushers that know the industry, its regulation, and how to deal with the bureaucrats.

With less regulation and no more "certificate of need" nonsense, it would be not only easier for competitors to start but just as importantly easier and more economical for them to remain independent. The government has created the environment in which monopolists thrive and the free market is stifled; people then complain and turn to the government to fix it? We're in the insurance mess to start with because of wage & price controls. Even the EU makes it easier to try new drugs, at least from a regulatory standpoint. The market is smarter than any pencil-pusher or congressman; let it do its job. Corrupting it is what got us here in the first place.

This ignores the fact that markets fail under certain circumstances. Removing regulation would not remove the fact that a significant portion of healthcare is a natural monopoly[1] due to the fact that a significant portion of the population cannot "shop around" when incurring medical costs and the starting costs to enter the healthcare market as a provider are high: provide adequate facilities, hiring staff, purchase of equipment

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

Medicine is pretty much every economist's go-to example of inelastic demand. And the go-to thing to ignore when saying "markets will fix everything".

Not all medical care is emergency care, and after a while folks learn which provider is a better value. They hear other's outcomes as well. Even if they don't choose perfectly every time, word gets out eventually.

Pricing transparency is necessary to the process, however. So, the assertion that folks "can't shop around" is exaggerated and about to become less true with the transparency law.

I think US dentistry is probably the best example of US heathcare, but it’s unusual in several ways. Most notably it’s not been part of standard heath insurance coverage and it’s mostly small independent practices. Together that’s keeping prices reasonable and bureaucracy to a minimum.

You get some shopping around, but many people will stick with the same dentist for years if not decades.

Nice, a down-vote without addressing the content and the reference to support said content. But hey, what do actual economists know about markets and monopolies.

The downvotes are flowing freely nowadays on HN. I think the downvote threshold could use a massive increase -_-

Haha, down-vote to that one too. Feel free to address the original criticism, I'm waiting to have an actual debate instead of an naive emotion fueled down-vote fest.

Got it, you're admitting you were wrong through your actions. Thank you for that, it's refreshing to see people that are willing to accept a different viewpoint and adjust their own beliefs when new information is provided.

I upvoted your first comment and downvoted the next 3. It’s not a question of what your saying, but how your saying it. Try actually reading though the guidelines and thinking about what makes a comment worth reading. Ex: Please don't comment about the voting on comments. It never does any good, and it makes boring reading.


You're right I got carried away there. The up/down vote system amuses me a bit too much sometimes. I'll file this one away to remember in the future.

I didn't downmod your original comment; even had I wanted to, I couldn't as it was a reply to my own (same applies to your reply to that one). You really can't believe that more than one person disagrees with you? I did downmod the second two because they were snarky and rude; someone not replying instantly is not an indication of abandoning debate. It's not as though there's a notification system on HN, and people sometimes get busy.

With respect to your natural monopoly argument, they typically occur when there are very high start-up costs. There are other cases where economies of scale are significant, but very few where they are infinite. Even Amazon, a company that occupies much of the e-commerce market and is well known for its highly-efficient supply chain, is having trouble maintaining them indefinitely. I think we're in violent agreement that the high start-up costs of medical practices and hospitals prevent competition, and I was advocating for removing most of the regulation on the medical field. Another example: the AMA is a horrible gov't-sanctioned monopoly that hugely increases medical costs; most procedures can be done by someone with a few months' training (see the military). Healthcare is one of the few industries that hasn't mastered "mass production" of procedures in spite of the fact that many surgeries are similar.

> healthcare is a natural monopoly due to the fact that a significant portion of the population cannot "shop around"

Except that doesn't mean there is a natural monopoly. If there are a dozen hospitals and you get in an ambulance you'll get rushed to the nearest one that has the right doctors (most major hospitals have most urgent stuff covered). While consumer choice is probably reduced here, it's not as though the ambulances all take patients to a certain place.

The point I think you were getting at is that most people have limited choice because they are often treated in time-sensitive situations. However, about two percent of healthcare spending is on such emergency care [0]. Most procedures give people at least some time to find options, get second opinions, etc.

Natural monopolies (aside from those caused by regulation) are caused by lower long-run average total costs than someone else, industries where economies of scale are nearly infinite. Even those that can't be "disrupted" by building a competitor that sells the same product can be supplanted by newer technology. For instance, many people and companies are exploring setting up solar-powered, battery-backed microgrids that would create serious competition with the government-sanctioned monopolistic utilities. In other words, while high start-up costs will certainly delay competition, they won't prevent it.

> I'll file this one away to remember in the future.

Care to elaborate?

[0]: https://www.politifact.com/factchecks/2013/oct/28/nick-gille...

First, thank you for responding and second don't take my idiotic self-amusement with the downvote/upvote nonsense as anything other than my own failure in that moment.

> Care to elaborate?

This was in response to the comment by Retric calling out my idiot behavior. Which, I agreed with.

> Another example: the AMA is a horrible gov't-sanctioned monopoly that hugely increases medical costs; most procedures can be done by someone with a few months' training (see the military). Healthcare is one of the few industries that hasn't mastered "mass production" of procedures in spite of the fact that many surgeries are similar.

Very good point. Reducing costs through other measures definitely are a valid approach. This is one I agree with.

>The point I think you were getting at is that most people have limited choice because they are often treated in time-sensitive situations. However, about two percent of healthcare spending is on such emergency care [0]. Most procedures give people at least some time to find options, get second opinions, etc.

This is true in part. However, mobility and access are often very limited to a significant portion of the population due to ability to travel, lack of time to take off work to travel, as well as the type of insurance a person has. If our society was more inclined to provide the ability for people who financially would struggle if they took a day let alone multiple days off of work to shop around to reduce medical costs this would make sense. But that is not the society we live in.

> mobility and access are often very limited to a significant portion of the population due to ability to travel, lack of time to take off work to travel, as well as the type of insurance a person has.

True enough. I do think allowing a market to develop will give us the tools to shop around with less hassle, e.g. online ratings and comparison based on hard data people will have to disclose to compete in a free market. Similar with transportation, changes in the way we get around will change this and make life a lot easier, hopefully.

With first hand knowledge this is correct but much more technically complicated at the ground level than you would ever believe.

“The hospital and its services are under no obligation to provide accurate pricing until ipso facto, and the pricing can often be changed because it doesn't stand up when placed under scrutiny”

That’s what’s driving me crazy. No other business can make up charges repeatedly and when found out, say “oops” and change them a little. In what way is this not fraud?

Try being uninsured. I had a woman come into my room (!) during my ER visit and ask for payment. I asked very clearly if this was covering the cost of the visit. I made it clear I understood the doctor and xrays would be billed separately. I paid. It wasn’t cheap.

I got the bill from the doctor. It was reasonable and I paid promptly. I got the bill for the X-ray and it was ridiculously low to my surprise. It was paid immediately. In my mind, I was done.

Then I started getting phone calls from a broken machine. Please call <actual silence> at <more silence> about your past due amount of <~$4000>. I assumed they were spam, but after about 10 of these calls over three days, the message variables were randomly filled or not on any given message. At no point was the message clearly about my hospital visit identified, but I figured it out by the phone number and the name of the parent company.

At this point I hadn’t even been mailed a bill. And I know they have the right address because the other bills came and I’ve only ever lived at my current house since the first time I went to this hospital.

So I went down to the hospital to sort it out. Well, they don’t have a billing department. They have “financial counseling” or something equally not what I need. And even though it was in the hours they are supposed to be there, everyone had gone home for the day.

I still haven’t paid. I haven’t gotten a bill, and I’m not entirely sure the calls aren’t just a scam someone is running.

Even when you're insured this happens. I had a woman come into my ER room and demand payment of my full deductible. They ended up refunding me 2/3 of it about a year later.

yep, same thing happened here. I'd seen pictures, but.. yeah.

Wife cut her hand Thanksgiving night - had to go to ER - bleeding pretty bad. Initial triage was a few minutes, then in to an ER room to 'wait'. Someone came in after about 10 minutes with a portable POS on wheels, saying we had to pay $450 for the ER visit. No explanation about anything, and... I paid, but... I was in no position to 'shop around', nor even be confrontational. If I make a scene, or refuse to pay, or ask for more details, will they make us wait 6 hours? Or 8? I wanted this addresses ASAP, and paid. And... we still ended up getting bills for around $3400 (total of 9 stitches on her hand). This is with 'full insurance', which, we pay $1k/month for for 2 people.

That anyone defends this system as 'the best' is beyond me.

I couldn’t even imagine going to a hospital uninsured. It means you are pretty much giving them a blank check to take all the money you have.

I have read and been told repeatedly that if you are not insured, you can typically negotiate any fee down to a reasonable rate, so long as you are diligent about it.

“Reasonable” is relative. Also first try to pull this off yourself. It’s not a pleasant process and takes a long time.

What's your other option? If you're critically ill/injured, the hospital/ER is where you go - that's who can treat your problem immediately.

If you owe a bank thousands, you have a problem; owe a bank millions, the bank has a problem. It isn't in hospitals best interest to have people go bankrupt.

it can work out exactly the same later on if your insurance it decides that they don't agree with doctors about a procedure being necessary, putting you on the hook for whatever.

Yep. My wife was billed almost $500 for out-of-network pregnancy testing when she went in for an injury, as they needed to confirm before they could give her painkillers.

She was certain that she wasn't pregnant, given she had seen her GYN just two weeks prior and was on implanted BC.

We're still fighting the appeal and the hospital regarding the use of an out-of-network lab instead of the in-network lab then used for the rest of tests.

College prices are kind of like this, in that they follow the simple formula

tuition cost = how much you can borrow + how much you can pay

What is strange is why do we stand for huge price discrimination in college and medical care, but not for buying a candy bar?

