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Money Won’t Buy You Health Insurance (nytimes.com)
596 points by epall on Feb 21, 2011 | hide | past | web | favorite | 423 comments

This really highlights how utterly insane our system is. I'm living off of my own business, which means that I don't have an employer to cover me under group insurance. But I really only make enough to live frugally and save a tiny amount each month--to me, an affordable health insurance plan would be between $50-$100 a month.

Fat chance of that happening. And if it did, the deductible would be so high as to make the plan worthless for anything short of a car-crash-emergency-type-situation.

But not only would it not happen at that price, but as the article says, it wouldn't happen period--even though I'm a healthy, nonsmoking, active 26-year-old male, I've had cubital tunnel problems in the past (typing) and surgery on my wrist (badly broken in an accident). If I applied, I would surely be denied--and again, as the article states, if you're denied once, your chances of being accepted in the future just dropped by a big percentage.

It literally makes more financial sense for me to pay minor expenses out of pocket and declare bankruptcy in the chance of crippling bills than to be insured.

Healthcare in America is utterly, utterly broken; it's damaging poor, middle-class, and rich people alike, and stifling innovation. I have the ability to innovate with my company because I'm young, single, and healthy; but many smart people have existing medical problems, families, or other factors that make them indentured servants to the company that pays their healthcare. As a nation we're under the thumb of the insurance companies, and instead of doing anything serious about it, we've done almost the worst possible option: require every one of us to be a customer of these monstrous companies, with little regulation on cost or other government oversight. I'm the first person to back health insurance reform, but we've reformed it in the name of shoveling more money into the pockets of industry instead of for regular people needing real care.

It's crap like this that's compelling me to make my current expat lifestyle permanent. America might still get the tax dollars my business generates (the only country to still tax you if you live abroad) but it won't get my brain or my talent within its borders.

Let's keep perspective here. Because, your critique of the health insurance system seems to simultaneously affirm and entirely miss the point of the article.

A close read of your first three grafs --- the only ones that respond to the article --- suggests that you wish you could get something better than "car-crash-emergency" insurance for 50-100. Well. Let's unpack what you're missing here.

(1) The author of this article, like my own family, can't get "car-crash-emergency" insurance for 50, 100, or 500 dollars a month. Never mind the deductable. If your records include a shred of evidence of 150+ seemingly-random conditions†, you're an automatic decline. That's the problem the article is bringing up.

(2) A system in which only "car-crash-emergency" care was automatically covered would be workable; a vast improvement over what we have today! Outside of car crashes and appendicitis††, you in fact don't spend $1200/year on health care. We're a family of four, and we don't spend $1200/year on health care, let alone $4800/year or (gak) the significantly greater amount we really spend on the low-deductable group coverage we set up for Matasano.

A $5k deductable would suit us just fine; we'd save, significantly, simply by plowing the money we would have spent on crazy bullshit low-deductable insurance into an interest-bearing vehicle and shelling out from it when we actually needed care, all the while secure in the knowledge that when someone ends up in the ICU, our liability is capped. Not for nothing, but this is a scheme that both Dems and Republicans buy into.

Health care in America is broken. But it's not "utterly, utterly" broken. Whatever the number of random medical bk's we have in the US, it's too high. But we don't need to transform our health insurance system into the National Health or the French system. We are epsilon away from a Swiss-style system of mandatory and guaranteed-issue private insurance.

http://www.thecasongroup.com/forms/enrollment/Humana/H1%20Un... .

†† Many tens of thousands of dollars. Happened to a friend.

Have you looked into this (for California but there are different plans in every other state)? http://www.healthcare.gov/law/provisions/preexisting/states/...

"$499 for a 50 year old subscriber in San Francisco"

Looking at other states, there are premiums as low as $172/month.

It would surely be much cheaper for you as a 26-year-old. Not quite the $50-100 you're looking for but I'd bet you could afford it.

Things are bad but maybe not as bad for you as you think.

This looks like a good resource--thanks for that.

Right now my current location is Monterrey, Mexico, so again, doctor visits are cheaper to simply pay out of pocket. As an example, my uninsured girlfriend had to visit a doctor last week--a walk in appointment at the major Monterrey hospital plus lab test, technician, and prescription medication: 800 pesos, or about $66. And this is in a modern hospital in the most expensive city in Mexico.

I'm 28 in Florida. I have a very decent plan for $75 a month. I have to pay for office vists (tho I am reimbused $50 for each one, they're usually around $125 or so) but i have a very low deductible that will cover me for any major illness or accident, and even for services beyond my coverage I get the benefit of the lower negotiated insurance company rates.

You can see these plans for yourself by checking our Blue Cross or Humana in Florida, among others.

Wow, for a family of five I pay $1200/month. And not a very low deductible. Also Blue Cross... go figure.

Wow Just to make it even worse for you, that's 1 year of Blue Cross for my wife who is studying in Canada currently. This is a private insurance provided by Blue Cross for students.

I pay about $550/mo for the 5 of us, but that's just because my employer pays 2/3s of the cost.

Only $282.30 in PA. Good to know about if I ever need it.


I got good insurance in CA for $167 a month as a 26 year old last year. This year, the premiums went up to $240.

to me, an affordable health insurance plan would be between $50-$100 a month.

Fat chance of that happening. And if it did, the deductible would be so high as to make the plan worthless for anything short of a car-crash-emergency-type-situation.

Actually, that's exactly the policy you want as a healthy 26 year old: $5,000 deductible catastrophic coverage, and nothing more. It'll cost you $86 per month from Blue Shield.

Health insurance, in the sense that you see it in group policies from your employer, is not worth the cost if you're buying it yourself. It will be 15 years before you get to the point where a $50 copay and low deductible make sense. Think about it. How often are you at the doctor? Once a year? Once every 3 years? And it costs you a hundred bucks or so. That's not something you need to be insuring yourself against.

The key is to keep a bit of insurance just in case you get in that car crash and need new hip joints, or if you suddenly develop bone cancer and are looking at $10k/month health care bills. Those things are crazy rare, and the policy that protects you against them is priced accordingly.

I guess you may be much healthier than the people I know, but I don't think I know very many people who go three years without a visit to the doctor. We all get infections that are considered minor and routine due to our medical care, but if we can't get that medical care they can be life-threatening, like strep throat or other common winter ailments. We all sometimes have accidents and trip and need to go to the hospital. There are lots of other things. Counting on visiting only once every three years is a bit dangerous imo.

I remember exactly one doctor's visit in my 20s (bad dose of poison oak), one in my early 30s (bad bouldering fall), then nothing until age 39. So yeah, your mileage may vary.

Needless to say, I never came close to hitting my $5k deductible. (or even my $250 annual deductible in the years when I had company-sponsored insurance).

>to me, an affordable health insurance plan would be between $50-$100 a month.

Fat chance of that happening. And if it did, the deductible would be so high as to make the plan worthless for anything short of a car-crash-emergency-type-situation.

This fits a fair number of cost complaints I hear over healthcare. Who wouldn't like to pay $50-100/month to have something better than emergency healthcare support? But think about the costs of such a system, regardless of inefficiencies / the problems of the current system that make things cost hundreds of thousands:

Doctors and nurses and supporting staff must exist. So must hospitals. They are highly trained, and will be expensive - period. They also have to keep learning, so they can't be busy making money all the time. And they must have such people available all the time, or people die.

Given that, and the equipment and check-up and hospital time, how much should a minor surgery cost? Not in cost to you, in cost. If the cost to you is mitigated in any way, it's extracted another way (taxes). I'd have trouble seeing it cost less than a few thousand dollars in the best, highly-used system. That's a lot of training and a lot of supporting necessities for any random surgery.

At $50-100/month, they would have to sap you for nearly a decade to make up a single surgery. It might even out for the insurance company if that was it - but certainly not when you get older, and not with any kind of routine, preventative care. Scale that up to emergency situations where major surgery and years of rehab for even 0.1% of the people they're covering - how many hundreds of years does that cost everyone on the plan?

Cataclysmic health insurance is cheap because it only covers cataclysms. Because one in a hundred lives cost an utterly enormous amount more than a single person generates.


None of this is to say that I think the healthcare system is efficient by any means, nor not full of corruption, waste, frivolous lawsuits, or damaging dogma. Merely that there is simply a bottom limit that the prices that people want to pay will never be able to support, unless all cataclysmic protection is dropped. And would you rather die from a car crash, or be rehab'd for a couple years and continue your life for another 60 years? So people choose the cataclysmic protection, and prices jump.


edit: because this seems it will come up often, some evidence for my claim based on Canada's setup, copied from another comment I made below: http://en.wikipedia.org/wiki/Health_care_in_Canada

>In 2009, the government funded about 70% of Canadians' health care costs.

>Per capita expenditure in 2009: 3,895

$227 per month, per person, comes from the government, which means it comes from taxes. And an additional $100 per person is spent per month on average ($324.58 per month). Far in excess of $50-$100.

Japan forces their doctors to charge only what's published in a book that the government issues and negotiates prices periodically. Simple price fixing in an otherwise private healthcare market. In return, Japanese doctors and hospitals (FYI, there are more private hospitals in Japan than the US) are allowed to set whatever prices for ancillary services (like private or semi-private rooms) that they want. BTW, the average stay overnight in a private room at a Japanese hospital is about $100. An MRI (which was 1400 negotiated down to 700 FTA) is $98, due largely to the fact that the Japanese have more MRIs and CT scanners per capita than the US. I mean, wasn't technology supposed to be our superiority play?

And, if you want to talk care and outcomes, let's pick the most grim of diagnostics: Cancer. Japan's 5-year survival rates are among the highest in the world, and the highest in particular cancers such as colon and rectal cancer. And, FYI, the US isn't #1 in survival rates for all cancers. It's spread evenly through the G8.

And, the most free of supposed free markets and tax-friendly wonderlands, Singapore, also puts price controls on procedures, with similarly successful outcomes. So it isn't a cultural or "economic" thing, it's a government thing. It always will be. An adult just needs to come in, put their foot down similar to what Tommy Douglas did in Canada, and declare either we all buy in to a government-run healthcare system, or we buy in to the government completely regulating the market much like it does the stock market or agricultural industry. States will have no say, no quarter, or feedback. They can choose to secede from the union to opt-out of the program.

And, while I love me some comment karma, I know that my position is tantamount to heresy on this board, so, get your dismissive hand cocked and ready to wave me away :D

What people don't like to admit is that free markets don't work for healthcare. What is the price you're willing to pay for curing that tumor in your gut? Everything you have. There is no supply vs. demand. Only supply vs infinity.

What would happen to the food market were it not for the generally high supply of food? It wouldn't be pretty.

Because of that, some sort of non-market intervention is simply unavoidable. As are the inefficiencies that go along with price controls and other similar endeavors. Ugly stuff, this healthcare business.

This is a weird summary of how "free markets" and "supply and demand" work. Yes, you will pay everything you have for a cure. But the guy who will offer you a cure for "everything you have minus one dollar" is going to get your business.

But the guy who will offer you a cure for "everything you have minus one dollar" is going to get your business.

Not necessarily. Suppose you have a deadly condition. Your information is extremely limited as non-professional. Would ... you can pay all your money now for the cure your doctor offers or you can wander over to an unknown provider for the best price? The quality of unknown providers is ... unknown and your doctor is known. And he knows he's got by the genitalia and will charge accordingly since with even a thousand unknown providers, your real choices are very limited.

Just as much. Presently, no American hospital publishes its price list. I believe there's no regulation about this. Why hasn't "the market" impelled these providers to publish their prices.

Presently, no American hospital publishes its price list.

Almost every American hospital publishes its price list to its primary customers: the insurance companies. The problem as I see it is that the insurance companies are the only entities that can get fair prices for health care, and they want to keep it that way. A potential solution would be to ban insurance discounts; a health-care provider could charge any price it wants, but it would be required to charge all customers the same price. Insurance companies would still negotiate for lower prices, so it would benefit all of us.