Somehow doctors and colleges have maneuvered themselves into a position where they act like greedy companies but have a reputation for working for the greater good and should be trusted more than regular companies . Also people still believe that non profits are dogooders which is completely untrue in the case of schools and medical facilities.

This is what I don't get about "financial aid". The "elite schools" name an outrageous figure, charge the rich kids, give money to the poor ones, and ignore the middle class. This is probably intentional: they want either students whose daddies will donate or students who look good on press releases about "diversity". Now that the feds have nationalized student loans, colleges can continue these stupid policies knowing that the bottomless credit card of the American taxpayer has their back. Federal student loans don't consider a student's major, either; there's no way a "xyz studies" or poetry major should get the same loan at the same rate of a stem kid, even if that student has the same financial situation. From an actuarial perspective, it's nuts: one is going to end up a starving artist and the other has a promising career.

Oh, and my two cents: if you want to end up with larger numbers of under-represented groups in higher-paying fields, maybe making the long-term outcomes clear at that stage would help. Saying, "follow your dreams!" is very, very stupid advice to an eighteen-year-old.

That's not 100% accurate (the middle class is NOT ignored at the elite privates). For example, Stanford meets 100% of the tuition for students with family income <=$150k.[1] And the assistance doesn't evaporate completely at $151k. For families with incomes <$65k, tuition and expenses are covered. Most of the Ivies are similar.

The problem is really at elite publics, which don't have the massive endowments, so cannot subsidize middle class students.

We're at a point where it can be LESS expensive for many middle class students to attend Harvard than UMich or UVA.

1 - https://financialaid.stanford.edu/undergrad/how/parent.html

Colleges and doctors are both decommoditized and competed over by those seeking "quality" and the minimal end up comparatively shunned if at all aware or having an alternative. High stakes breed those sorts of markets - it is no accident that doctors and lawyers are synonymous with highly paid non-management roles.

They are also seevices which means there is no preserved buffering possible. You can't just have a factory of doctors fill a warehouse with 40 hours of medical care each every week. Given the opportunity cost trying to "squeeze in" what they can in a discard free knapsack problem sort of way makes sense given the incentives even if the outcome isn't ideal or fair.

>tuition cost = how much you can borrow + how much you can pay

I need this flushed out a little bit more. I have worked in higher ed for decades, and have never encountered a college that charges in that manner. They have a flat tuition, and the student fills that payment however they are able. But it's not like it changes based on how much capital they have access to.

Can you please explain that statement?

It sounds to me like your parent is describing financial aid at high end colleges. The college has a sticker price, say $50k/y, and for people that can't afford it they have need-based financial aid. They ask you lots of details about your family's income and assets, and come up with a number that they think is the most you can pay.

It's price discrimination, in that it's charging people in proportion to what they can pay.

Are you referring to the loan-based "financial aid"? This is one of the most hypocritical terms I came across. It's a loan, not an aid. An aid would directly reduce the amount of money you have to pay (discounts, scholarships, grants, etc.). A loan is not an "aid".

I'm primarily talking about grants, not loans, since that's where the price discrimination is clearest. They're effectively setting the price at exactly what they calculate you can pay.

No, the generous "financial aid" policies of many universities amount to perfect price discrimination. They meet "one hundred percent of demonstrated need"; their phrase, not mine. This means they calculate how much you can afford to pay and charge you that much. That' is every monopolist's/oligopolist's dream. Oh, and they don't show how they calculate that "demonstrated need". I got prices much higher than what I could afford.

It's not on the level of individual student, but overall market. As ability of whole group of students to pay goes up, the price also goes up.

Just wait until Uncle Sam foots the bill directly.

He has quite the "ability to pay".

Right, but he also then has a lot more incentive to keep costs down and the power to enforce some requirements and controls to keep costs down.

Seems to work OK in every other civilized country on Earth.

In what way is this not fraud?

In the way where you buy the legal definition of fraud from the senate.

Hopefully Congress passes medical price transparency and this game will end, and price competition can truly begin. If a hospital has to publicly announce they charge Blue Cross Blue Shield 20% of what they charge cash patients, they'll be in an untenable position and have to make drastic corrections.

I expect a lot of service providers to become untenable after price corrections, go bankrupt, get bought out by more efficient providers who remove all the unproductive staff.

Course this is all premised on Congress doing something useful, so...lol.

My wife was denied short term disability for a foot operation due to a completely unrelated medical issue. It took 6 months to reverse the idiotic decision, which of exactly what they wanted. Infuriating.

Real world example (slightly annonymized). You have a 50 FTE "billing and collections department". You can outsource, but at a certain scale it makes sense to build your own.

How do you motivate these people? Or manage their performance? Or manage a good outcome for the busieness, the payor and the client?

This wasn't a hospital setting. Much lower acuity. Upon joining they measured exactly this: CPT codes, bills, A/R, etc. 95% of the time those metrics correlate with their job: getting your complex insurance to reimburse for a procedure they administered.

It's a) not clear that's what you should measure, but let's assume it's not the worst thing in the world, b) straightforward how you can get the "evil" white board example you mentioned.

Not saying this is good or bad and American healthcare is arguably broken. But just another example to maybe calibrate your view.

EconTalk recently did an episode on pricing in healthcare that talks about a lot of these issues. Well worth a listen: http://www.econtalk.org/keith-smith-on-free-market-health-ca...

Next time ask for that demand in writing. That's an easily winnable lawsuit. In fact you should just tell your insurance company that they demanded this AND tell your state's attorney general. That nonsense will be squashed immediately.

> the director of the hospital's billing department told her that all past bills must be payed before they are able to remove the stent

That's nuts.

What has changed about healthcare in the last 20yrs to drive up the cost of insurance premiums and pretty much everything?

I'm so happy I don't live in the US and have to deal with private healthcare.

I hope your wife has made a full recovery!

Speaking of medical billing insanity...

I recently had a MRI, and in the process of filling out the usual new-patient form at the imaging center, they wanted me to sign a blank LCD touchscreen. No indication whatsoever what I would be signing. Is it even a contract if you never saw the offer and thus no "meeting of the minds"?

After explaining that I wasn't going to sign a "blank check" contract (and would always need to read the entire contract before first), they eventually figured out how print the actual document. After several minutes reading the 8 page (!) contract, I found a clause I haven't seen before. After more or less normal stuff about agreeing to pay for the service, in a section about sending the bill to a collection agency if I didn't pay, they wanted me to agree to 1) pay for the collection agency and any other fees associated with recovering the debt, and 2) pay their attorney fees if they decided to take me to court over the debt.

I wounder a judge would actually enforce that clause. Agreeing to pay someone to sue yourself seems unconscionable. I told them I wouldn't sign their unreasonable contract (that wasn't the only problem) and they sent me off to have the MRI scan anyway.

I'm glad I'm not the only one. I just got a signature on a screen for a regular doctor visit and I was like, "What am I signing? There's nothing here."

She gave me a laminated card; three pages. I think she was kinda shocked I read it.

Kinda unrelated ... I was at a Wal-Greens and the checkout person wanted to scan my ID. I was like, "NO! I do not consent."

She called her manager saying, "No one has ever said this before." I asked about their data retention policy, wanted to see their privacy policy. I know this was useless, because they're not going to know. The manager said, "Unless we scan your card, you can't buy alcohol."

So I turned my bag upside down, emptied everything out and said goodbye. I no longer buy alcohol at Wal-greens (or anyone who scans my ID), and I find it disturbing I was the first person who asked.

Most people don't care about their privacy or what they're signing. It's fucking insane.

"Unless we scan your card, you can't buy alcohol."

PhilosophyTube recently posted a great video essay (Socratic dialogue?) that explores that exact situation.


Typically the attorney fee assignment clauses go both ways, and the prevailing party has their fees paid. In some jurisdictions one sided clauses can be thrown out

Recently had an MRI as well. I was given an iPad with lots of documents to sign. Most of it was what you'd expect. Just poorly scrawl your name & initials where indicated.

The one that really jumped out to me was the Power of Attorney. Yes, the provider wanted me to grant them an indefinite Power of Attorney as part of being a patient. I asked if I had to complete this and was told I could skip it. I was really glad to see that about 1/2 the people in the waiting room had the same question.

> Power of Attorney

Isn't this similar to the same trick those business loan sharks employ? They ask you to sign a "Notice Of Default" or similar document upfront, that they present to the court to get an instant summary judgement if anything goes wrong with repayment?

It can't ascribe the same attitude to the provider of medical services, but it certainly stinks.

> Power of Attorney

If I remember correctly, there might have been something about PoA in my contract. I already hand several reasons to not sign it, so I only skimmed the last ~1/3 of the document.

For comparison, I had a minor surgery (ulnar nerve release) in the surgical center across the hallway from the imaging center. I think they are part of the same umbrella healthcare company? The surgery center only wanted me to sign a short, concise contract that was mainly standard stuff (surgery always has some risk). I don't understand why an MRI (very safe, short) needs 3x-4x longer contract than surgery (always has some risk, involves a lot more people). This seems backwards.

> wanted me to grant them an indefinite Power of Attorney

Surely this should be reported to someone that could do something about it. I would hope so anyway, as that seems like a dark pattern that could be litigated.

How does the person in charge of this decision justify that kind of thing to themselves?

> I wounder a judge would actually enforce that clause.

Yes. It's a normal and enforceable clause. It's very common in all kinds of contracts.

Depending on the situation, it could be reasonable to argue that you were under duress or undue influence to sign the contract. This is all situation dependent, of course, but it is probably rare that an individual would have the resources and wherewithal to win such a case anyway (which is another problem).

When you sign the LCD screen without the ability to see what exactly you are agreeing to, that gives you ammunition if needed later in court. When you sign on paper there is less wiggle room for you.

Just sign "No contract provided" and hand it back like it's no problem. If the employees don't care to actually give you a document, what are the chances they are going to scrutinize your "signature?"

A co-worker decided it would be funny to draw penises on the credit card signature forms.

The credit card companies apparently didn't care.

I’m confused, so what exactly do the hospitals want to gain from this “medical” credit score?

If the hospitals simply want to gain insight on your ability to pay your medical bills, wouldn’t your “normal” credit score be able to provide that insight.

What’s different between your “medical” credit score and your normal credit score?

Edit: Additionally, there are laws in place in the US that state in emergent situations, no hospital (public or private) can deny care - regardless if you can pay or not. So the article title might be a bit sensationalized.

I'm with you, not paying medical bills affects your credit score the same way as any other bill. To me, it seems like it's just another service for the credit unions to make money on, while giving private hospitals some legal protection.

Really, it's disgusting.

s/credit unions/credit reporting agencies/

credit unions are one of the few pro-consumer entities in the financial world, it would be a shame to smear them

I will add credit unions are chartered banks...but unlike "banks" they are not owned by shareholders, they are non-profits made up of the members (account holders).

Ideally in 2008 all the "banks" should have gone bankrupt and the vacuum should have been filled with credit unions, instead lawmakers gave the banks $2T as a reward for ruining the US economy so they could float their own debts instead of declaring bankruptcy and enough so they could buy up their competitors to further consolidate the marketplace.

Medical debt is regarded less harshly in FICO 9. I am not sure how widespread the use of FICO 9 is currently among credit bureaus but it is the latest standard.

It is not exactly the same. The bill cannot go into collections for 180 days. This is different from regular debt.

180 days is generally how long it takes their system to adjust the charges and send you a semi-fraudulent bill instead of the fully-fraudulent one.

It is possible that in non-emergency situations, the vast majority of situations, a hospital may deny or change the quality of care based off of your likelihood of paying it off. No one knows the difference between a "medical" credit score and a normal credit score, but we do know that this special, secret credit score is being used to calculate patient treatment.

Wouldn’t the easier solution be to not accept patients without insurance (and low co-pays).

And given that it’s now a US requirement to have medical insurance, I’m still struggling to understand what this medical credit score is accomplishing.

>And given that it’s now a US requirement to have medical insurance

It became a "requirement" in 2014 with Obamacare, but since the repeal of the individual mandate in 2019, there is no financial punishment (except well, the increased possibility of medical bankruptcy) for not having insurance:


I'm glad the requirement is gone. I had trouble affording insurance under the marketplace plans when I returned to the US:


Medical insurance only covers treatment from specific medical practitioners, of which an entire hospital may contain a wide array of medical practitioners under and also not under any specific patient's insurance company. Having a routine surgery from a surgeon that is covered can still rack up an intense medical bill from an anesthesiologist who is not covered.

Similarly, if the insurance company for any reason disputes a hospital claim for any reason, up to and including disagreeing with the hospital that the issued treatment was appropriate in lieu of a cheaper treatment, the hospital goes to the patient to foot the bill.

So it is entirely possible to be fully insured and still be forced into unpayable medical debt through factors completely outside of one's control.

> So it is entirely possible to be fully insured and still be forced into unpayable medical debt through factors completely outside of one's control.

It's frustrating to me that this point is very often overlooked in the discussions about health insurance in the US. A lot of people who go bankrupt over medical bills are fully insured and suffer for reasons entirely beyond their control like the hospital an ambulance decides to route them to when they're unconscious.

Which sometimes makes me wonder, why pay for insurance at all? Sure sounds like a racket, "pay us and you may get into medical debt, don't pay us and we'll make sure that you do"

Precisely because "pay us and you may get into medical debt, don't pay us and we'll make sure that you do".

This depends on the state. Many states have passed surprise billing laws, and limit what an out of network provider can charge

It's a requirement to have medical insurance, but the cheaper qualifying plans have enormous deductibles.

A Bronze family plan will typically have a $13k deductible. You pay that entire amount out of pocket before insurance kicks in, and it resets annually... so if you're in the hospital December 31 through Jan 1, you might be on the hook for $26k.

There's also nightmare scenarios where the hospital is in-network, but the doctor isn't. https://www.reuters.com/article/us-health-insurance-surprise...

The high deductible plans were originally for healthy young individuals with an health savings account to pay for the occasional deductible. These plans could be used as tax free investments if you got lucky. These days families end up getting the high deductible plans because that is all they can afford. And they do it without savings to back it up.

This is incomplete. A bronze family plan will typically have a deductible of $6k for an individual, and 13k for the family, but it also has an out of pocket max of slightly over that, so once you meet the deductible that is all you pay. Also almost all bronze plans cover the first 3 doctor visits with a normal copay, and any preventive care has no copay. Gold and above plans typically do not have a deductible, and the out of pocket max is lower.

Many states have surprise billing laws to limit what bills you can receive from out of network providers.

> so once you meet the deductible that is all you pay

There are a lot of subsidized folks on the Bronze plans with zero ability to pay an unexpected $400 bill, let alone a $13k deductible. They're insured, but only technically.

> Also almost all bronze plans cover the first 3 doctor visits with a normal copay, and any preventive care has no copay.

Sure, but I'm referring to the sorts of bills that bankrupt people, not an annual physical.

Also the deductible fiscal year conveniently restarts halfway through flu season.

There are laws against denial of service.

Only in life-threatening circumstances.

Which is kind of funny: all medical problems are life threatening. The only differentiator is how long it'll take them to kill you.

Well, the requirement is more specific: the hospital must treat you if you are in immediate danger of dying. They only have to treat to enough to stabilize you, though, then their legal responsibility is complete.

I agree with the OP in a stronger spirit. It’s in society’s own best interest to ensure a basic level of quality of life to its members. There are many illnesses out there which can severely, negatively affect a persons life but otherwise aren’t always treated because of mitigating factors. Sleep apnea is a good example. Many can get by without treatment, but eventually complications from it or side effects of it can lead to chronic fatigue/reduced productivity at work, and even lead to death. Back pain can do similar. It’s not life threatening but can lead to reduced work productivity which could contribute to being terminated.

Yes, I agree as well. I was just describing how things are, not how they should be.

That's patently not true. Acne is a medical problem faced by a substantial portion of the population at one time or another. In all but the rarest of cases it is not life threatening.

From the acne Wikipedia page:

"There is good evidence to support the idea that acne and associated scarring negatively affect a person's psychological state, worsen mood, lower self-esteem, and are associated with a higher risk of anxiety disorders, depression, and suicidal thoughts."[1]

While Acne probably won't kill you, it certainly won't make you happier and could contribute to suicide if left untreated. We are lucky that acne meds are cheap, but there is nothing stopping those companies from shooting up their prices tomorrow.

[1] https://en.wikipedia.org/wiki/Acne#Prognosis

In that case depression is the life-threatening ailment, not the acne. Just like pneumonia is the reason you go to the ER, not a common cold on the off-chance it might later become pneumonia.

Also by the way, the requirement to provide care to any walk-in patient only applies to ER's, and only until they have stabilized the patient.

Standard Credit scores are more lenient for medical debt. It takes 6 months for unpaid debt to show up and fully removed if paid in full even after it is sent to collections.

Nit pick, but I think the word you two are looking for is “emergency” rather than “emergent”.

Since you're nit picking already and because it's a "today I learned" opportunity, parent's usage fits one of the definitions of emergent, the first one here: https://www.merriam-webster.com/dictionary/emergent.

TIL indeed. Must be industry jargon or trade usage as another reply put it. As a lay person I’ve only ever heard it referred to as “emergency services”.

"Emergent" is the term used in the trade. Webster has this to say:

> “Emergent” properly means “emerging” and normally refers to events that are just beginning—barely noticeable rather than catastrophic. “Emergency” is an adjective as well as a noun, so rather than writing “emergent care,” use the homely “emergency care.”

I have corrected this, despite some discussion back and forth, for clarity.

I believe medical debt is no longer allowed on credit reports now. Maybe this is to get around that?

"Specifically, the NCAP prohibits adding medical debt to credit reports until after 180 days from the time the account was reported to the credit reporting agency. It also mandates the removal of previously reported medical collections that have been or are being paid by insurance." [1]

Medical debt can still be added to your credit report.

[1] https://www.creditkarma.com/advice/i/how-to-remove-medical-c...

They might want people to be afraid that if they don't pay their bills, they might die. Since the threat of debtors' prison is no longer viable, I guess.

Moves like this erode my opposition to nationalizing the entire US health-care sector. If they're going to cartelize or confederate, patients--which is to say everyone in the country that lives and breathes--will also want a seat at the table.

From a more generous perspective, this may be a tool for price discrimination. Hospitals will charge based on what they think the patient can pay, rather than the actual costs of providing the care. When you receive care, you will be billed for a number that is calculated to make you sigh, flinch, or wince, but not call a bankruptcy lawyer.

This is a symptom of illness in the system, and leaving it untreated seems like a bad idea.

I bet 'Likely to be litigious' score is part of that Score. Physicians and hospitals would kill to see such a score before they start treating new patients

> Edit: Additionally, there are laws in place in the US that state in emergent situations, no hospital (public or private) can deny care - regardless if you can pay or not. So the article title might be a bit sensationalized.

This is true, but many life-saving treatments (such as chemo or radiation treatment for cancer) are not "emergency" treatments, despite being necessary and somewhat urgent.

The legal obligation hospitals have is that they must treat you if you are have a life-threatening emergency happening. That treatment can be the minimal amount needed to stabilize you so that you aren't at immediate risk of death. There is no obligation to treat you beyond that, nor to engage in follow-up care.

Yes, that is the current legal obligation. This is not enough, and important life-sustaining healthcare (such as cancer treatment) should be available to everyone, even if it is not an immediate emergency.