My experience has been that if you don't have insurance, the hospital will cut a big chunk out of your bill immediately. Their "negotiated rates" are all just made up things they put on the insurance bill because insurers can pay a lot of money. The insurer calls and says "Hello, I would like a discount". And the guy says "Ah, yes, our standard rate is cash rate + $1000, but for you, I'll take off $500".

For instance, a podiatrist I know charges $350 to the insurance company (which shows this as the discounted, negotiated rate) but $150 cash to remove an ingrown toenail.

I'm sure there are exceptions.

Just had a pair of major surgeries in my immediate family. When we offered to pay cash, they immediately knocked 50-66% off all the costs. That included anaesthesiologist, room rental, and doctor's time.

This "retail rate" mentioned in the article is crap.

I see this cash discounting frequently, and it makes sense, as it's easier (faster, more certain) for the doctor to take the cash than to deal with billing the insurance company.

A bigger problem I have is that it's hard to get this information ahead of time. Hospitals don't want to tell you, if you come in for this operation and are willing to pay cash, total cost will be $x (and it should be total cost, including rooms, drugs, anesthesiologist, surgeon, nurses, etc.). If you could get that quote, you could comparison-shop hospitals ahead of time.

My doctor and I had this discussion recently. He said that he is legally not allowed to advertise or share prices. The laws won't allow it as to prevent price fixing.

This was in Texas, so maybe someone that understands the laws can chime in and comment on that.

I work in healthcare and while I might be incorrect, this is my understanding of the situation.

Medicare is the largest payer of insurance claims by far. Medicare also has a lot of rules. One of these rules is that, in order to prevent providers from shortchanging Medicare, they have to charge everyone the same price (otherwise medicare would be overpaying....). Medicare will then pay 80% of the indicated amount and the rest is covered by medigap insurance, Medicaid, or by the patient.

As you might imagine, the lack of ability to price discriminate, even to patients, hugely distorts the market. However, private insurers have gotten around this (how I don't totally understand), by using what is called the contractually "allowed amount". This is an agreement that the provider will write off the variance between the allowed amount and the billed amount. This results in de facto price discrimination for large insurers while getting around the medicare law. Patient's don't have this kind of gig.

Of course, there are tons of other corruptions and inefficiencies in the system. I could tell you a story about a friend who once worked for NY Medicaid who was actively prevented from working to prevent the state from going bankrupt by paying claims.

I don't have the answers, but there is serious distortion of the market ATM.

If you dig enough in the medicare automated billing system documentation, you can find prices for particular codes. At least what medicare is willing to pay.

I hope I never have to use this information, but it's out there.

here's the medicare fee schedules. You need to map codes to costs and locations, but it's doable.


I will try to speak for the parent. I think that he meant that everything being equal most people would rather save that dollar.

What are we discussing here? Do you not know the difference between elastic and inelastic markets? Health Care cannot ever be a free market because it is utterly inelastic.

By that argument, food, water cannot be a free market either. I am not saying that health care works best in a free market or not, but whether it is elastic/inelastic is not the only factor. Also, depending on which health care we are talking about, it is certainly elastic: sure, if you just got shot and are mortally wounded, you are pretty much ready to pay anything you can to get treated, but maybe that private room or new cancer treatment twice as expensive without proved benefits is not that necessary.

No he wont. The next guy that comes along and offers a cure for "everything you have minus TWO dollars" gets the business, and so on, until an equilibrium is reached where it is not worth being in the business by offering cheaper prices.

That's not exactly encouraging.

You're not encouraged that there's price competition in health care, or you don't believe that there's price competition in health care?


Sorry - I was joking. Perhaps I should have added a smiley. I get what you're saying. I also think that:

1. the medical industries/professions work very hard at discouraging price competition.

2. price competition is not sufficient to create a healthcare marketplace that works well for society. I'd like to see people without means have at least some access to medical technology/services, even at the cost of inefficiency. But that's just me.

Like I said - it's a beast.

that is true for certain procedures, and not true for others.

you don't have time to shop around for services while unconscious in the back of an ambulance.

Few will admit that we don't have anything close to a free market in healthcare today (or for the past several decades). A truly free market is one unfettered by the FDA, medicare, medicaid, doctor regulations, hospital regulations, HMO regulations, insurance regulations, etc. All of these controls were ostensibly put in place to protect patients, but in actuality they serve to slow innovation and true access to medicine to a crawl.

It is true that some people will choose badly when left to their own devices, but that's better than forcing the same dumb rule on everyone. Each of us is an end in ourselves. So long as we do not violate the negative rights of others, we are responsible only for our own lives, not the lives of our brothers.

How wrong you are.

No man is an island. Neither you, nor anything you create is created in isolation.

Dependencies are ever-present and failing to understand this leads to failed ideas such as "true free market" not unlike the idea of "true communism".

In reality the very fact that you are alive to write your words is a testament of other peoples effort including your parents to guard you against the many many dangers in this world.

Ultimately you don't own the right to anything, not even yourself.

It's an agreed upon right not a natural law.

I agree that there are some times too many regulations. But claiming what you do here is simply wrong in a very unfortunate Ayn Rand way.

Then it's wrong in a very unfortunate Founding Fathers way also. Because the Declaration of Independence states that we DO have inalienable rights and they ARE natural laws (i.e., endowed by our creator, which is a religious way of saying natural law).

The Declaration of Independence says it, so it must be true? The DoI is, among other things, a social contract that most Americans have agreed to, which is exactly what ThomPete said.

My point is that saying the belief is Ayn-Randian is disingenuous, because a lot of founding fathers believed that also. But I guess it's easier to diss on Ayn Rand than it is on Thomas Jefferson.

It's easier to diss on Ayn Rand because her claims are so much bigger. I am not American btw, so I don't have any specific problem dissing Jefferson, I just don't see why I should. I am not against property rights I am against the idea that property rights are natural rights.

I can forgive Jefferson for living in different times, but Ayn Rand should have known better.

The Declaration of Independence is not a natural law it is in any sense of the word a political law.

The Founding Fathers declaration doesn't apply to the 5.8 billion people who lives outside the US.

And even if it did it would not by any metrics be a natural law. Property rights is a human construct nothing else.

For someone who puts so much faith in free markets you don't appear to understand how they work. In your studies, look up "market elasticity" for a clue.

The phrase "market elasticity" is meaningless.

Elasticity in economics describes the relationship between two variables (normally price and demand which is price elasticity [of demand] but by no means exclusively).

But unless you define your variables (or state what sort of elasticity) it's not a useful term and certainly not something I'd be bandying about while suggesting that someone else didn't have a clue.

>The phrase "market elasticity" is meaningless.

Nonsensical. What kind of market theory are you following that doesn't factor in market elasticity? Rush Limbaugh eco 101?

Market theory as I was taught at university during my degree. And you?

As I said the term elasticity isn't meaningless, but without defining the variables you are defining as elastic (or inelastic) it doesn't make sense, at least not without assumptions which obviously may or may be wrong.

Personally by default I'd assume that you were referring to price elasticity of demand - that is the relationship between changes in price and the resulting change in demand, however there are many other types of elasticity (see http://en.wikipedia.org/wiki/Elasticity_(economics)).

So if you want to explain exactly which variables "market elasticity" refers to then that would be great, but as "market" is a very loose term, on it's own it's not very useful.

If you have a degree in economics then you should know very well that health care can not function properly in a laissez faire market. Customers cannot simply "opt out" of health care.

I've not said anything about what I believe in this area (certainly not in this section of the thread), I've merely questioned your use of the term "market elasticity" and what exactly you mean by it.

You're just trying to get me into a semantics battle so you can find some slight difference in my understanding of a word and the text book definition. What is the point of such conversations? Do you dispute that health care cannot function properly in a laissez faire system for the reasons I have mentioned so far?

The point of such discussion is about respect.

You pulled someone up for not knowing what they were talking about ("For someone who puts so much faith in free markets you don't appear to understand how they work. In your studies, look up "market elasticity" for a clue."), when it seems the same accusation could be levelled at you.

But, I never really meant it to become a big deal so I apologise for being picky and I'll move on to answering your question.

Broadly I agree with you but I think it's slightly more complex than that a straight forward "it doesn't work" and for me the issue is how you factor in the failures which in healthcare tend to result in injury or death. For instance, would a law covering corporate homicide (that is an organisation causing the death of someone in the course of their work due to incompetence or carelessness) count as market regulation? Or even manslaughter if a doctor acting alone did the same? Would that be regulation?

Because of this I think any civilized society wouldn't accept the possibility of severe injury or death without significant consequence, so even if it might work in theory (more below), we'll never know in practice as it would never be allowed to come about.

More generally though my view is that markets of any sort only work well when you've got a few factors at play:

(1) the deals and decisions are being made directly by those they impact - that is the patients so the deal genuinely reflects the will and interest of the patients (as opposed to them being one step removed as with insurance companies where their interests muddy things)

(2) the system has to be such that there is a financial consequence to the patient of the decision they make (that is they see the benefit of getting a deal which is good value as well as good medicine otherwise why would they look for value)

(3) there has to be as close to perfect information as possible to allow these decisions to be made on a true and fair basis - and when you look at the PR machines we see today exist, you've got to think that's not going to happen without regulation.

My issue is I don't see how you'd consistently get those factors without regulation. I couldn't say it's impossible but it certainly seems highly improbable, certainly in the culture we have now (point 3 being the one I can't ever see coming about without enforcement).

As an aside - I live in the UK where we have nationalised healthcare and it's frankly great. The market reforms over here terrify me because they're ideologically driven by people who seem to want to drive us towards an American system so in theory while I'm not intrinsically against the market playing a greater role in health provision, in practice I'll tend to fight it on the grounds that it looks like they're going to the whole thing up a treat.

How is that relevant here?

Health care is, by definition, an inelastic market.

The point being? Sorry if I'm being dense, but no market is truly elastic.

Not true. I don't have to buy a smart phone, for example. I can live a wonderfully productive life with a normal cell phone. This means the price we see for a smart phone tracks very close to its value. You cannot do without health care. If you get sick you will pay any and every price to get well. If you die, your money is worthless anyway. A market you cannot opt out of is inelastic and normal free market forces wont be able to find the correct price as they would in a more elastic market.

You cannot do without food either, but food markets are pretty elastic because you can do without food from any particular seller. If there's a variety of healthcare providers of reasonable quality then the usual market mechanisms can work.

Which isn't to say either (1) that they actually do work well in, say, the USA, or (2) that some less free-market-based system mightn't work better. (I'm in the UK; the situation in the US looks absolutely horrifying to me. I don't know what an ideal healthcare system looks like, but it surely can't be that.)

An individual's need for food is generally stable, predictable, and bounded (eg, 2500 calories/day). An individual's need for health care is unpredictable and unbounded, meaning that you can be financially ruined by it in a sudden and catastrophic way. Having a variety of providers doesn't address this crucial difference.

"What would happen to the food market were it not for the generally high supply of food? It wouldn't be pretty."

You turned cause and effect upside down. You think the free market for food "works" because food supply is "abundant"? Think again. The supply is high because it's market is "free" (not really but fairly) globally and (sorta) works.

If only doctors were as easy to grow as carrots...

They sure are not more expensive to grow than good engeers or teachers?

And of course, they will grow better if they eat their carrots ;-)

> free markets don't work for healthcare

Healthcare can be broken up into a lot of smaller markets, and for a lot of those the free market works just fine. The market for coffee in the cafeteria of the hospital works fine as a free market. Do you know what percentage of healthcare cost pertain to the cost of the actual treatment itself? (hint: it's a very small part)

Could you please cite somewhere in the world where the free market is working for health care? Every other first world country either has socialized medicine or a tightly regulated health industry.

Singapore - arguably the most efficient healthcare system in the world. Tim Harford talks about it in his excellent book "The Undercover Economist" (worth commenting that he's not rampantly free market - he spends time putting the boot into the US system too as well as praising the UK's NHS).

Basically everyone has to maintain a fund (the government pay into it for the poorest) for healthcare. This is what they spend when they have healthcare needs.

Because the people are making the purchasing decisions themselves (as opposed to the insurance company doing it) they have a far stronger incentive to demand value and to be informed, and you get genuine competition between providers (as if you don't like them this time you'll go elsewhere next time with no insurance company mandating who you can see).

The government then picks up the few areas that aren't well catered for by this system.

I think it costs about 40% of what the US system costs (possibly even less) and Singapore has a typical life expectancy of 80.


... has a price- and service-controlled market, set not by the healthcare industry but by the Singaporean government (you know, the guys that cane graffiti artists and banned gum-chewing?) They also provide government subsidies to citizens as well as permanent residents (though not as much) for their compulsory Medisave program. So, their invisible hand is very visible and it's called "their government regulates or pays for alot of their care".

Basically everyone has to maintain a fund...

And with that, you're no longer in a free market.

If you want a definition that tight then I'm not sure that you'll find a first world country with a free market for healthcare, working or not.

Good point. I over-simplified. There are many causes to the current state of the healthcare market, only one of which is the problem I described.

The free market does work in healthcare, you just need a government option as a baseline. If someone wants better care then the socialized healthcare, they are free to pay. That's the system in England and Australia.

This is basically a recap of the Japan segment of the Frontline special "Sick Around The World", which you can watch online at: http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/.

The Japanese system is not without its problems. More importantly, the "price fixing" approach to health insurance simply isn't going to happen in the US. What parts of it do you think we really can adopt? Because nobody is going to fix US healthcare by fiat.

"More importantly, the 'price fixing' approach to health insurance simply isn't going to happen in the US."

Why wouldn't it? Would there be riots in the streets? Roving gangs of healthcare-affiliated hooligans throwing rocks, burning patient effigies? Doctors lining up to leave the country en masse for a freer medical marketplace or just throwing dirt in the eye of medicine to go be a quant trader at a hedge fund?

The more important question is: Why hasn't that happened worldwide, in places where there truly _is_ universal/free/government healthcare?

"What parts of it do you think we really can adopt? Because nobody is going to fix US healthcare by fiat."

And, nobody but the rich and upper-middle class will be able to afford healthcare by Market. We can already see that today, with over 50 million uninsured Americans, up from 37 million just two years ago. How many will it be next year?

No, there won't be riots in the streets, because it would take amendments to the Constitution to institute price-fixed health care. Clinton's wildest single-payer fantasy (which, coincidentally, is one of my wild fantasies) would be easier to accomplish, and it, too, is D.O.A.

My objection to your point is twofold:

(1) It is total wishful thinking.

(2) It's wishful thinking in the face of pragmatic solutions that could resolve the problems we have now without utterly restructuring the market for health care.†

I'd also appreciate it if you wouldn't attempt to frame any critique of your comments in terms of "you're either with me or against health care reform". As you can see from a casual glance at this vast, Reddit-like thread, few opponents of health care reform would dare poke their head up on HN these days. I'm not an opponent of reform.

Recap of my wish list: mandatory guaranteed-issue private high-deductable health insurance, an exchange-type system that fosters 5+ insurers in every major market (up from the 2 we have today), and broad adoption of cost-cutting services like telemedicine-issued scripts and nurse-practitioner clinics.

Price-fixed health care may be a bad idea, but I don’t think it would be unconstitutional. The Supreme Court retreated from that whole line of interpretation during the New Deal; in the early 1970s, wage and price controls were instituted by that notorious socialist, President Richard M. Nixon.

"Recap of my wish list: mandatory guaranteed-issue private high-deductable health insurance"

Guaranteed-issue meaning "you have to get it, but we [the insurer] can charge whatever the hell we want. So, you, small biz of 10 employees with one person who had cancer, you premium is now more money than the GDP of Haiti, per month. Thanks and come again!"

That kind of practice can be fixed by either 1) price-fixing or 2) subsidies forever, the latter of which is really, REALLY expensive.

"an exchange-type system that fosters 5+ insurers in every major market (up from the 2 we have today)"

The one that the Obama administration just gave $240 million to 7 states (Kansas $31.5 million, Maryland $6.2 million, Massachusetts $35.6 million, New York $27.4 million, Oklahoma $54.6 million, Oregon $48.1 million and Wisconsin $37.8 million) to implement as part of the healthcare overhaul passed last year? I think it'll work, too. Funny how that needs federal dollars, though. Shouldn't the free market sort this stuff out without the magic hand of socialism?

"Broad adoption of cost-cutting services like telemedicine-issued scripts and nurse-practitioner clinics."

That I'll agree with, big time along with EMR mandates. That with HIPAA are a big step toward alleviating alot of the administrative burdens in healthcare management, especially tracking and billing.

When one person in a typical mid-large group insurance plan (of the sort available to contractor "guilds" today) gets cancer, premiums for the group do not shoot up. It's hard for me to take you seriously. You sound like a DailyKos diarist.

I disagreed with you that what we need is the Department of Health and Human Services to set prices for health care by fiat. So, first, you attempt to paint me as against all reform and in favor of people dying instead of companies going into debt. Now, you've tried to reframe the discussion so that you're either in favor of market-based approaches or a "socialist".

And, after you've done your level best to suck all the oxygen out of the conversation, it turns out... you agree with me.

Please stop writing like this on HN.

"When one person in a typical mid-large group insurance plan (of the sort available to contractor "guilds" today) gets cancer, premiums for the group do not shoot up."

I didn't say they did. I said 10-person startup. And, regardless of the existence of an "exchange" or not, policies of that size will still be meted out case-by-case, and those little start-ups will get squeezed, especially if they have someone on board with a pre-existing condition.

There's no getting around that problem unless each state acts as a group insurance pool. You will ALWAYS run into the small business, part-timer, or self-employed worker problem. Full stop. No arguments.

"it turns out... you agree with me."

Let's get this out of the way from square one: I don't agree. At all. In principle or in general. I may agree in some finer details, but my ultimate pie-in-the-sky wish for America is for us to implement a mandatory system in which every man, woman, and child, regardless of age or infirmity can get covered for a nominal price, unless they are a religious or conscientious objector and chooses to opt-out, but must themselves still pay, like we do with defense.

"I disagreed with you that what we need is the Department of Health and Human Services to set prices for health care by fiat."

And, I disagreed that the free market cannot correct what is here _in practice_. Not some theoretical America where we didn't have a glacially large government or a sedentary populace with 50 Million uninsured that didn't eat Cheetos and Mountain Dew for dinner. I'm talking about the reality of the situation and how it will take more than EMR and telemedicine changes to close that 50 Million (and counting) gap, though I do agree that technology can play a non-trivial role in cutting administrative costs.

See, I have wiggle room and patience for negotiation.

"Please stop writing like this on HN."

You, I can see, don't.

...it would take amendments to the Constitution to institute price-fixed health care.

Government-dictated pricing wouldn't necessarily violate the Constitution, it's been done several times throughout American history.

I think the goal was more to state that our government is heavily influenced by rich special interest groups, who won't let it happen here, even if it costs them billions of dollars every year to fight it off.

Funny mental picture though :D In my head they're wearing those stereotypical nurse hats and brought their own stretchers to carry off the wounded / exhausted / weaponry.

Isn't price fixing is done for U.S. Medicare payments to doctors, hence the constant wailing over the "doc fix" issue?

I can imagine a scenario where the age for Medicare was lowered slowly over time to cover more and more people. (Unlikely, but not beyond the realm of possibility).

I think that someone else said it here (somewhere in these threads), but I believe Medicare mandates that everyone is charged the same price for procedure X, but doesn't mandate what that price is. The point being that if everyone gets the same price, than Medicare always pays the cheapest rate (since there is only one rate).

What Tommy Douglas did was revolutionary, but Canada's healthcare system is no longer something to be proud of. We have some of the highest wait times for Cancer patients in the industrialized world, hurried appointments, cuts in coverage. I don't blame the government, I blame us Canadians. If you've seen the Micheal Moore movie, SICKO, you've seen the average Canadian's view on our system, which is, that it is truly great.

The government is getting a pat on the back for removing essential services because the masses aren't taking notice; we've fanboy-ed our system while ignoring its degradation of the fundamentals. Our current system is not a positive guideline to success.

A Macleans article about the state of our system: http://www2.macleans.ca/2011/01/25/our-health-care-delusion/

Japan's hospitals are going into debt because they can't charge what things cost. http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/c...

So, the solution to that in the US is for the patients to either die or go bankrupt rather than hospitals or insurers going into debt.

Everything has a price, but that seems a little lopsided.

This is an utterly nonresponsive comment. If the economics of providing healthcare don't work out, they don't work out. It's not as if "go into debt" means "fat cats make less money". No, it means that the skilled labor and capital that drives the insolvent health care system will simply migrate somewhere they can deliver it profitably. Say goodbye to hospitals for rural and poor areas.

"Say goodbye to hospitals for rural and poor areas."

That was happening anyway, if it weren't for Medicaid, that is. There was a definite brain drain of doctors (especially specialists) who choose to go to affluent suburbs and urban areas simply because they get more (and better quality, AKA rich) patients. You think if we _further_ privatized the market, those in rural areas would be _better_ served? Isn't that the opposite of what the free market would actually do? In fact, take a look at this study[1] about physicians in rural America. It's eye opening how they advocate federal and state intervention (read Medicaid and Medicare) as one of the solutions (along with opening training up to more potential candidates, which even I as a liberal elitist supports).


Few doctors want to live in a rural area for lifestyle reasons more than salary. A GP or surgeon can make more money in a rural area.

How? Do they charge higher rates than elsewhere - effectively using supply and demand and saying: "You don't have anywhere else to go, so pay my rates."

Most doctors these days are salaried employees at a large health care organization. They get higher salaries in the sticks because nobody wants to work there.

Ah. Thanks for that info.

Source for this assertion? It seems more likely (to me) that they'd make less due to their smaller and less affluent clientele.

Well neither is sustainable, so neither is a solution.

I generally trust a self-correcting free market over a government bureaucracy to solve such problems, but in this case it seems the fundamental problem is that there just isn't enough margin for for-profit insurance companies to prosper without turning the screws on either doctors & staff, patients, and/or taxpayers.

Since we in the United States end up expending at least double per capita what Japan does then we should be in the clear then, right?

The Medicare system in Australia works in a sort of similar way to how you describe Japan. The government publishes a list of fees for every possible procedure and treatment. The medical service provider can "bulk bill" where they collect the money directly from the government, and the patient never hands over any money. Alternatively, the provider can charge whatever they want (because they're a noted doctor, or their office is in an expensive location, etc.), and the patient can then claim the set amount back from Medicare.

Bulk billing is so much more convenient for everyone that you'll see signs advertising it on the outside of doctors surgeries, thus the cost of care is kept down. On the other hand, the doctors are free to charge what they want. Sounds like a fair way to do it.

Thank you, thank you, thank you. Someone needed to say it!

And the funny thing is, Singapore and Japan both are rather well-off nations, not much different wage and price wise than the US. Biggest difference is medical cost...


In fact, forcing US hospitals and doctors to publish a price of any kind would be a simple improvement.

It is amazing with all the other twiddling that this approach never appears - at least not much.

Some may argue (though I don't) that it is tantamount to price fixing, because doctors aren't free to have a "sliding scale" of care, even though about 95% of what they do are routine. Hell, even my plumber and mechanic have a book that they're more than happy to show me for what a service costs. My broken arm, though? I _deserve to shit bricks in fear of the bill if I'm a part time cashier with no insurance. Let that be a harsh lesson to me to become a rich computer programmer.

I think the issue is just too complicated to draw conclusions from broad inter-countries comparisons. I find the Japanese system terrible - I have been living there for 7 years and I have yet encountered a foreigner coming from a rich country who thinks the system is good.