I agree, but we're a long way away from that in the US.

In Switzerland private hospitals will calculate the possibility of success in your case and if it is too low you will not be accepted, because they want to keep their success rates high... Maybe such "Medical Credit Scores" could be used for the same reasons...

I believe medical bills over $100 no longer count against your credit score so of course that created an opportunity to break them out and market them specifically

I think you’re viewing the problem backwards. It’s not that they intend to send out a standard bill and know in advance who can pay. It’s that they intend to send out bills scaled to people’s ability to pay.

It’s probably more profitable for them to send a small bill to a poor person than a large bill that is never collected. It’s definitely more profitable to throw the most ludicrous bill at those who can and will pay whatever cost is sent at them. You can also adjust the kinds of treatments given according to likelihood of profit.

I wouldn’t be surprised if the latter case is illegal (or happening or not). I’m pretty sure the former case is perfectly legal, though symptomatic of a bigger problem.

I’m surprised this doesn’t violate HIPPA or CCPA.

Every time you visit the doctor, the hospital tells experian (by querying the experian system) and then experian resells this information for profit.

IANAL. It is not a HIPPA violation if Experian has signed a BAA with the hospital. It's on the hospital to perform the due diligence checks, to verify that Experian's capable of upholding the terms of the BAA.

This article talks about how Experian have SOC-2 issues, which is a cause for concern, but smaller hospitals with tighter budgets could be inclined to look past it.

In general, it's important to understand that HIPPA doesn't prevent data from being shared, it gives it a legal framework to be shared within. When things go bad, the HIPPA-associated paperwork provides a roadmap for assigning liability.

Liability does get assigned, and companies (providers, insurers, network providers) are held responsible, despite the popular imagination: https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf

Minor point, but it's HIPAA with two A's, not two P's.

HIPAA pertains to PHI and PII (protected health information and personally identifiable information, respectively). The fact of your office visit is not either of those if it's not linked to health information (labs, medical records, notes, itemized bills).

Further, it may be allowed under permitted uses and disclosures as-is, without authorization under the language for payments. I couldn't tell from the article, but the health systems could simply decline to treat you without your authorization for the credit check.

Separately, people love to make healthcare into the bad guy, but it's not a monolith and there are hospitals closing down because they are losing money. There is a systemic problem in the US here, and I bet this is those 2nd/3rd tier markets in smaller systems that can't absorb defaults like nationals can.

> HIPAA pertains to PHI and PII (protected health information and personally identifiable information, respectively). The fact of your office visit is not either of those if it's not linked to health information (labs, medical records, notes, itemized bills).

False. Directly from HHS, emphasis mine:


“Individually identifiable health information” is information, including demographic data, that relates to:

* the individual’s past, present or future physical or mental health or condition,

* the provision of health care to the individual, or

* the past, present, or future payment for the provision of health care to the individual,

I do deal with this stuff, but got sloppy with boundaries of entities covered by BAAs. Thank you for the correction.

HIPAA does not preclude hospitals from sharing data with business partners as needed to conduct their business affairs, assuming those partners likewise comply .

> sharing data with business partners as needed

"As needed" is a definition that most patients would disagree with

HIPPA protects you from gossipy front desk people. The rest is a joke.

Your prescriptions, hospital admissions, radiology orders, etc are in the hands of any of a dozen third parties before your claim is processed. It is trivial to un-anonymize the data.


While I agree that the current leadership is probably the worst we've had in this regard (at least in recent memory), there's no way this all just started in 2017.

I recently received treatment for Hodgkin's Lymphoma and have been trudging through bills for the past 3 years. I've found that most if not all of my medical bills contained errors, which had I not looked into, would've cost me in excess of $10k+. The most common error was the billing department submitting a bill to my insurance company months after the date I received the services. I wrote a post explaining how I used python OCR to look for these discrepancies.

My father is also a pharmacist (and now owns a pharmacy) and he constantly tells me horror stories about the cat and mouse game that insurers play with patients, where they have doctors prescribe and offer discounts on specific drugs, depending on what is most profitable. He pointed to an interesting bit of software [1] that uses machine learning to find the best margins.

I could seriously go on and on about all the insanity that is our healthcare system. These problems runs deep, from top to bottom.

[1] - https://amplicare.com/

The medical system in the US is so awful that I already avoid getting medical care unless it's absolutely unavoidable. I guess I need to add "never go to a private hospital" to that habit.

Same here. Just went to an emergency room with a fever and was charged $700 for 5 minutes with a doctor who told me to go home and stay in bed. I have insurance and had to spend several hours on the phone to get charges reduced to 240.

Why did you go to an emergency room for a fever instead of urgent care or a nurse practitioner working out of a grocery store?

At this time of the year the urgent care will decide you have the flu, and if your BP is elevated (You have a fever, so it will) they will send you to the ER as a legal liability mitigation.

If you look really bad, they'll refuse to check you in.

Because I called the insurance and they told me to go to the emergency room.

Did they give you a cost? That's fucking shitty they would encourage you to do something that just earns them money. I fucking hate private insurance (and I worked in it for ~3 years)

Of course they don’t give you a cost. You are essentially signing a blank check. The hospital can charge whatever they feel like and the insurance can pay whatever share they feel like and you are in the middle trying to figure it out.

I've worked extensively with credit bureau data, and there's a fair bit of misinformation both in the article and the comments.

First, bureaus get very little detailed information about the episode of care that led to the medical bill: essentially, they'll just get info on when the bill was due and what amount on it is still overdue, plus enough info on the patient to match it to the right person (name, address, phone, SSN if available). HIPAA and similar legislation allows the sharing of billing data like this, and no other PII (or any PHI) gets shared in the process.

Second, medical debts have been a part of bureau data for a while now. What's new here is that Experian is trying to build a machine learning model on it to try to sell the model as a new product. I've never worked for any of the bureaus before but know many people who do, and in general, these specialized scores seldom sell well, but since the marginal cost to Experian is low (let a few data scientists at it for a few weeks), they still put out new ones anyway. Even things like new FICO/Vantage scores like the new FICO that's been in the news lately tend to take a while (on the order of years) to make it out into the wild since lenders like to have consistency in their processes as long as possible.

Third, it's actually beneficial to most consumers to have medical debts split out of the bureau data explicitly. Most big lenders use raw bureau data much more than the aggregated credit scores, and since the US medical system has so many distortions that correspond more to broken processes rather than a person's creditworthiness, many exclude medical debts from consideration explicitly, and others implicitly as models they build don't often find those attributes as useful as others.

All in all, it's good to be thoughtful about how information like this is disseminated and used, but the dire warnings of the article are really not warranted in this case.

Great. Now Experian gets to decide whether you can the surgery you need. They also decide whether you can get a job, rent an apartment, and whether you should remain in police custody [1].

[1] https://bigbrotherwatch.org.uk/all-media/police-use-experian...

I usually don't give medical providers my social security number. It's on all their forms, but I just skip that section and no one has ever come back to clarify that it's required.

I have no idea if they can require it or not, but I always assumed it was optional because they wouldn't turn away foreigners without SSNs.

Refusing to give your SSN doesn't prevent things from showing up on your credit report.


> Experian doesn't match information to a person's credit history using only the Social Security number. Experian matches information using all of the identification information provided by the lender, so the account will be accurately shown in your report, even if no Social Security number is provided.

I guess that makes sense. I have been doing it just because I figure it's an easy way to limit my potential data breach exposure. Didn't know about this medical credit score thing.

It's common for people to not give SSN, but they don't need it. A name and date of birth is enough to match you to existing records the overwhelming majority of the time. Phone, address, insurance, and so forth, resolves the majority of what remains.

Usually the only time they'll fail to ID you is when you show up to the front desk with no identification and lie about your personal details, which I don't particularly recommend doing.

Additionally, some American citizens do not have a Social Security number.


Bear in mind this fact when working on systems that make use of SSNs.

As a Californian resident, how does stuff like this not violate CCPA?

Brokers reselling my health info is far more critical to me than my buying habits.

Is there a "do not sell my health info" checkbox?

According to Experian, it looks like they claim they do not collect medical or health information on California Consumers. https://www.experian.com/privacy/ccpa-privacy-policy.html I would love to send them a request to see if that is in fact true.

> Is there a "do not sell my health info" checkbox?

Yeah, except, sadly, it'll most likely be "You're welcome to try the hospital across town if you'd like...".

A lot of people say you should just not pay crazy charges from hospitals and wait until they reduce or drop them. I bet hospitals want to track people who do that. They want patients who will pay whatever kind of charges hospitals dream without questioning anything.

I have been traveling in Latin America for the past 2.5 years. In Mexico, life expectancy is 77 years, pretty much the same as in the US. An American retiree expat told me that his MRI cost him $200 here, versus $3500 in the US. I have been to doctors too. A typical payment for a doctor visit is $30 cash, less than my copay in the US. I had a stomach parasite from Guatemala when I flew back to the US. My PCP scheduled tests, then more tests, copays, bills and finally a $200 medication. While doing all this, I simply took a Mexican anti parasitic medication that I bought for $1 (one dollar) in Arrilaga, and it went away, before I got the $200 medication!

I think the medical field here in Mexico is much more affordable because it's cash based, with real competition between doctors

In 2017 financial bureaus changed their scoring system to be more lenient on medical debt and also remove collection reports if paid in full. This stemmed from a state Attorney General settlement against the hospitals that were extorting patients with threats of ruining their credit when disputes between hospitals and insurance companies arouse. Hospitals would just collect from the patients and let the patient deal with the insurance company to recover funds.

Hospitals want this leverage again so they built their own credit system.

It’s not just Experian... TransUnion has it too, with the same name as a matter of fact. Although it looks to be a report and not a score just yet, unless I didn’t read it correctly: https://www.transunion.com/product/patient-financial-clearan...