The problem with comparing global stats like cancer survival rates is their weak correlation with the health care system. For example, the reason why colon/rectal cancer survival rate is high is because Japan is basically the only rich country where those cancers are the most common one (in other rich countries, prostate, breast, lungs usuallly come first for the concerned sex). There is also the issue of "free-ride", where most western countries benefit from research being done in the US and a couple other countries - which is not so easy to quantify either.

Designing good indicators is incredibly hard, and for that reason alone I think it will always be a political question first, and an economical one second (i.e. economics can help making a decision, but it won't give you the decision).

That's an interesting way to do things, didn't know Japan did that. Thanks for the info! How much do things like emergency services cost? Do they fall under ancillary or not? Anything that's nigh-essential that does? Know if the hospitals are supported by the government, and how much taxes it takes?

For most insurance, patients pay 30% copay maximum for any procedure (emergency or standard), but the minimum monthly payment (yes, it's not due all at once, which I think should also be legislated here in the States) is capped according to income.

Hospitals are private, and both they and doctors negotiate every two years to set prices for everything from MRIs to stitches. The insurance industry is also private, but they have a public-run insurer for Japanese poor. AFAIK, taxes are taken just for the public-run insurance, to which only a small percentage of Japanese apply, but for private insurance (which the rest are mandated to have), it's paid through premiums per month, which is on average about $250/mo per family (and employers pay for almost all of that).

> FYI, there are more private hospitals in Japan than the US

Incidentally, as near as I can tell, a hospital in Japan is equivalent to a clinic or doctor's office in the US. They also seem to be open weird hours. (example http://www.youtube.com/watch?v=Mi31MJrRjhE)

We are way, way above the amount of money health care should cost.


So as a matter of priority versus other spending outlays, we're way out of line.

Here's per capita GDP: http://www.wolframalpha.com/input/?i=per+capita+GDP

Spitballing from these numbers, it looks like we spend about as much in absolute terms as Switzerland, with everyone else way, way far behind.

Here's another interesting graph, since I seem to be on a roll here:


The degree to which our government is in the red is in no small part a result of the degree to which we're invested in the health care money pit.

The amount of money that is going to health care should blow your mind. People go bankrupt every day due to health care expenses, and even if you don't go bankrupt your tax dollars are supporting this nonsense.

I was talking to a gentleman the other day who works for a medical hardware company. He said they had a radiation treatment device that costs one hundred million dollars. A tenth of a billion dollars for one machine! "Jeez," I said, "How long does it take to pay off such a thing?"

About a year.

There is, of course, a debate on how to fix health care. Is there really a debate on whether it's broken?

Nope, I'm pretty sure everyone agrees it's broken. And just to re-clarify: I'm not claiming we're not paying too much. I agree with everything you've said. Just that $50-100/month is un-doably low regardless of brokenness.

I'll be reading through the links, I can always use more detailed info for future debates. Thanks!

edit for repliers: before stating that location X has 100 or less per month, how much do your taxes cost for this? That counts too, ya know.

No, it's not. I pay $120/month for a family of three, and get pretty good care for it.

I know that smug Canadians are a cliche in any discussion of health care, but we are an existence proof that acabal's expectations are totally reasonable.

How much of that is subsidized by your taxes? That counts towards the final cost. Spreading it out doesn't make it less real.

edit: answered for you:

>In 2009, the government funded about 70% of Canadians' health care costs.

>Per capita expenditure in 2009: 3,895

$227 per month, per person, comes from the government, which gets its funding from your taxes. So you're paying $801/month for that plan (three people). Significantly less than many Americans, there's no debating that, but $120/month isn't anywhere near correct.


Two points - one, is that odds are he's not paying $807/mo out of his taxes due to a progressive income tax. He's probably paying a good portion out of his taxes, but not $807/mo.

Point two - and this isn't a rebuttal of any kind against your claims, just an observation - that same graph shows that Canada spends a lower portion of government revenue on health care than we do. And we don't even have universal coverage!

The takeaway - you're actually paying for what should be your healthcare in your taxes as an American, but you're not actually getting the healthcare, because that would be socialism.

>that would be socialism.

That is a massively incorrect statement, which pops up every time government-mandated healthcare debates appear, which I wish to squash ASAP: http://en.wikipedia.org/wiki/Socialism

Universal healthcare != socialism. Not even remotely. It's a political mud-slinging attempt to equate healthcare changes with the historical fear of the USSR that seems to have infected far more people than it should even have reached. Yes, fear the Reds, they'll lob bombs at you now that the cold war is over. They've just been waiting.

At the absolute closest would be if the government were to run all the healthcare directly (it's not - there are and will be many private healthcare markets), and then it would be a socialist action, not socialism (a socialist government).

To make matters worse for this use, any form of taxation can be described as a socialist action. That doesn't make any government that taxes its citizens a socialist government.

You've heard of irony, I take it?

Of course I don't think it's socialism - but everybody around me in Indiana damn well thinks so. Not that they know what socialism is, mind you - but they know it's really Evil, and it's something liberal people on the East Coast force down our throats in order to pay for all the welfare queens in the cities.... ah, hell, there's that pounding in my temple again.

I catch it now. And may I say thank you? :) I've just met far too many otherwise-apparently-competent people that actually believe it. And a bajillion tea-partiers.

Thanks for the catch, everyone-else, my bad!

Oh yeah -- the fear-mongering against "Obamacare" has definitely pulled heavily from imagery surrounding breadlines and gulags. But I imagine vivtek's comment was a sarcastic jab at the acceptance of pouring money into the health care industry w/o getting a commensurate benefit out of it. (Correct me if I'm wrong.)

I think the parent meant "pundits would say 'that would be socialism'".

I think most here know nationalize health isn't socialism.

There is also corporate tax, and personal tax is assessed at graduated rates depending on income. If their income is low, say ~60k split between husband and wife, they would pay roughly ~0 for health care.

Corporate taxes come out of paychecks. Unless all that is refunded if that's their income, then they're still paying something for it in addition to their direct monthly bill.

It can be carried further: money they get refunded comes out of other areas' funding, as the difference gets made up somehow. Their property taxes go up, the cost of food goes up because others are carrying a heavier burden, jobs across the board pay less / hire fewer, everything always costs something, even refunds. Less in some situations, but not zero. And we're still not reaching $50-$100.

But by the "whole system" argument you're making, health care could easily have a negative cost.

Let's hypothesize that all the engineers working in SV get an AIDS-like illness caused by spending too much time on news.yc.

If there was a health care solution that would make sure that all the employees of Google, Intel, HP, etc. continued to function as usual by caring for those engineers, then even an extremely high up-front cost for that care would result in a net-win for the budget/economy/country.

Of course, that's silly as it won't happen to that extreme. But, I don't think the downward-spiral of more-cuts-here-and-there that you describe is the only possible outcome. A positive virtuous-cycle of increased wealth production is also possible.

Before that positive outcome can have a chance of happening, we have to get rid of the obscenely expensive hopeless palliative end-of-life care (cue teabaggers screaming about "death panels"), and make basic healthcare universally available.

The only ways that increased healthcare spending can increase productivity are through effective preventive measures and corrective treatments that return the patient to sufficient health to be productive, but that's not where our super-high healthcare costs come from.

They come from the consequences of delayed care (eg. using only emergency rooms when you're uninsured, necessitating more risky treatments for more advanced problems, which means higher malpractice premiums) and from end-of-life care.

And breaking a window stimulates the economy because it means the window-fitter gets more business.

I don't see how it's possible to have a cost of less than $50-100/month for healthcare. And all forms of cost have to be accounted for - direct + taxes being by far the easiest to measure, but when people start claiming that it "costs nothing" they're ignoring the bigger picture of the economy as a whole. Especially when $60k/year is your bottom margin - that includes a lot of people => a lot of drain on the rest if it doesn't come from them.

Nice reply, btw :)

The issue, I think, is that government spending is really in a different boat to private expenditure when it comes to the effect on the economy. Trying to model it as "you spend $X in taxes to pay for that healthcare" is a drastic oversimplification.

If you instead look at all government spending as economic stimulus, and all taxation as a factor in inflation management, you get quite a different picture.

So my taxes count, but acabal's don't?

Check out how much private insurance costs in Australia:


Most plans are around A$100/month or less

Australian private health insurance isn't necessarily a good comparison for two reasons.

First, it's a complimentary insurance meaning that it's for extras that people otherwise pay out of pocket or go without like dental, private hospital rooms, etc. It doesn't cover the really expensive unpredictable things like major surgery, cancer treatment. The basics (eg GP visits) and the big expenses are covered by medicare.

Second, it is subsidized from both ends. The insurance companies get paid by the commonwealth and the expense is mostly tax deductible.

You really can't use the cost to us as a measure of what it costs to run.

I also looked at insurance intended for non-Australians living in Australia (not covered at all by national insurance) and found prices to be pretty much the same

From Wikipedia the total annual cost of medicare (the australian national insurer) is about $18.3b, $900 - $1000 per person living in Australia.

The graphs comparing total healthcare spending of various countries put Australia's at close to $3500 per capita, so medicare must only be part of the total.

There are some funds going into health in one off ways like states funding hospitals, donations, people paying above medicare rebate amounts (usually about 30% more for GPs in my experience). There's drugs, some of which are subsidized. Then of course there's private insurance which a substantial portion of people have.

I had private insurance for foreign students for a few years. From what I understood it's basically a tax administered by an insurance agency.

Basically it's complicated and subsidized in all sorts of ways. It's like that in The States too. You can't just look at a doctor's bill or insurance premium in one place and assume that it's representing cost in some meaningful way.

You may or may not know, but non-Australians living in Australia are covered by Medicare (depending on your visa type), so that could explain the similar pricing.

It's dependent on your nationality and whether your nation has a reciprocal health coverage agreement with Australia, which many EU countries do but most countries do not (including the US of course).

One other interesting thing about private health insurance in Australia is that once you reach a certain income threshold, if you do not have any extra private health insurance, your income tax rate goes up a percent or two.

That wasn't intended to argue the point either way, though, I was just saying :)

Thanks, you saved me from having to do this myself.

$70, Basic hospital, extras like dental work and optical ($300 / yr... Two new pairs of glasses, effectively, or the year's supply of contact lenses), private rooms.

It depends on whether anything is done about the racket going on between insurers, pharma, and healthcare providers. These are the people who blame each other for rising costs and likely a free market mentality is to blame. It's a circular argument in the US, which needs to be broken.

I'm astounded that something that expensive can find a market. Out of curiosity, do you know what it is ?

I don't know specifically, but it is a radiation device for the treatment of cancer. So my word is hearsay in this case - I'll have to get some better information for you. However, if you ran such a machine 30 times a day every day all year, $10k a pop, you'd hit $100m in a year. $10k for a treatment isn't unheard of for cancer treatment.

Doctors and nurses and supporting staff must exist

I got a $800 bill for 10 minutes doctor visit (swollen toe). Not exaggerating a tiny bit. No insurance company involved. "Must exist" is not an argument. Something is broken in the system where a doctor charges you $4,800 per hour. Insurance companies, obesity, poor lifestyle choices (all usual BS reasons I hear on TV) do not explain why this particular ####le charged me $4,800 per hour.

This saddens me hearing that most discussions about healthcare are circling around the question of "how?" instead of asking ourselves "why so much?".

Something is broken in the system where a doctor charges you $4,800 per hour

That's about right. A few years ago, I thought I had food poisoning and 40 uninsured minutes in the ER set me back $3800. But I was "lucky." I've had friends who were in bicycle accidents and ended up with $13,000 and $37,000 hospital bills.

ER bills are absolutely insane. It's not hard to break a few dozen thousand dollars in almost no time for almost no treatment. It strikes me as opportunistic preying.

The way it works is they bill outrageous amounts in the expectation that they will either be totally stiffed or have to negotiate a much lower settlement (which is essentially what insurance companies do, AFAIK). In the rare case where somebody actually pays the full bill, they're subsidizing care for those who walk out on the bill (or part of it). This strikes me as an extremely broken way of doing things, but it seems to be the norm, so maybe it's a really, really bad Nash equilibrium.

That only makes the costs even worse, especially ethically. They're sapping the most money from people least able to defend themselves from their preying.

Actually, most of the people least able to defend themselves walk out on it, just as the hospitals expect, because they have the least to lose. When you're already horribly impoverished, what does one more bill that you'll never be able to pay mean?

The ones who really catch it in the shorts are people who have never been unable to pay off an obligation before: their credit and hard-earned reputations are probably ruined (the first for however long a bankruptcy takes to go off the books, the second possibly forever), their day-to-day lives will become a gigantic burden since a bankruptcy will demolish any accumulated wealth/assets, and that's not even considering what it will do to their self-image for them to feel like they aren't living up to their personal standard.

Just so we're clear: I think this system is terrible, and desperately hope that something is done to fix it. I'm not sure what the right fix is, but I hope somebody out there finds it.

You went to the wrong doctor. When I get my bills for office visits, the rate is something like $300 on average (including lab tests). My insurance company then negotiates that down to something like $75, and then I pay the $10 co-pay. Now, all these numbers could be made up, but $300 seems about right for a doctor's visit when you consider how expensive it is to run a medical practice. It's not something I'd want to have to pay every week because I would die if I didn't, but it's not exactly financial ruination either.

If I had some rare disease but still wanted to do a startup, I think I would just work for Starbucks for 20 hours a week or something, simply for the health insurance.

It's very difficult to price-shop, though, because unlike in most normal businesses, nobody seems to publish price lists, and they aren't very forthcoming giving quotes over the phone, either. So it's not too uncommon to end up with something absurd more or less by chance, especially if it's urgent to see a doctor.

Unless I've totally missed it, there's certainly no hipmunk for medicine, where I can put in that I want X service, and get a list of doctors and prices within a 50-mile radius.

Your health insurance should have this service.

I'm with Aetna and I can get lists of MDs within a 10 mile radius and I can get a price list of common procedures.

True, but I was talking about the case where I don't have health insurance and want to price-shop for cash service. =]

I'm sure you can pick up the phone and call the doctors which are recommended to you.

> Unless I've totally missed it, there's certainly no hipmunk for medicine,

note to self: build a startup that's HipMunk for medicine

All you need is a mascot and boom ;)

exactly. and my axe! :)

Doctors and hospitals bill you more if you're uninsured. TFA mentions this as one of the reasons to get a high-deductible plan in which you will be paying most of the cost out of pocket.

Not in Indiana, they don't. Right now my wife is teaching, so we have insurance - but last year we normally got a 10% discount for being uninsured. Lots less hassle for the office, so they're willing to kick back a little for you.

You get a 10% discount, but the insurance company gets a 50-90% discount on most stuff. My kids spent 64 days in the NICU after being born three months early, and the bill came to $2.5 million. Insurance paid $600k. Our ER visits tend to bill out at $3-5k, and get covered at about $1k.

If you're happy about a 10% discount for being uninsured, the scam is working.

Last year visiting California I was sick for over a week. 30 minutes for a prescription (which I knew would be the result of that visit) cost me $600. $300 for the doctor and the same for the hospital. In New Mexico (one of the poorest states in the US), the equivalent a few years previous cost me about $100.

I stopped getting insurance because as a self-employed person it was expensive and rising. I played the odds and won. Sure doesn't make me feel happy.

In a civilized country, if you knew what the prescription would be, you could just walk into a pharmacy and buy it. The dotor charges $600 and provides no value. He exists to charge rent on his DEA license.

You do realize how terrible that idea is right? We'd see the rates of antibiotic resistant bacteria go through the roof in the first week.

Lots of countries have sold antibiotics freely but the epidemic of resistence mostly seems to show up in the prescription-only countries where doctors push antibiotics on everyone with a cold in order to justify their offensive office visit fees.

Also, even if there is a case for antibiotics, there still isn't any case for 95% of medications.

Any evidence for your claim? Drug resistant TB is highest in "the former USSR, the Baltic states, Argentina, India, and China, and was associated with poor or failing national tuberculosis control programmes". Some 10-40% of the people who take antibiotics don't finish a course of treatment because they are feeling better and think they don't need the hassle any more.

The WHO and various countries including the US say there is an association with antibiotics in animal feeds and an increase in antibiotic resistance in human diseases. This has nothing to do with "doctors pushing antibodies."

Drug resistant staph was first found in the UK. Do doctors in the UK face the same pressure to justify their so-called offensive office visit fees?

I had a 1000 euro bill for getting 4 wisdom teeth removed by the oral surgeon, in a hospital, where I was out in 30 min (two 15 min procedures). The beauty? I pay 100 euros a month in coverage, with a 175 euro deductable, which I easily went over that year. Oh, and doctor's visits are free.

Welcome to the Netherlands... (and yes, we have waiting lists, and other issues with healthcare, but atleast it's affordable)

All good points, but the fact remains that at my income, it simply doesn't make financial sense for me to be insured. If I must declare bankruptcy in case of cataclysm, then the system just lost much more money than they would have were I paying an affordable (sliding?) amount per month over my lifespan.

Anyway, this isn't the place to get in a discussion about how to fix the system. But as it stands now, it's just a fact that my bank account is better served by not being insured, having minor procedures done in another country, and declaring bankruptcy in the event of a cataclysm. That's not what the system in the richest and most powerful country in the world should look like.

Totally agree, for relatively healthy younger people willing to risk bankruptcy, it's a massively cheaper option. I'm merely saying that that kind of cost is nearly impossible to achieve, as reaching it would incur costs elsewhere. Distributing the cost doesn't make it less real.

You say it, but you don't back it up with evidence. How is it that the US already pays more money per person for health care but with measurably worse results (measured as life expectancy, infant mortality, etc).

How do they achieve what you call impossible?

The US pays more money because it has more health care being provided, in many cases.

It just so happens that more health care doesn't necessarily translate to measurably better outcomes (e.g. cancer screening helps reduce mortality for some cancers but not others).

It also just so happens that it's very rare to study whether a particular care regimen actually improves overall outcomes as opposed to just the thing it's ostensibly aimed at treating. Continuing our cancer example, cancer screening helps reduce mortality from _cancer_ for almost all if not all cancers, but for some the increased mortality from operations and other cancer therapies cancels out the improvement.

That's not to mention the fact that people in the US prefer to get care even if they know it'll likely make them worse than not getting care. I'll dig up the reference for this; I don't have it offhand.

The first claim above is pretty broad; coming up with a single reference to support it would be hard, and coming up with a wide range of references time-consuming.

But as examples:

http://www.ncbi.nlm.nih.gov/pubmed/2268793 (2.5x more coronary artery bypasses per capita in the US than in Canada in 1988; admittedly somewhat dated).


I realize that's pretty weak support; I don't have anything better off the top of my head, unfortunately.

Reference for the last part there: http://www.ncbi.nlm.nih.gov/pubmed/16282212

So we pay more money then other countries but don't get better outcomes? Could we save money and get the same outcomes? And since we get worse outcomes then they do, could we spend less and still get better outcomes?

How do you defined "more health care?"

> So we pay more money then other countries but > don't get better outcomes?

Yes, exactly.

> Could we save money and get the same outcomes?

That seems like an obvious corollary of the above... But yes, I think we could.

> And since we get worse outcomes then they do

Not necessarily worse; just not better. Measuring and comparing outcomes across different populations is hard enough that it's hard to say more than "our outcomes are not clearly better than theirs".

> could we spend less and still get better outcomes?

This question is based on a premise which doesn't seem to be true, so probably no.

> How do you defined "more health care?"

Number of procedures per capita per year for various procedures is a reasonable measurement (where procedures can be MRIs, surgeries of various sorts, etc, etc). Usually people focus on the expensive end of this, by the way; having more physical checkups won't necessarily blow up your healthcare costs the way that more invasive cancer surgeries will.

Your logic works both ways. If you say it's hard to measure then how do you know that get the same outcomes?

"Number of procedures per capita per year" is a horrible measure. It assumes that procedures done is a good proxy for overall health, which it isn't. Public health (clean food and water, trash pickup, promoting exercise and outside activities, cutting down on smoking, etc) is also important.

Here's a scenario. Country A and B are identical except that country A has pushed for potable water and B has not. As a result, 10% of the procedures in country B are from dysentery, cholera, and other water-borne diseases which are relatively cheap to treat (keep hydrated with a solution of salts and sugar). As a result, country B has more doctor visits per capita, and on average these costs are cheaper than in country A. Country B also has lower life-expectancy, more days sick per year, and other measurable outcomes.

By your definition, country B has the better health care system but I think most people would prefer the overall health of country A. Therefore your measurement is not so useful as an indicator of overall health outcomes.

> It assumes that procedures done is a good > proxy for overall health

My whole point is that it's not a good proxy for overall health. However it _is_ a good proxy for amount of money spent on the system. Which is how you can end up spending more but not getting better overall health.

Do read what I said again. You're arguing against a strawman.


>The US pays more money because it has more health care being provided

Reference for this, too, please.

Measurably worse results than where? It's measurably better than many places.

I say it because many many many other places subsidize healthcare at least as much as America does. And people don't seem to count the taxes they pay as part of the monthly cost.

edit: edited my top comment, sources are there. Canadians, famous for cheap healthcare, pay $324 per month per person for healthcare. The government covers $227 of that, which means $227 per person per month comes from taxes.

Measurably worse than the rest of the G8, according to your source (http://en.wikipedia.org/wiki/Health_care_in_Canada) at least on life expectancy, infant mortality, per capita expenditure, costs as % of GDP, and % of government revenue spent on health.

Not true.

We beat Japan on life expectancy, provided you restrict the comparison to people of Japanese descent. Japanese Americans live 84.5 years on average, Japanese only 82.6.



(Would love to see data doing similar comparisons to other G8 nations.)

That's funny, but I'm not sure it's true. Your first link seems to say (it's worded awkwardly) that Japanese women in the US have a 84.5 year life expectancy. This isn't quite as high as the 85.66 life expectancy Japanese women have in Japan (https://www.cia.gov/library/publications/the-world-factbook/...)

That's despite people of Asian descent in the US having higher income and education than the average, both of which are positively correlated with life expectancy.

Even if it is true, I'm not sure what the significance would be. I would be surprised if you couldn't pick out many subgroups in the US which do better in the US than in their places of origin, without it supporting an argument about the quality of the overall system.

Oops, I think I misread the article. I stand corrected.

Even if it is true, I'm not sure what the significance would be. I would be surprised if you couldn't pick out many subgroups in the US which do better in the US than in their places of origin, without it supporting an argument about the quality of the overall system.

Very true. To actually make the argument you are trying to make, you'd actually need to do a carefully controlled study. But most such studies (which include ethnicity, rural living, diet, etc as predictors) actually show no significant relationship between marginal changes in health care and health outcomes.

> declaring bankruptcy in the event of a cataclysm

Some procedures are not covered in your scenario depending on your state. Organ Transplants in Arizona etc.

At $50-100/month, they would have to sap you for nearly a decade to make up a single surgery.

How many surgeries per decade do you think typical healthy nonsmoking twenty-somethings are having?

How many decades you expect him to be a twenty-something?

Him in particular, 10 years. Probably his risk category may be similar or even better into his 30s though.

But nobody claimed he in particular should have the same policy or the same rate for the rest of his life. The point of insurance is to aggregate risk over large populations.

How many decades do you expect there to be twenty-somethings, period? (Isn't this also the operating principle behind social security?)

Isn't this also the operating principle behind social security?

Perhaps I'm mistaken, but I thought that the reason his age was brought up was to justify giving him a lower premium. The principle behind social security (or at least the variation where I live) is that everyone pays, and everyone gets healthcare. His age and his health don't come into it.