It's not clear from this article how people are being "denied care" based on this Experian product; the video example provided appears to be about a special need-based admission offering at a provider, not a normal admissions process. In other words: a check that you're poor enough to require the special service.

She mentions that the product helps screen for the patient's "propensity to pay". From that I gather that if the patient has a low propensity to pay, then they get denied by the hospital.

This is from the product's lit:

"Predict propensity to pay using our proprietary Healthcare Financial Risk Score, which factors in historical healthcare payment outcomes and the patient’s credit history"

She mentions that the product also lets them pull "FPL", which in this case I imagine means "Federal Poverty Level", in addition to household size. Cincinnati Childrens has some info that might put that info into context: https://www.cincinnatichildrens.org/patients/resources/finan...

She says explicitly that she's pulling that information in the context of eligibility for "the charity program".

Further, unstated, perhaps speculative context: most people who go to the hospital pay through insurance and out of pocket. But if you go to the hospital without insurance, or can't cover your out of pocket component, most (every?) hospital will negotiate a lower rate; almost nobody pays rack rate out of pocket. So what they're calling "charity" might just as likely be the name they give the program where they come up with their real rate on the fly (I've been through this process with a large hospital chain in Chicagoland).

Either way: it doesn't support the post's claim that Experian's health score --- which I'm disinclined to trust, just like everyone else --- is being used to "deny care". That's an argument the article does not appear to marshal evidence to support.

Maybe you are right, but what difference does it make if the program is used to screen out people who can't pay?

Tacking on to your comment, it's important to realize that hospitals do not usually lose money on patients that can not pay for routine procedures (because of generous government subsidies). The substance of this article certainly smells funny (experian is known to be shady), but it is not as nefarious as the author makes it out to be.

For context, hospitals are only likely to lose money on very complex patient cases, i.e. the kinds of program described in the video. In those situations, it makes sense that hospitals will want to make sure that either (1) the patient will be able to pay or (2) charities or government programs will cover them, once they apply.

Experian's system claims to helps them make that assessment. Will that lead to patients being turned away? Maybe, but it's not a straightforward conclusion, like you imply. The comparison to Uber ratings holds no water.

The reality is that American healthcare is a complicated market with many sources of revenue that aren't patients' bank accounts (charities, govt subsidies, insurance), and it doesn't lend itself well to this kind of oversimplifying analysis.

To be clear: the impression I got from the video was that this was a charity that the provider was offering, not that they were using Experian to validate eligibility for other charities.

The revenue for their charity is most likely dependent on government subsidies that are contingent on the financial status of the patients they're helping.

Even though they're determining eligibility for "their own" charity, they're likely determining eligibility for "other charities", if you follow the money.

I don't know what this has to do with my point; you can do this "follow the money" analysis to take any argument anywhere. On message boards, at least, it seems to turn out that it's almost never a good idea to just "follow the money".

You walk into to a supermarket to buy a bottle of milk. None of the items have prices. There isn’t even milk on the shelves. You present your supermarket card to someone and then talk to a consultant who then does a bunch of tests and gets you milk plus some other items (which have high margins - like a special green bottle cap)

Then you go home and receive separate bills that trickle over several months. One from milk consultant, one from the doorman, one from the cleaner and other folks you never even met. The total bill could buy you a truck of milk in other countries but you’re glad you have supermarket insurance and you only pay the price of 10 gallons of milk out of pocket.

> The Financial Clearance system combines medical records along with the financial records Experian already has on you to calculate the score.

How is this not a complete violation of HIPAA?

Are they working around it by having very general HIPAA release forms?

The law explicitly permits sharing with other entities for billing purposes.


> The Privacy Rule permits covered entities to continue to use the services of debt collection agencies. Debt collection is recognized as a payment activity within the “payment” definition. See the definition of “payment” at 45 CFR 164.501. Through a business associate arrangement, the covered entity may engage a debt collection agency to perform this function on its behalf. Disclosures to collection agencies are governed by other provisions of the Privacy Rule, such as the business associate and minimum necessary requirements.

> So wealthy people get access to better care and everyone else has to take whatever is available.

That's how Canada's healthcare system works, too.

> Government health insurance plans give you access to basic medical services. You may also need private insurance to pay for things that government plans don’t fully cover.


This is not how Canada's system "works" by definition as their definition of basic health care is a lot wider than the US.

The above aspect of "wealthy people get to buy nice things" really doesn't contribute anything interesting to the conversation.

”That's how Canada's healthcare system works, too.”

Their Standard for basic care is much higher though. You can’t compare that.

Not really. In the US, you get medical coverage if you are old, an honorably discharged veteran, or indigent (either through ER or Medicaid).

In Canada, you get Medicare-like primary care, benefit from price controls on drugs, and can buy secondary coverage to get more. In the US, you get to subsidize drug development for the world and enrich a variety of different cartels.

"Private hospitals are now consulting a secret medical credit score from Experian before you even see a doctor. As a patient you do not have access to this score, nor can you see how it is generated. All you know is that you may be denied care, or receive different care, because of it."

Could we classify 'not being able to afford, either time wise, emotional labor wise, or money wise, to deal with the messed up medical billing system' as a pre-existing condition?

I had my credit increased from 420 to 800 within a short time with the help of bbirdeye1@gmail.com some from here linked me up with them, at first I was skeptical about it but I contacted him because I needed to get a loan, now my family is happy and grateful to bbirdeye1@gmail.com. I have recommended him to few of my friends and you can contact them through email if you need your credit fixed too...

It's too bad TFA doesn't mention either way whether a credit freeze will prevent hospitals from obtaining information on you. A bing search reveals nothing.

OT: I left google and use bing now. Interesting, google's search results for my query were absolutely horrible. obvious spam and various detritus. and all the results had the little ad icon ^W^W favicon! I thought they backtracked from that? oh well.

The one bright spot to this is that, since it's a ratchet that can only go in one direction and find more reasons to deny people as it gets more data, privatized health care will eventually be its own undoing when enough people are frozen out of coverage that they can form a voting bloc and give this system the bullet to the head it deserves.

Considering how much of the population keeps voting for this system, I don't see that happening for decades at the least.

Here's another version, besides the private insurance companies themselves, of the death panels opponents of universal healthcare always blabber on about. Now we have two branches of death panels, each one slightly differently evil. Yet another issue that would be solved by universal healthcare.

Maybe congress should actually focus on privacy legislations than being obsessed with orange man.

The video they show in the page has nothing to do with what the article is about. The person is talking about finding eligibility information for patients for things like worker comp, medicare, etc.

As if the US healthcare system couldn't get more dystopian..

I mean, in a for-profit system you can't blame them. But at the same time, this seems insane to me. Thank god we (still, just) have the NHS...

So I've come to the conclusion that the US model of private health care is ultimately doomed and nothing will save it. Of course it's going to kill people in the meantime but it is doomed.

While on vacation recently I ended up listening to the Bear Brooks podcast [1]. It's a little longwinded at times (but it is aimed at non-technical people) but is not a bad way to spend a long drive.

The interesting thing about this story is how advancements in DNA testing have taken us from the simple case of is or is not a match (used in paternity testing and for forensics) to figuring out how much of a match you are. This has created a new field of genetic genealogy that famously led to the identification of the Golden State Killer [2].

So there's a lot of talk about privacy and your DNA but much like having your contact information uploaded by someone else, this is showing that that will be insufficient as your DNA will ultimately be inferred (at least in probability terms) by people who aren't you. There's really no putting this genie back in the bottle.

So take a disease like Cystic Fibrosis. Currently this requires life long medication and care. Depending on the severity, you may require one (or more) lung transplants. All of this is expensive.

So if you have CF and want to get private insurance in the US this may well be a pre-existing condition and excluded. Now this disease is usually quite apparent from birth but there are other diseases that are not (eg Huntington's). If you'd had a test and know you have it the insurance company has a "right" to know it (if you accept the premise of the US health insurance system, which I, of course, do not).

But this is only going to get worse. Ultimately health insurers will able to figure out if you're much more likely to have certain expensive conditions by knowing, say, that a sibling is a carrier (which greatly increases the chances you have it).

Taken to its natural conclusion, the system of private health insurance cannot survive. The only workable solution is group health insurance. Sufficiently large groups statistically even out. That's how insurance is meant to work. This could be a fully public health system or something in between (eg state-level).

So back to the medical credit score. There will be fights over this. At some point you'll have a right to see it and get corrections. This will probably be championed by states since the Federal government seems to have forfeited, well, governing. But all this is just arranging the deck chairs on the Titanic.

Of course there's still the separate issue of costs (in the US) to deal with but one step at a time.

[1]: https://www.bearbrookpodcast.com/

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

The medical system in the US needs more regulations, and people should push their politicians to fix this, or vote them out.

Great to see healthcare sector innovating in new levels of depravity. These people put the Marquis de Sade to shame.

One mention of universal healthcare and all McCarthys of the world unite in uninformed shit talk against it.

I wonder Experian will buy fitness trackers/apps data now and use it in ratings.

Yet another reason for single-payer.

I really hate it when people response to single payer with "I don't trust the Government to..."

First, Medicare/Medicate are contracted out to all the same health care companies that currently do employer insurance. They're given tighter money constraints and can't waste as much.

A singler payer would mean contracting out. Private companies wouldn't go away, they'd become government contractors, would need to reduce waste, stop useless advertising and probably layoff a ton of useless people.

I agree though, we desperately need fully universal healthcare .. where everyone gets the exact same level of care because they're a citizen or tax paying legal permanent-resident.

Vote for Sanders or Warren, folks.

It doesn't matter if they believe in standard health care, they have to be able to implement it, which is going to be very difficult for anyone, no matter if they have a D or an R behind their name.