Hm. What I was referring to was how current US Social Security benefits are paid for by current workers, and, generally, how insurance is based precisely on the notion that there are healthy young people paying into a system that they don't use to its extents. Not sure if the OP was saying that or not.

Actually, everyone pays, and everyone receives an amount related to but not equal to the amount paid if they live long enough. You are less likely to live long enough if you are black or poor, and you are likely to receive 924 times the amount you contributed if your name is Ida May Fuller.

In the UK healthcare related costs are extracted from income tax. The monthly cost depends on your income:

£12k (grad student, trainee) - £62 per month £24k (young professional) - £114 per month £60k (moderately wealthy) - £318 per month

The average price is probably near your lower bound but the fact that it scales with income means that you aren't a slave to your workplace. You can quit your job and start a business without fear of crippling medical costs.

(Source is http://wheredoesmymoneygo.org/)

  At $50-100/month, they would have to sap you for nearly a 
  decade to make up a single surgery.
The point of insurance is that the risk that you need a lot of attention is diluted by being in a pool with insurance takers that mostly don't need that attention. You pay for your surgery together. Insurance has the interesting property of being an inherently Socialist service that you are purchasing from capitalist companies: Big Brother takes care. The main problem in the US seems to be that people refuse to accept the Socialist nature of the service, which means they feel everything above their own medical expensen is too expensive. That means you just don't understand the service you are purchasing.

You are betting that you will have large bills. Your insurance company is betting that you won't.

I'd be interested to hear what you think a reasonable basement price would be. In Minnesota for a (very) healthy family of five, I pay over $600/month for a plan with an $11,000 deductible, meaning I essentially write a check every time one of my kids has a checkup.

Which brings up one of the biggest red herrings in this whole debate - the notion that the U.S. has a "market-based" system. The next time you go to the doctor, ask someone what it's going to cost. Guess what? No one outside the two people working in the basement billing office have the slightest clue, because it's all paid for by the insurance fairies. There's nothing even remotely resembling an efficient market for healthcare in the U.S., but the insurance companies like to spout otherwise, because it's entirely to their advantage.

Hospitals in the US over-prescribe, and over-treat, because health insurers will pay.

Drug companies will charge US customers more, because health insurers will pay. Good luck importing drugs from ebay - it's not legal!

Doctors, and hospital managers charge more, because health insurers pay. Good luck getting an unqualified doctor to prescribe penicillin - it's not legal!

If the government was paying for more of it, they would train more doctors, and force drug companies to lower prices (as they do in most countries). Removing the profit motive in public hospitals makes them focus on better care, not more expensive care. Then the private sector has some real competition (Australia and Canada both have private health ... it's better than the US for most people).

In my country (Uruguay) if you pay for medical treatment outside the health insurance cost are not cheaper than in US, but health insurance cost between 50-80 dollars a month and are "all you can eat" insurances (regulated by the state in the cost they charge each month and in the amount of services they include), of course when you are ill and need of they service they loose money, but they win every month you don´t use it or you just use them 2 times in a year to give you a prescription to flu medicine, as the vast majority of people never has really expensive treatments, they are profitable companies

> "($324.58 per month). Far in excess of $50-$100."

Invisible cost: Medicare/medicaid. You pay into it regardless of whether or not you use it - how much medicare/medicaid withholdings are in your paycheck?

Add that onto your actual private monthly premiums to get the real cost of health care.

I don't know about you, but mine works out to be considerably more expensive than $325 a month. And in the Canadian case I can be a bit happier knowing that everyone is covered.

Remember that a big chunk of the cost in canada (or the UK) is for geriatric care, mental illness, addicts etc - people who need long term 24x7 care. Things which are really social services.

The cost of actual medical care for a 20-50 something is a fraction of that if you were buying insurance purely for your likely illnesses. If you are comparing what a critical illness cost/month would be for a healthy young adult you could half this figure

> $227 per month, per person, comes from the government, which means it comes from taxes. And an additional $100 per person is spent per month on average ($324.58 per month). Far in excess of $50-$100.

Still, $324 is a pretty nice average, when you weigh in the mix of young and elderly, and of course if it comes out of taxes, presumably someone who is only able to afford $100 a month is going to have a lower tax burden as well.

> But think about the costs of such a system, regardless of inefficiencies / the problems of the current system that make things cost hundreds of thousands

That's why Germany has a social system where people pay in a fixed percentage (15,5%) of their income. That way, everybody pays the same percentage and everybody gets the same service.

If I wasn't self-employed, my employer would have to pay 50% of these costs, so it would be about 8% of my income.

The nice thing: this gets automatically deducted from an employees pay, so if he gets a raise or a cut, the percentage always stays the same.

The downside of it: I make decent money at the moment and have to pay 600-700 euros/month for healthcare.

If you make over a certain amount of money or are self-employed, you can opt-out of this system and move to a cheaper and better private one.

I won't work for long because of demographic change, but it's an ok starting point

What explains the rapid and sustained rise in costs?

Health care might have cost thirty years ago but not the same degree.

Further, Health care is approaching twenty percent of GDP where once is was less than five. Wouldn't that be large factor in costs? And doesn't that seem a tad less than necessary?

Part of the rapid and sustained rise in costs comes from that a) more things are being treated that existed before but got no treatment, and b) more availability of new drugs, because we're now able to create ones which were impossible / inconceivable back when costs were 5%.

Would you rather go back to colloidal silver someone sold you as a wonder-drug out of the back of their wagon? Or use the significantly more tested drugs the (fairly problematic and corrupt) FDA lets through? Antidepression drugs, for all their overprescribing (IMO, that's a debate for elsewhere), didn't exist before, and psychotherapy was largely viewed as in the realm of quackery and going to one was considered shameful (still is, but not as much).

Not that it accounts for all of the change. Or even a large portion. Just that the rise isn't entirely due to waste.

Not that it accounts for all of the change. Or even a large portion.

Then what is your argument??

Just that the rise isn't entirely due to waste.

No one argued that.

Even the most egregious health insurance policy abuses are generally something more than waste. Often, there's been an effort to enhance "choice" and "responsibility" but generally without understand that the average person simply has limited horizon for navigating such things.

It's not mere waste, it's mere corruption but a combination of multiple "perverse incentives" - effort to fuse government and private industry which aim for the best of all possible worlds but end in the worst.

"It begins with a blessing, it ends with a curse. Making life easy by making it worse 'My mask is my master', the trumpeter weeps But his voice is so weak, as he speaks from his sleep" Soft Machine

We face a challenging world today...

Not a whole lot of an argument, admittedly. A bit of a jump to a conclusion based on your 5% starting point, which was in a very different world than today. Since the rest of the G8 seems to be around 10-ish%, start comparing there; I'm not sure why America is so much higher than that, but higher than 5% is pretty easy to account for.

Not that 10% is the best it can be, but I find it unlikely to go significantly lower as long as people refuse to do what's best for themselves, health-wise. ie, ever. (maybe Americans are worse at preventing health problems? no idea, just musing)

Here's why it's broken. It's a long read, but worth it. The reasons are not what you'd expect, and not what you usually hear.


You beat me to it! Fantastic article from a former startup CEO (I worked for him about 10 years ago). I thought I had heard all the arguments before I read it.

> the only country to still tax you if you live abroad

Not that it has anything to do with the main subject, but that is not true. Other countries tax their expat citizens.

"For fun, let’s imagine confiscating all the profits of all the famously greedy health-insurance companies. That would pay for four days of health care for all Americans."


Insurance company profits are not the problem.

FWIW, I went to the Web site that Massachusetts residents use to find affordable health-care programs. For someone of my age and zip code buying insurance for just myself, the premiums started at $272. (In Massachusetts just about everyone must have health insurance and insurers may not discriminate based on pre-existing conditions. Households making less than triple the Federal poverty rate get subsidized plans.)


Per capita spending on health care in more sane developed countries in the world is about $4000/yr. To get your so-so full service health care, the sane market price is about $333/month, and in most of those systems, medication isn't covered fully if you have an income. $50-$100 month just doesn't work other than emergency health care. Emergency plans at that price also have clauses like the first $2500 of an accident is deductible free.

In Canada, I pay $60.50 per month (was recently $57) into our Medical Services Plan:


The West Coast, by the way, is beautiful. Vancouver BC and Seattle WA are practically sibling cities.

Apply for citizenship. We'd love to have you!

What we have is everything that is bad about a private healthcare system combined with everything that is bad about socialized medicine.

Over-regulation, high cost, and impossible to get without an employer or some other kind of large group.

The American system benefits only one group: insurance companies.

In austria, if you have your own business, you have to pay for the state own insurance company a part of your total income, which is usually a beween a few hundredths and thousand bucks PER MONTH. So don't argue with $50-$100 a month.

American expat in London here. Can't agree more. Healthy 26 year old with no conditions. I don't need NHS and don't mind pay taxes for it. I want to know it's there when I do need it though.

"instead of doing anything serious about it, we've done almost the worst possible option: require every one of us to be a customer of these monstrous companies, with little regulation on cost or other government oversight"

This is a common misunderstanding of the economics of this situation. The principle involved here is "Adverse Selection".

To illustrate, let's look at automobile liability insurance. The reason this insurance is so affordable for most americans is that 1) everyone with a car must pay it and 2) there is price competition among insurers.

Imagine for a moment that automobile liability insurance was optional. Who would benefit the most from having this insurance? Accident-prone drivers or non-accident-prone drivers?

That's right - the accident-prone drivers.

And since accident-prone drivers have the most incentive to have liability insurance, you would see the customer pool of the insurance start skewing heavily towards these high-risk drivers.

Then, since it's mostly the high-risk drivers in the customer pool, the number of claim payouts would go dramatically up along with the average payout per claim.

In order for the insurance company to remain in business they would be forced to raise their rates OR to be super strict about not insuring customers that seem risky.

Naturally, the insurance business only works if you have more money coming in than going out. And in order for the insurance to be "affordable" to most people, then the risk needs to be spread amongst most people (not just the more risky ones).

So, while I understand and share your frustration at the current state of health care in the U.S. - it's important to point out "why" everyone needs to be insured in order for the rates to be "affordable".

Of course there are other important variables affecting health insurance premium rates (rising health care costs is a major one), but the "Adverse Selection" issue is probably the most important.


Another point to consider is that the current big health insurance companies have focused their skill on just a couple things:

1. Avoiding risky customers (by denying them or offering only super-high premiums)

2. Paying out as little as possible (by reducing health care costs and denying claims)

The dynamics of the health insurance market are about to be dramatically changed. #1 will no longer be nearly as important and there will be a huge jump in the size of the market. This will be a huge opportunity for disruption in the industry.

The old health care companies are extremely slow, bloated, and resistant to change. It's easy to see that new entrants will be able to grab significant market share from them and initiate some real price competition.

It's frustrating to have to wait the few years until this happens, but I'm very optimistic about the future (assuming the recent health care reforms won't be diluted before they can be enacted).

Argumentum ad nauseum is getting too common here.

All that space for a fallacious argument.

1) Do you really think only sick people want health insurance? 2) Not everyone has to buy car insurance. Only people who drive. High rates will force people not to drive. There's nothing people can do against high mandatory health insurance premiums. 3) We've tried incentivizing people to be healthier seven ways from Sunday but somehow they getting sick. So, like Bullwinkle said to Rocky, "this time fur-sure".

-- The beatings will continue until morale improves.

Emotion winning over the understanding of basic economic principles is not the path to actually solving the problem.

One must understand the reality of the variables involved in order to come up with solutions of value.

Emotional outbursts have rarely solved any important complex problems. See Hacker Code 11.3.7 ;)

The subtle but crazy part about this is at the bottom when it details the author: "Donna Dubinsky, a co-founder of Palm Computer and Handspring, is the chief executive of a computer software company."

I'm going to go out on a limb and say money is not an issue for Donna, yet she still can't even buy insurance if she wants to. I've always thought healthcare access was a bigger hurdle for entrepreneurs than tax rates. If I make a lot of money with my startup, great, I really could care less if I pay 15% or 40% of that to the gov't, because it will be a whole lot more than I make now. But not having health care insurance (or worse, having crappy insurance that denies you all the time like most individual plans do) is so damn risky it makes me afraid to step out on my own.

I've said it before and I'll say it again - the MA health care law ("RomneyCare", which is functionally very similar to "ObamaCare") is really what let me start a startup - the money wasn't the issue, but the ability to get an individual policy at a reasonable (not at all subsidized, just group-negotiated) rate was.

+1 on mass health care, very reasonable rates and abundance of good options. I was very much against it and actually voted no but came to see the benefits and changed my opinion

Amazing. I just looked over MA's health care info, and it's much more affordable (and covers much more) than the average insurance plan in other states. Congress, THIS is what we need for all of America (or something that's at least that level of coverage for that price...)

The beauty of large groups negotiating!

That said, that's roughly what the ACA ("ObamaCare") will likely end up with, if it doesn't get derailed, except that it'll take a few years to get there because 50 states is more complicated than one.

Actually, it could scale reasonably well, but for political reasons wasn't set up that way. So instead, each state will set up its own exchange; I suspect some will be MA-quality, some will be better, some will be poorer.

Do you have to have lived in MA for a while to be able to get this or do you just need to live there when you apply for medical insurance?

You can do it right away - and in fact, basically have to, since the other part of the puzzle is that you MUST be insured. Ultimately it's not really that clever - the state just acts as a giant group purchaser, and the fact that it's compulsory spreads the risk around so that it's not an adverse selection problem. It seems silly to shill for it, but all the details are (more or less) explained on the site: http://www.mahealthconnector.org

Note that the reason you can apply for it right away, unlike other state "benefits", is that it's not really a benefit - there's no subsidy (at least, not for self- or startup-employed folks like me who very well can afford it), so there's no real cost to the state of letting 1, 2, or 17000 more people buy in (and in fact there's an advantage, because you increase the risk pool).

It looks like you can only enroll between July and august. Man this insurance thing is like the hardest block in becoming an entrepreneur!

Now if I could only buy into it without moving to MA...

Good point, Boston is very high on my list of places to move for the startup scene (I currently live in eastern CT, previously worked in NYC, so I'm closer to Boston than SF.)

I think she could buy insurance if she really wanted.

I've thought about this a lot because I could easily be in this situation. If I did anything on my own I would need a group plan quickly. You only need 2 people to create a group.

So you can buy insurance its expensive, here is how you do it.

1) Start a company.

2) Hire another employee (this costs a lot)

3) Make a group health insurance policy for the company.

There you bought insurance.

I know this is stupid, but I'm just the kind of person that when someone says "You can't do XXX" I automatically have to see if I can do it.

If the insurance company suspects that you've done something like this, they will wait until you need to claim (so they can take in the premiums) and then deny a payout on the basis that you formed a company purely to get round having been denied insurance. Every day, insurance companies look for ways to deny payouts, and they've thought of this one.

In no way did I say make a fake company. You'd have to start a real company to do this.

If you create a completely real company with the driving intention to get yourself health insurance because you can't or won't do it as an individual, it won't matter how real the company is. The insurers will decline to pay out.

It's not the difference between a family and a company, its the size of the group. Thus the costs for a company with 10,000 people is far different than a company with 10.

Also, if you have a group of 2,5,10 or 20, the insurance company has an easier time denying you because if you get pissed and drop them, its not a big loss for them. In contrast, if you deny the right person at a 10,000 person company, they lose a big account.

Actually, has anyone tried banding a group of startups together until they have several thousand employees, then buy insurance as a bloc?

Another idea I've kicked around: Create a sort-of incubator where, on paper, all of the startup founders and employees are employees of the incubator group. Then the incubator can handle the whole mess of both insurance and income taxes. (Bonus: Since the "incubator" now has a ton of developers on tap, it could double as a consulting agency.)

I work for a PEO -- Professional Employer Organization -- and that's essentially what we do. Clients that come onboard with a co-employment contract for their employees. We pay their employees, our clients pay us and we become the employer (in most states though laws are always changing). This means we have 90k employees that help us negotiate some pretty good rates for Benefit plans. It's actually a pretty decent way for a smaller company to offer benefits to their employees that are competitive to larger companies.

We do try to take on companies of a minimum size (10+ employees) but sometimes end up taking on companies with 2 or 3 employees because the owner forecasts explosive growth -- which never happens. All that said, it's a freaking battle with the carriers every year to try to keep the increases at a lower rate. Also, we have "rate buckets" where we place clients according to risk and past medical history of its employees. It still tends to work out better than if they would attempt to get insurance on their own.

> place clients according to risk and past medical history of its employees

shudder This is the part where a small employer can basically be forced to find an excuse to dismiss anyone with a serious illness, who is then doubly screwed. A public option would have been so much more humane.


Haven't much looked into this (being as it now pertains to me, maybe I should!), but the Freelancers Union was making a bit of news last year[1].

Also, there are HR-outsourcing companies like TriNet that negotiate as a group for smaller/startup companies[2].

1. http://www.freelancersunion.org/

2. http://www.trinet.com/about_us/default.htm

I've been using Freelancers for about a year, paying ~350/month for a decent PPO and dental. Not incredible, but it's the best option I could find apart from high deductible plans. NY only unfortunately, and I'm not aware of any similar things elsewhere.

I'm kinda wondering if YCombinator or one of the other incubators could do something like that. For me, a major reason why I'm not doing a startup now is that I'm not sure I could get health insurance. My last startup was done in Massachusetts when I was 25, so it was no problem to get an individual high-deductible policy. I'm not sure I could do the same thing in California, now that I'm pushing 30.

I'm in the same exact boat at 29. As a result, I'm currently looking for partners who are under 26 and still covered by their parent's health insurance. The last thing I need my precious capital going towards is a booboo. It means I have one less thing to worry about. I've set aside monies just to cover my own.

I've spent some time thinking about different startup ideas / permutations to address exactly this solution. In my research, I've found attempts at both methods you describe above, in various forms and various states, with widely varying degrees of success, but most have ended in failure. The "successes" tend to offer some limited choice in plans, but the rates certainly aren't great and the deductibles are still pretty high -- mostly it's a fallback safety net for serious emergencies.

I think a startup that can help tackle this issue would create tremendous value in the payor / consumer market, but the field is extraordinarly complicated and requires a very rare multi-disciplinary background in individual state law (CA's system alone is very different from, say, MA's bc CA is HMO-based and MA has a public option), behavioral economics, gov't regulation, insurance underwriting methods, insurance administrative practices. Oh, and if it's a tech startup, the team would obviously need web dev / product skills as well.

The problem is, developing a basic mastery of all these subjects takes a lot of time -- reading, thinking, and experiencing to understand the pain points deeply. That tends to cut against the stereotypical startup team of two young twenty-somethings hacking away and living on ramen, who have never studied the insurance industry or directly experienced the pain of searching for or relying heavily on health insurance (bc young 20 somethings tend not to have major health problems). I think that's a key reason why startups haven't done much innovation in the insurance payer market.

My latest line of thinking is about whether there are hacks around the problem that can incrementally chip away at and disintermediate insurance payers as the sole gateway to affordable healthcare.

Sounds like an umbrella company (http://en.wikipedia.org/wiki/Umbrella_company). Almost all contracting in the UK is through umbrella companies or a single member LLC's rather than directly between the employee and employer.

Just employ the employees in your 1-N person startup through TriNet and be done with it.

As a group you have more leverage purchasing pretty much any service. I wonder what it would take to put together a group buy app for health insurance.

> As a group you have more leverage purchasing pretty much any service

although this is true, the leverage gained through group is different for other services, where a bulk order is much cheaper. Assuming everyone's making rational decisions, the only people that would want insurance would be the high risk ones. Insurance companies would loss money regardless of the rates they charge because the only rational people that would pay it would be the ones that think they would likely benefit from it, since they have additional information (eating habit, risk level, etc ) over the insurance company. By putting a lot of people (high risk and low risk) in a group, the insurance company can balance out the group and make a small gain on top of the expected payout.

Even healthy people are made out of meat, which is the ultimate pre-existing condition. Are there really a significant number of people who think it's rational not to seek insurance, as opposed to not having enough income to meet the market price?

You're not considering the value of the "float" that insurance companies get. I.e. they get your money up front, but only have to pay out later. This is a huge advantage.

My auto insurance company (it operates like a cooperative) provides a group plan for members to purchase health insurance. (Coverage is provided by an external company).

My auto insurance company also runs a savings bank for its members and offers loans at markedly better rates than retail banks.

Consumer cooperatives would seem the simplest way to alleviate this issue--no need for additional legislation. To confirm, I live in the US.

What's your auto insurance company?


A two-person group is not going to fare much better than an individual plan, and I'm not so sure that there are that many companies that accept two-person groups anyway.

Not true in CA anyway, you can have a 2 person company and apply for small employer group coverage. You can't be denied for pre-existing conditions and your rates have to be within 10% of larger group rates.

Yeah I think you'd need to hire about 49 more people before you had a substantial group going.

I work at a company with a 2 person group and it fared much better than an individual plan.

The idea isn't that stupid. You just need to be more than 2 people. Is there any reason why a group of self-employed people can't go together and get insurance as a group? If the group is relatively homogenous and are able to pay the bills, surely the insurance companies would be interested?


If the Republicans are serious about an economic recovery and want startups to flourish, then universal healthcare is a cornerstone of such an effort. I know of other people too who are afraid of leaving their (big-company) positions because they have a wife + young kids, and lack of health insurance terrifies them.

What could possibly have given you the idea that the Republicans want an economic recovery?

Well, eventually. Just not under Obama. Maybe if they wait a few years?

I was also confused about that. I may be misunderstanding how the law works, but isn't it true that group coverage can deny pre-existing conditions only for a limited time (6 months)?

In California you need at least 2 employees to qualify for group coverage. So you start an actual company, perform business (presumably turning in some money to cover your costs), and also get coverage for your dependents. There's one caveat that the coverage does not start until your company has been around for 6 months (unrelated to the pre-existing 6 months figure above.)

Or was the author's post related to (presumably) retiring earlier and specifically not wanting to start a company again?

Well, once her current software company (Numenta) deploys AI maybe she won't need coverage. /joking

I would have died at the age of 19 if it weren't for the help of the UK's National Health Service. My parents and I didn't have to worry about hospital bills, future insurance issues, being tied to a job, any of that crap. Just get some rest, get better, go out there and be productive again. The American system looks like a horrible joke from over here. I just can't understand any of it.

I moved to the US from the UK over a year ago and I can't find words to describe the feeling of not having the NHS to rely on. This whole new world of potential disaster has opened up. It's something you've never had to think about before that is now at the forefront of your consciousness.

You can be young, fit and healthy, but get hit by a car and your life is over. Once you're bankrupted by medical fees, you'll never have good credit again - and in the US, this is like the mark of the beast.

It's no wonder that American streets are filled by the homeless and disabled. This is a great country, with wonderful people, but in some ways it's medieval.

While a bankruptcy does stick around a long time (10 years iirc, 3 more than the Jubilee standard for which other credit entries endure), it's not true that "you'll never have good credit again". Many people in the US have gone bankrupt and they are still able to buy and finance homes, cars, and obtain other credit-dependent financial products. Generally it's 1-2 years after bankruptcy where no one will have anything to do with you, but after that, you can be considered a normal person again.

Of course, that presupposes you don't need to pay out-of-pocket for major medical care more than once every 5-10 years.

Just out of curiosity, does your NHS insurance cover you while you're in the US?

No, but if you can make it back to the UK you'd be covered, but you'd still have to pay for any sort of treatment you had abroad. You'd be broadly covered within Europe if you're from the UK.

Note that it's not "insurance", either. The NHS is just another tax-funded service.

"I just can't understand any of it."

Neither can those of us who live here.