I'm starting to think it's better to not be born (into society today) unless born into a rich family. The sociopaths have no checks & balances and everyone can just watch everything get worse.

I'm pretty much an anti-natalist. I don't want kids personally. I'm still fine with other people having them, but I can't morally justify bringing people into this world just to suffer.

Here we go killing people over money again

Well that's terrifying

uoaei on Feb 6, 2020 [flagged]

You may not like it, but this is what peak private-markets-for-public-goods looks like.

This comment broke the HN guidelines by taking the thread on a generic ideological tangent. Those are predictable and boring, and lead to flamewars. Please don't post them here.


What is the line between policy tangents and ideology tangents?

I'm not sure, but the underlying principle is that we're trying to avoid repetition. Especially the kind of repetitive arguments where people turn mean.

How so? Last I checked there are massive laws about who can open a hospital, who can operate as a doctor, who can sell what kinds of insurance, who can sell drugs, and what can be sold as a drug. This is government granted oligopoly.

Edit: Technically oligopoly, not monopoly, though it may tend towards one.

The logical conclusion to private markets + unrestricted lobbying + Citizens United. They literally made the laws that restrict competition. They were only capable of this because of the insane amounts of profit they extracted from an otherwise public service, which they spend on schmoozing lawmakers.

Two questions. First, Citizens United is a case about spending money on political advertisements, not lobbyists. Are there political advertisements involved in this rent-seeking process?

Second, what exactly do you mean by "an otherwise public service?" Are you simply saying, in the absence of private medical care, that "medical care" would be purely owned by the government? This seems uninformatively tautological and I get the feeling some other meaning or implication is meant to be attached but I cannot pin it down.

>Two questions. First, Citizens United is a case about spending money on political advertisements, not lobbyists

Those 2 are conflated because Citizens United permits lobbyists to sidestep campaign donation limits by allowing industry groups to effectively spend unlimited amounts of money on behalf of or in opposition to candidates.

I think one needs to blame the First Amendment for this, not lobbyist. If I want to put up billboards advocating for a given politician, that is fully in my right. That I rent the space on the billboards to others and they use it to advocate for a politician isn't a significant difference. Even if we were to say that speech cannot be sold, then all that does is force the contract to become a bit different (instead of me renting the space, I sell it to the one putting up the adds with a promise to sell back or a certain fiscal penalty if I don't).

At the core of this problem is that speech can be amplified with money. Even if we ban selling of speech to others, organizations can still spend the money to host/print/post/billboard/telecast their own messages. Those with money will out message those without.

Is there a way to fix this that doesn't result in government control of political speech?

>I think one needs to blame the First Amendment for this, not lobbyist.

The first amendment has only been loosely upheld throughout our history. There are many types of speech that are regulated in spite of it.

>Is there a way to fix this that doesn't result in government control of political speech?

We had a system in place prior to Citizens United that didn't turn into government control of political speech. Many other developed countries have limitations on spending money on political speech that don't turn into complete government control of political speech.

There's no reason to assume that a few men in the 1780s got everything right. And a slippery slope argument is no reason to throw up our hands and stop trying to advance egalitarianism.

I'm saying that it's good for a citizenry to be healthy. When a government is encouraging its citizens to stay away from treatment because of prohibitively high costs to access it, that is not good. It is a public service since it serves the public to keep everyone healthy.

It also requires removal of limits on what laws the government can pass. If governments were limited to what laws they can pass when it involves consenting individuals, this would also not occur.

Limited by what? A constitution? Like the one we already have that taken literally grants far fewer powers to the federal government than they routinely exercise.

Interesting. Are you suggesting that in cases where all parties must consent, the law may not be passed until those parties explicitly provide consent?

I meant more that the government has no place legislating the behavior. I take the idea that what two consenting adults do in their own bedroom is their own business and not the government's and apply it even if they are, for example, trading or doing drugs in their bedroom.

Granted, all of this is pretty much meaningless when you have a government overstepping its bounds and doing what it wants. In that case, it seems the blame of the corrupted system would fall on those corrupting it (the corrupt government allowing itself to be bribed in exchange for monopolies).

Absolutely untrue as the only markets we see this in are ones which are heavily regulated. And we're not talking safety regulations, but regulations to shape the market, which is likely impossible to keep from being corrupt (easy to believe if you've ever met an actual human being). I'd bet 50% of states have explicit laws limiting the number of hospitals in areas to protect county/state hospitals from competition, leaving many urban areas without high quality care, and yet somehow, through some chain of conspiracy theories, capitalism is to blame.

I don't think anyone's talking about free markets, just private ones.

Those laws exist because capitalist forces incentivize healthcare providers to limit competition.

That's not true. In a lot of places those laws were put in place to protect county hospitals from private competition.

I recommend you look into the history of why these sorts of regulations exist. Start here: https://historynewsnetwork.org/article/149661

> which is likely impossible to keep from being corrupt (easy to believe if you've ever met an actual human being).

Have you met any human beings? Try not to be so cynical, damn.

Peak? This is the most heavily regulated market in the US, and fully 40% of all medical spending is from federal, state, and local governments.

This is peak political corruption.

I have seen estimates that as much as two thirds of healthcare spending actually traces back to the govt when you count subsidies too. It is a mostly-socialized system at this point.

And of course even where the govt is not funding the product, they are stipulating in detail what it must include. E.g. insurance must include a long list of things from mental health care to nicotine patches, forcing people to go through their insurance rather than through a market where they would negotiate prices.

Huh? Medicine is highly regulated. If this was a market you would have hospitals posting prices and negotiating with customers directly on price / quality.

Instead health plans market to EMPLOYERS (not the consumers of the actual product). Trust me - the service there is pretty amazing! Tax law is designed to in many cases benefit these employer negotiated plans.

The market conditions as they stand today were constructed by the participants in that market. This is an outcome that one can reasonably expect, since lawmakers can be bought and a large proportion of health services are pretty much completely inelastic.

Buying people off isn’t a result of capitalism, it’s always going to be a problem because of fundamental human incentives. Any system will fail if it’s administrators are corrupt and simply abandon the system. You’re basically blaming capitalism for the government failing to uphold capitalism, it’s absurd.

> Buying people off isn’t a result of capitalism

Buying people off is the essence of capitalism.

But otherwise I could be made responsible to pay for that other poor soul, the concept of risk distribution is too complicated and strokes of fate never touch me.

The issue in the US seems to be that even if you have a decent insurance plan you can still easily end up getting treatment by someone out of network. An anaesthesiologist or similar.

I wonder how it works if you're wearing a shirt that says "Don't touch me unless you are in network with xyz insurance plan #".

That won't save you. The doctor left the room and did a quick phone consult with a radiologist about your x-ray. Radiologist is out of network, so you'll get a big, fat, separate bill from them.

I’m just waiting for experion to get hacked again and all this info to be public.

That was my first thought—then I recalled, "no that was Equifax, wasn't it?"

Sadly, no. It's been all of them, including Experian. This seems flat-out mad to me.


Well, the Equifax hack was way bigger. Probably took a little pressure off of the other bureaus when that happened.

Periodic reminder that there are more bureaus than just Equifax, Experian, and TransUnion, and all of them buy and sell your data every day. One of them [3] even sells your salary data to prospective employers so that they can negotiate against you more effectively.

1. https://www.thebalance.com/6-small-credit-reporting-agencies...

2. https://www.doctorofcredit.com/two-credit-bureaus-you-should...

3. https://www.theworknumber.com/

Holy shit at number three. As if we didn't have enough reasons to despise Equifax already.

Nonsense. A public good is something that doesn't run out when more people use it, such as knowledge. Medical care makes use of limited resources such as drugs, hospitals, doctors and nurses.

So absolutely happy to be Canadian.

Eventually coming to all countries as the elite in power are falling for the prospect of huge money...

I hope the US Federal Government does something to fix the situation for Healthcare. Healthcare and Education seem like the biggest issues in the US currently, just being unlucky on either aspect, even if you make amazing money can throw you into poverty it seems.. seems like a horrible way to live in constant fear.

As a consultant, with a couple of monthly prescriptions (thyroid, asthma, allergies), and a wife with a couple of monthly prescriptions (allergies, asthma), we pay just under $2000/mo for insurance, then about $200 every few months for doctor bills, and around $150/mo for all of our prescriptions.

All in all, we spend about half the median household income each year in health care. When my wife got pneumonia after the flu, we had to drop thousands on an ER visit.

If I wasn't well paid, between our allergies and asthma, we'd probably dead.

This is where my family was in 2017. In 2018 I took a FT job with my biggest client when they offered to pay 100% of a significantly better health plan for my entire family. I didn't regret it then and I don't regret it now.

Congrats, sincerely, but it seems very wrong that an arrangement can exist where if you lose or leave your current job, you might die.

In the US if you leave your job for any reason you don't lose your insurance. You have access to the same plan for at least 18 months (some situations up to 36 months) through a law named COBRA. You have to pay all the premiums but that's what an emergency fund is for.

That doesn't address the underlying problem, namely the absolutely bat-shit insanely high cost of health care in the US. I have the cheapest family plan I can get. It comes with a ~$12k annual deductible and still manages to cost more than my mortgage every month.

Under COBRA, you have to pay the employee portion plus a 2% administration fee, which means that for the average family you'll be paying 3x to 4x as much.

How many families have an emergency fund that can cope with: rent/mortgage, car, utilities, and $2,000+/mo healthcare in the event of unemployment?

This is the crazy part to me. You have private insurance, but the quality of the insurance is so piss poor that one wonders what the point of it is in the first place. Nothing seems to ever be fully covered under it.

The insurance is there to pay for the $20k+ heart attacks, premature babies needing NICU at probably $100k+, hemophilics needing $500k+ medications, etc. Also, if you're young, you're subsidizing healthcare for the old. If you're not poor (per government definition) and don't qualify for health insurance premium tax credits, then you're subsidizing them too. And if you're a male, you're subsidizing childbirth and other women specific costs. And who knows what else.

In other words, it's the same as a tax to pay for healthcare for the country, except it goes to insurance companies, and you have to deal with in network and out of network. Except this tax goes up the older you get (but capped at 3x what youngest/healthiest person pays).

Presumably, if you add up all the insurance premiums paid for every year of a person's life, it should theoretically add up to close to how much the insurance company expects to spend on you (plus some profit, capped at 20% by ACA).

The biggest joke is that Americans think that the amounts they are charged for healthcare services is what those services really cost to administer. It's really not even close. A heart attack does not cost $20k+ to treat in other developed countries. A broken arm costs maybe $200 equivalent in the UK vs multiple thousands in the US. I'm not talking about how much the patient is charged, I'm talking about paying the doctors for their time and affording the equipment to perform the treatment.

There's always the anecdata that floats around the internet claiming that you can fly to Spain, live their for 6 months, get a hip replacement, and fly back to the US for the same amount as the outpatient surgery costs in the US. It's basically true, though the numbers may have drifted slightly since it first started making the rounds.

> it's the same as a tax to pay for healthcare for the country, except it goes to insurance companies, and you have to deal with in network and out of network

I think this is one of the strongest ways to frame government-provided healthcare. It's no different paying a tax vs paying the company directly, and in the former case you have the whole US government bargaining on your behalf for reasonable healthcare costs (in the case of single-payer a la M4A).

> capped at 20% by ACA

20% is a lot when we're talking about these outrageous numbers.

> 20% is a lot when we're talking about these outrageous numbers.

It’s not 20% net income, it’s 80% of premiums have to be paid out to healthcare providers. There’s still all the costs of operating the insurance organization, and financials of publicly listed health insurance companies show net income in the 3% to 6% range.

Take the NHS in the United Kingdom.

For my high wage, my NHS fee would be just under £7k for the year, my taxes just about at 30%.

Granted here in the US, my taxes are ONLY 25%, but my healthcare costs are close to $30k/year.

That $20k difference is ridiculous ($11k more than in the UK when comparing tax+health), and I HAVEN'T gone to the hospital for a heart attack or premature baby or hemophilia, but if my wife did have a baby, it would cost us out of pocket around $8k (according to the likely VERY skewed numbers in my insurance packet).

A colleague I know is 54, he is single, has only catastrophic coverage and pays $1200/mo. Nothing is covered except 40% of any emergency hospitalizations. The bronze plan was $2000 and had a $15k deductible, and also was basically only co-insurance with $30 generics.

The way we are doing this here in the US is literally killing people. Medical debt is increasing.

My little sister-in-law was on vacation and walking along a path on a jetty with handrails, and benches, and dozens of other people. A rogue wave came and hit her and her friend. She was taken under, knocked unconscious and drowned (and died), until a random stranger who was standing near her finally found her and resuscitated her. She was medivaced to a hospital by helicopter that insurance only covered 10% of because she was out of network, she was then treated by a dozen or so doctors for multiple days as she got pneumonia and broken bones, and head trauma, all out of network. She ended up owing close to $100k with her insurance only covering the first $25k. In any other first-world country, she'd be out of pocket maybe a few hundred bucks. Not in collections for being unable to pay $75k for a freak accident.

Interesting that your NHS fees are at £7k for the year. That's about the amount I pay for my family's annual insurance premiums + deductible.

I'm no fan of insurance/hospital bureaucracy, but at least I can go to any specialist doctor I want without having to see a GP first. And I pick the job and insurance provider I want to reduce the amount my family pays each year.

Emergency situations like the last one you mentioned, if they are out of network, are still covered at in network rates, thanks to my insurance plan specifically stating that in their plan documentation. I feel bad for your sister-in-law and am glad she survived, but she did have a not so great insurance plan. I would strongly consider getting a different job or lobbying hard with my workplace HR if I had a plan that would only pay 10% in true emergency situations.

> That's about the amount I pay for my family's annual insurance premiums + deductible.

Look at what it would cost to cover you and your family on the individual market without government or employer subsidies. As a contractor, I pay double what you do on the individual market, and that is only coverage for myself.

Your employer must be paying for a portion of your health insurance premiums, so you have to include that if you’re going to compare to the $7k GBP figure.

And everyone would get a different job with nice health insurance offerings, if they could.

Not to disprove my original point about how affordable the NHS is compared to my Made in America insurance, but the £7k is only the employee side, the employers also pay a bit (though much less), but a common benefit of most employers is private insurance on top of national insurance.

If my math is correct, employer + employee national health fee for £140k salaried employee is a few quid short of £10k which is still half of my annual health care expense, so my original point still stands.

Medical debt is the #1 cause of bankruptcy in the US.

Being forced to ruin your credit because you got sick or had an accident is sociopathic.

> And if you're a male, you're subsidizing childbirth and other women specific costs.

And to that I say: fine. I will happily subsidize, through my tax dollars, health care to pregnant women, addicts, the obese, down-and-outers, whoever, so long as it means that everyone has access to doctors and hospitals when they need it.

I am far less worried about paying a few bucks a year to support someone whose condition I will never have, than I am about sustaining this spider's web of private health insurance, with its unaffordable deductibles and an endless list of shady practices. America doesn't need health insurance companies to act as intermediaries between us and our doctors. They add nothing.

> And if you're a male, you're subsidizing childbirth

Replace "male" with "child free" and this makes sense but suggesting men are subsidizing childbirth is ridiculous.

> and other women specific costs.


> Men die younger than women, and they are more burdened by illness during life. They fall ill at a younger age and have more chronic illnesses than women. For example, men are nearly 10 times more likely to get inguinal hernias than women, and five times more likely to have aortic aneurysms. American men are about four times more likely to be hit by gout; they are more than three times more likely than women to develop kidney stones, to become alcoholics, or to have bladder cancer. And they are about twice as likely to suffer from emphysema or a duodenal ulcer. Although women see doctors more often than men, men cost our society much more for medical care beyond age 65.

Yes, it's very likely I am wrong about that statement.

I assumed that because before ACA, childbirth was not covered by insurance and insurance pricing based on gender was allowed, and post ACA, childbirth was mandatory and insurance pricing based on gender disallowed, that it must mean that, in general, healthcare costs more for women than it did for men.

But perhaps that's only true for young men and women, if true at all?

if you weren't well paid, you could be one of the various state/federal welfare programs such as Medicaid and your bills would be much, much lower

Depends on where they live[1], there are several states that didn't expand Medicaid under the ACA. They'd also have to make under 100-138% of the federal poverty level, which is ~$12,490-17,236.20 for individuals and ~$16,910-23,335.80 for couples.

[1] https://www.kff.org/medicaid/issue-brief/status-of-state-med...

In most states to qualify for that you have to be very poorly paid. And in many states, like Georgia for instance, Medicaid covers needy children, pregnant women, parents/caretakers, elderly, disabled and blind residents and people in need of nursing home care.

Good luck if you fall outside of that list.

Indeed. Don't live in Georgia.

Unfortunately the people who are most impacted by this are the people who are least able to afford the move to another state. Especially when nearly every state in the south decided not to expand medicaid.

healthcare is getting so bad that eventually medicare for all will be a republican position too. They will call it something else, but it will happen. the party has fundamentally changed.

Oligarchs know that money has to be spent to keep the plebs just well enough to prevent revolt.

> medicare for all will be a republican position too. They will call it something else

There was a survey that went around a few years, asking Republican voters something along the lines of:

"Would you vote for an Affordable Care Act if it was offered as an alternative to Obamacare?"

A significant amount said "Yes".

There was also a survey (not filtered by party affiliation) asking if people would support a single-payer program with an elimination of private insurance. A majority said "Yes."

Unfortunately, there is no evidence of this, especially when Republicans recently took away food stamps people rely on to feed themselves.

Can't revolt if you're disabled and untreated, tied to your job to keep your kids healthy, incapacitated by treatable illness or weak from hunger.

yeah we have a few more years yet before the turn of the tide, but I remain confident it will happen

I'm not sure where the confidence comes from when in 2017, Republicans in the House and Senate tried to repeal the ACA without a replacement. It's on their radar and part of their platform is removing any type of protections or public access to healthcare.

but what did the president say in his recent address? he said the opposite. he said that because it's popular with his base. the republican party is now his party, and the old core ideals will be washed away.

like I said, they'll call it something else. repeal obamacare and make something new that will basically be medicare for all in some shape or form. it will be a handout to the big insurance, drug, and healthcare companies, I'm sure.

The president also said he had a great healthcare plan, trust him, and that he'd repeal the ACA with that great replacement. When it came time to repeal the ACA, there was no such replacement. The president says a lot of things, many of which aren't true.

Yeah, I know, he's a buffoon. What's important to me is his base. Other than the evangelical vote that is single-issue (abortion), the base is essentially just "rage against the elites" and they need healthcare badly.

I didn't specify before but I'm talking like 8-12 years down the line.

I think so too. The main thing is that it might even lower how much money is paid for that healthcare system in total.

I wish we could see promotion of good health and good education as investments in our country.

So every other country in the first world offering some form of socialized medicine will inevitably be like this, the US is just "winning" and leading the charge?

Or are we more the token outlier with a "worst of all worlds" system?

Government-run health care systems tend to lead to higher healthcare costs, since the beneficiaries aren't the payers.

Around the world, it appears that low costs lead to universal healthcare, not the other way around.

What America needs to do is make it cheaper and easier to become a medical practitioner without taking on half a million dollars in debt and wasting half of one's pre-retirement life. No fancy government program will work without first addressing that issue.

What is your evidence for this? The US is almost alone amongst developed countries in not having a government-run general heal care system, and has the highest costs (while not covering everyone).

And Medicaid, Medicare, and the Veterans Administration (the three big government run healthcare systems here) all run more efficiently by every measure than any private health insurance system.

Note that I fully recognize the problems that the VA has had, but when you really look at it fairly, they have many parallels to problems in the commercial side of the system, we just don't tolerate that when it comes to government (nor should we).

>What is your evidence for this?

After Canada implemented universal healthcare, costs rose rapidly before stabilizing: https://www.ncbi.nlm.nih.gov/pubmed/379054

Both private insurance and taxpayer-subsidized programs pay astronomically high prices for healthcare; I haven't seen any examples of Medicare paying European-level prices for services.

> Government-run health care systems tend to lead to higher healthcare costs

I know this feels true because laissez-faire and commie-bashing rhetoric is still common in the Western world, but there have been numerous studies recently showing that the US is the most costly per capita. The next 3 countries (by 2016 numbers) are all places where most things are more expensive because the country and its citizens are relatively rich: Switzerland, Luxembourg, and Norway.

There's even a Wikipedia article about it: https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

Of particular interest is this graph, which breaks it down by public vs private spending: https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

Can you explain how your links dispute the notion that "low healthcare costs lead to universalization, rather than the other way around"?

I feel like you didn't read and fully understand my comment.

Sounds pretty defeatist to me.

What I don't like is low-effort memespeak on HN (even if I agree with the sentiment). This is one of the last places that has kept that at bay - until recently.

From the HN guidelines:

"Please don't submit comments saying that HN is turning into Reddit. It's a semi-noob illusion, as old as the hills."

Yes, I can see that your account was created in 2011 :)

I'm aware of that guideline which is why I didn't say that exactly.

Regardless, I don't think silent downvotes really cut it anymore either - nowadays I tend to run out of them after reading only a couple submissions with active comment threads.

Seems like proper application of the downvote button is called for.

I did apply it, and this is my explanation of why, which is proper etiquette.

I think one-offs like this are ok, and I'd like to think mine was a step above "low-effort" ;) Besides, check out the discussion it spawned!

It's those long chains that end up being an out-of-order recital of some famous TV/movie scene that really irk me, personally. Those and similar are cases where the value is only in recognizing the source and getting that dopamine hit, and not in any further contribution to the discussion.

Can we call it a cartel market instead of private markets?

The various healthcare leaders use their wealth to strengthen their position through laws.

Most sectors cannot operate like US medical, they are their own beast.

> The various healthcare leaders use their wealth to strengthen their position through laws.

Everyone who can does that. Laws and politics aren't a separate magisterium from business; there are no hard borders here.

There is one difference: violence. Laws are enforced on threat of violence. A business cannot force you to follow their procedures, at most they can deny you business. If I start selling drugs I import at a cheaper price, the government will use violence to stop me (including potential enslavement for a few years).

That one difference is all that matters.

That's a difference, yes, but orthogonal to the topic.

As a businessman, as much as you can direct the behavior of both your customers and your employees, you can influence the lawmakers. After all, they too want money or things that money can buy.

Violence is just one side of the coin that is power. The other side is voluntary (or technically voluntary but not quite) participation, which is primarily controlled by money. That's what makes politics and markets intertwined.

Then healthcare shouldn’t be a business because the natural result of refusing to provide it to those in need is injury and possibly death. That seems a greater and more imminent threat that people in the US face than most forms of state violence.

Isn't it natural to want to only "sell" to "customers" that are profitable? This is a natural function of other markets.

It's also pretty natural to not want to die because of an error on your credit report. Imagine, for a moment, that some other cwzwarich filed for bankruptcy a few years ago. By some (incredibly common) mistake, their bankruptcy ends up on your credit report. And you go in to the Emergency Room with a potentially life-threatening injury.

The doctor runs credit on you before providing treatment, and because of this erroneous bankruptcy that you may not even know about(credit reports can only be reviewed once per year), you are placed in the hallway instead of being given a private bay despite the increased risk of infection. The hospital wanted to make room for paying customers, you see.

So while it's natural to want to "sell" to "profitable customers" in this case applying free market principals to this makes a complete mockery of our health care system. And given the credit bureaus' track records of high inaccuracy and difficulty in disputing the reports, you're likely to get poorer treatment inexplicably, and entirely by accident.

Is there anything that shouldn’t be treated like a market?

Street lights? Police and Fire protection? Water access?

I don't think that health care (or the things you mention) should be treated as a market. I was only responding to the claim that this is a "cartel market" and not basic market behavior.

Gotcha. I've asked myself those questions to probe my feelings. I think things are going to get pretty ugly as the US starts to grapple with this again.

Which law specifically permitted this behavior, and under what laws was it illegal before that?

Maybe finding new ways for the market isn't the best approach. What about publicly shaming the people who profit off of this?

I remember there was a big outrage about Martin Shkreli's actions. Meanwhile the CEOs of these companies probably get lauded in business magazines.

Calling these miserable, greedy, selfish bastards out for what they are could be a first step. God, how I'm hoping for a socialist revolution to take place within my lifetime...

What about publicly shaming the people who profit off of this?

We've seen that this is something that absolutely doesn't work. They (that's the people who matter) just find a scapegoat and everyone else carries on just as before. Shkreli ended up in prison, but Valeant is still busy making profit off the backs of patients, and despite Hillary Clinton's professed outrage prices for such drugs as Syprine haven't gone down a penny. Netflix has a documentary on the case.

Where is the revolution? Where is single-payer healthcare?

Americans don't want single-payer healthcare. If they did, they'd be voting for it. Instead, they (especially poor, rural voters) strongly vote for the party that says they're keeping "socialism" out of healthcare.

Americans are getting exactly what they voted for.

A socialist revolution? Do you mean that you'd like the US to become more like Sweden, a social democracy? Because it bears repeating, there is not a single desirable place to live on Earth that is not primarily governed by free market forces, including Sweden. Sweden, Norway, Canada...these are not socialist states.

Also, let's be clear about one more thing. Martin Shkreli is not a free market capitalist, he's a crony. Leveraging state patent systems to create abusive monopolies is not free market capitalism, that is textbook crony capitalism and the enemy of a free market. Without arbitrary state enforcement of medical patents on insulin and epipens, do you think that these would be exceedingly expensive items? Are you being bankrupted by Benadryl? Hardly.

There are absolutely elements of healthcare that are far better serviced by a command economy than a free market, and I think the weird hybrid system in the US is the worst of both worlds in many such cases. But a socialist revolution? Socialism is an authoritarian nightmare that cannot suitably answer any question related to scarcity or competence.

The thing you're missing about "free market capitalism" is that, in the USA today, our "free market capitalism" absolutely does include state patent systems leveraged to create abusive monopolies. You might call it "crony capitalism", and you claim that it's not "true" "free market capitalism" (which sounds like the No True Scotsman fallacy to me), but the fact is, one of two major political parties in this country does say that what we have now, and what they want to retain, is "free market capitalism".

As for "socialism", again you're disagreeing on definitions. To most Americans, Sweden, Norway, Canada, etc. are "socialist".

Almost no product that you use is subject to abusive state monopolies, which is why almost every product you use is competitively priced. So no, free market capitalism is not indistinguishable from crony capitalism.

As far as definitions go, my definition of "socialism" is actual socialism, not social democracy. This quote is overused at this point, but Danish PM Rasmussen explicitly clarifies "I know that some people in the US associate the Nordic model with some sort of socialism. Therefore I would like to make one thing clear. Denmark is far from a socialist planned economy. Denmark is a market economy." Adding central planning to ameliorate some of the rough edges of market economies does not create a socialist state.

>As far as definitions go, my definition of "socialism" is actual socialism, not social democracy.

Again, most Americans will disagree with you. The definition of a word is whatever most people agree it is.

>This quote is overused at this point, but Danish PM Rasmussen explicitly clarifies

No one in Denmark has any authority to define a word in the English language as used by Americans.

>Adding central planning to ameliorate some of the rough edges of market economies does not create a socialist state.

According to Americans, it absolutely does.

>So no, free market capitalism is not indistinguishable from crony capitalism.

Again, according to many Americans it is.

Here's a challenge for you: pick out 100 different rural counties across America. Go to each county, and take a poll, asking them, "Is Denmark a socialist country?" I guarantee you that a clear majority of those polled will answer "yes".

If this conversation is now between whether "socialism" means "socialism" or "social democracy" to you, I actually don't care. As long as you are not advocating for a revolution that results in actual socialism, then I have no problem with you.

I'm not advocating for anything. All I'm doing is attempting to point out that it's really hard to have a rational discussion about something when people can't agree on basic concepts and definitions. And the problem in America now is this: we can't even agree on what "socialism" is, or whether we want it or not.

Just try having a conversation with the average American voter (esp. in rural districts) about "socialism" vs. "social democracy" vs. whatever, and see how far you get. They're probably going to say Denmark is "socialist" because they saw it on Fox News. But these are the people electing the leadership here (or about half of it anyway). We have two "sides", and even many on your side probably would have a hard time with these concepts. It's no wonder things are so broken here, and I don't see how it can get better any time soon when the two sides can't even have a rational discussion because they can't even agree on basic language or concepts.

'public good' doesn't mean 'thing I want the government to give me'. Your sentance is complete edgy nonsense.


For those who don't know the definition:

"In economics, a public good is a good that is both non-excludable and non-rivalrous"

"A good is considered non-rivalrous ... if, for any level of production, the cost of providing it to a marginal (additional) individual is zero"

"... a good or service is non-excludable if non-paying consumers cannot be prevented from accessing it."

I suppose "public service" is technically the more appropriate term. But it is a public benefit in the sense that healthy people can contribute more to a healthy economy.

You know what he's saying though.

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