I mean, I can kind of understand the series of historical accidents of how we got here. What I can't understand are the politicians promising to fight tooth and nail to roll back the very minor reforms just enacted, and all of the people who enthusiastically just voted them into office last election, based on that platform.

Those "minor reforms" were 10,000 pages long and I doubt that anyone understands them except the lobbyists who wrote them.

> Those "minor reforms" were 10,000 pages long

So what? We live in a litigious society, laws are verbose because they have to be. Make it too vague and you just force the issues to be resolved in the courts making it even more confusing because the rules become written in case law.

The "what" is that our so-called "lawmakers" hadn't written it, much less read it, understood it, and debated it in any rational way before they voted on it.

Call me an idealist, but I think that's bad.

Like a tax code, usually these kinds of things end up working out mostly to the benefit of the larger parties who pay the most lawyers and professional staff to find and execute on the loopholes.

I don't know, it took about a year for them to pass it. I understand it fairly well because I've read a lot of perspectives on it from both sides. The "IT'S SO DAMN LONG NOBODY CAN UNDERSTAND IT AND THEY SHOVED IT DOWN OUR THROATS SO FAST" is just a tactic to try and sway people who haven't been following in detail to be against it. Anything trying to change this convoluted system is going to be complicated.

I do engineering for government contracts. The spec for the system I work on covers thousands of pages. I've read about 6" thick worth of it and that is less than 10%. But they detail down to the most minute thing what you are allowed to do and not allowed to do. The big picture stuff fits on the first 10 pages, and then they drill down into exactly what kind of thread you can have on a fastener and exactly how you are allowed to stress a weld for the next 1,000 pages. But it stems from previous experiences and errors, and it leads to a better product (though a more expensive one).

So I don't think "# of pages" should ever be a metric for judging a law.

The "IT'S SO DAMN LONG NOBODY CAN UNDERSTAND IT AND THEY SHOVED IT DOWN OUR THROATS SO FAST" is just a tactic to try and sway people who haven't been following in detail to be against it.

Yeah, well what you said is just a tactic to try and sway people to think what you believe. See where that line of reasoning goes?

I do engineering for government contracts. The spec for the system I work on covers thousands of pages. I've read about 6" thick worth of it

I've read and implemented big specs too and I know how much work they take to produce. And I know darn well it wasn't some committee of smart and well-intentioned elected representatives that wrote it.

then they drill down into exactly what kind of thread you can have on a fastener and exactly how you are allowed to stress a weld for the next 1,000 pages. But it stems from previous experiences and errors, and it leads to a better product (though a more expensive one).

Are you seriously claiming the health care bill is so big because it's a precise engineering document which "stems from previous experiences and errors, and it leads to a better product"?

If so, how much does 10,000 pages of high-quality engineering documentation cost to produce?

Who do you think paid for it?

I think you're just imagining that it's what you want it to be.

Well, the health bill that was passed had a lot of the standard "real rules coming later" in it. So, actually reading the bill didn't give much information either. I was really interested in what would be an acceptable insurance based on deductible.

If this were something the health insurance lobbyists wanted, why have the health insurance companies spent so much in the last election to try and overturn it?

Maybe they didn't like the outcome either.

But the bigger reason is probably that ultimately they know the key to maximizing their long-term profitability is to funnel as much money into Washington DC as they possibly can.

There will be more laws regulating healthcare in the future.

Baby boomers are going to be using a lot of healthcare in the coming decades and retired people vote. The debates will be no less political.

I have to be honest as someone else from a country with universal health care I'm not sure I can tell if the reforms are actually an improvement.

The United States spends more per capita on health care than any other country in the world. Health cost inflation is the number one problem with the US health care market. If care were cheaper, coverage would expand and costs would be less of a burden.

In my opinion, the "very minor reforms" you mentioned will probably accelerate health cost inflation by subsidizing more consumption of health care goods and offering no incentive for offsetting conservation. They may ease the symptoms for a time, but they will exacerbate the underlying illness.

I can give you one perspective. Moral hazard and fairness.

The vast majority of costs borne by and in the US healthcare system are the results of overeating, oversmoking, and underexercising. Period. Heart disease, many forms of cancer, diabetes, most forms of pancreatic, gallbladder, and adrenal conditions, are largely the result of personal choice.

Setting aside for a moment the fact that congenital defects, hereditary disorders, infections, and accidents are no fault of the victim/patient, it should be important to note that a system that REQUIRES those who take care of their health by eating and exercising properly to subsidize the consequences of the choices of those who do not, is taken by many Americans to be fundamentally unfair.

If legislative initiative were taken to find a way to exclude universal coverage of lifestyle diseases, while still permitting universal coverage of non-lifestyle conditions, many people would not have such a viscerally negative reaction to the notion of universal health care.

I'd have up voted you if you hadn't said "period". Unhealthy behavior is a biggie but anyone that says "here, this ONLY is the problem" just adds to the mess.

The US health care system is melange of many complex and perverse incentives. I recall a study saying unhealthy behavior adds at most 50% to costs but costs have increased many more times than that in the last thirty years. The billing system, medical education system, end-of-life-care, the health insurance system, ad-nauseum. It takes a LOT of crazy schemes to eat up 20% of the GDP of the once-most-prosperous country in the world.

The same lifestyle diseases are at the top of the list for every country that already has some form of universal health care.

I'll admit it - I'm a former fatty (BMI 34). In Canada the government paid to send me to a dietician, along with an 8-week course that now makes me more informed about nutrition and dietary choices than most of the population.

That played no small part in getting me back in shape.

A single-payer/public system has a strong incentive to preventatively fight lifestyle diseases in a way that bickering insurance companies simply do not.

The thing to do, is if your health care is paid for by taxes (like the NHS), is for taxes to be levied proportionately on the higher-risk things that will hospitalize you. The UK already has sky-high taxation on tobacco. I rather like the idea of the Fat Tax as well.

Placing a tax on fat content would increase the proportion of earnings used for the NHS by those who would use it the most. It would also provide a disincentive to eat unhealthy in the first place. Of course, many many people think this smells a lot like social engineering (what isn't at government level?), so this wouldn't pass in the UK, let alone the US.

Lots of good background on Fat Tax in the References at http://en.wikipedia.org/wiki/Fat_tax

Fat content has virtually nothing to do with obesity. I get 20-30% of my calories from fat (mainly butter and cheese), weigh about 155 lb., 6-1, lipid levels good.

Kudos to you. So many people equate fat to increasing your fat. Granted, drinking a glass of bacon grease is no good for you, but replacing it with chemically altered low-fat everything is not a viable replacement.

You could tax calories instead. Calories in - calories out seems to be a pretty good proxy for weight gain. And I bet I wouldn't drink quite so much soda if it couldn't be had for 75c per 2-liter bottle.

Calories in-calories out is a pretty bad proxy for weight gain and health in general. Google Gary Taubes; he's done a great job of digging up and deconstructing a century's worth of research on the matter.

There is massive debate still going about the Taubes' arguments against 'calories in - calories out'. There is a lot of evidence in support of 'calories in - calories out' and it is way too early to conclude that if Taubes said so, it must be right.

The fact that there's a massive debate means we don't know enough about nutrition to legislatively micromanage it.

Speaking of fat, you should have a look at the http://en.wikipedia.org/wiki/Ketogenic_diet

Yes, it's not like US-style unhealthy behavior stops at the US border...

The basic problem is the cost. The cost of health care is so outrageous the only way to make it bearable on the population is just to give the government a license to print unlimited money in order to pay everyone's health care bills.

Insurance (which is a horrible system for health care, since insurance depends on people who buy it not to use it, and all of us need health care, usually multiple times per year) and government programs merely mask the root of all of this, which is that health care is completely and utterly unsustainable at its current rates. Something has to change about the way we administer medicine because nobody can afford it.

Everyone outside of the US has seen that people can't afford it and instead of fixing it, they've just said "the government will pay whatever it costs, don't worry any more, peasants!" In the US the problem has existed so long because we've covered it with insurance companies, but that system is crumbling as it gets harder for anyone without a job at BigCo to get reasonable care.

Our options are to figure out how to make health care cost a reasonable and affordable amount of money or let the government print money to fix it all for all of us (in the short term, ignoring the consequences of printing a bunch of money to keep an unsustainable system alive).

The current plan to force everyone in the United States onto an insurance policy with minimal modifications from existing policies is a pretty bad plan imo. The rates will be about the same and I'm sure the insurance companies are going to be thrilled to get tens of millions of new customers to suck dry by legal mandate. The people that will qualify for state subsidized insurance rates are only a handful more than the people that currently qualify for state medical programs like Medicaid anyway.

Ironically the US actually spends more $/person for health care than the UK or Canada do to cover everyone.

Simply because the insurance and billing drive costs so much higher

It's not really moral hazard, since that implies a rational choice is being made to make themselves sick because they know that they won't be bearing the financial costs. However, there are a plethora of non-financial costs to the diseases you've mentioned - up to and including death - so the moral hazard is mostly avoided.

It's simply that some people make irrational, bad choices, and the incentives on the whole make no difference.

Moral hazard doesn't have to be rational, just a deliberate choice.

Such as the choice to smoke, or over-eat. Yes, they can be addictive, but there are supports and cures for both, and involve willpower and sacrifice, but they're there.

I say this as a fatarse who has lost 20Kg by eating less (The Horror!) and doesn't blame anyone except himself.

Moral hazard is a concept entirely based on rational economic actors.

If the potential future cost of dying of lung cancer doesn't deter people from smoking, then the potential future cost of bankruptcy from paying for lung cancer treatment isn't going to, either.

It's about the mispricing of future risk rather than moral hazard. If you brought the cost up-front, by giving them health insurance but charging additional risk premiums to smokers, then you would likely find more rational decision-making around smoking.

> What I can't understand are the politicians promising to fight tooth and nail to roll back the very minor reforms just enacted, and all of the people who enthusiastically just voted them into office last election, based on that platform.

It's the Republican Party. They serve a certain set of masters. This set of masters is not the everyday Joe. This should be old news. Unfortunately it is not. And yes some folks vote for them that probably should not, but we have a sort of Bell Curve of intelligence and education out there -- though everyone's vote counts exactly the same -- combined with a variety of different levels of empathy for others, combined with a propaganda-rich media environment. This is what happens under those conditions. Ideally, we want to change these underlying conditions.

In the UK, or anywhere else in Europe, or Canada - or pretty much any other capitalist country - you can leave your job for a better paying one or to start your own wealth creating business. This allows the country to maximize the value of your labor.

In the US you can't leave your job to start your own business because your children might get sick and die. Even leaving for another employer is tricky because there is often a 6-12month gap before the new health coverage kicks in and anything you had treated in the past (like a broken leg in a childhood cycling accident) becomes a pre-existing condition and the new place denies you coverage.

This very effectively reduces wage costs since the whole 'importing people from africa' thing was banned.

This is important! It highlights the difference between dejure protection of freedoms, and defacto protection.

As a relatively well-paid (when I wasn't working for myself) Canadian, it just never occurred to me that I might need to stick with a job just for the benefits. I had the freedom to move.

Thus allowing you to maximize your income, skill utilization and benefit to society - hence a commie plot (apparently)

A stipulation of most group insurance plans is that the insurer will not deny coverage to any person in the group. Most people switching jobs will not have to worry about insurability if they are switching to an established company with an extant group plan. Working for such an employer is in fact one of the only ways many people can get health insurance.

A six or twelve month wait is also unusual on switching jobs. Generally it will take ~60 days from hire for the new insurance to kick in, but rarely more than 90.

Importing people from anywhere else is on it's way out in the US as well. (even willingly)

I would have lost my sight and probably then died slowly and painfully from a tumour some time in my teens if not for Australia's national Medicare system that's been treating my condition since I was 12 years old.

Instead I've only had to pay a nominal fee every time I need medication. Surgery, over a dozen MRI scans and visits to specialists over the years plus other tests and whatever else have all been paid for at no cost to me.

It scares the crap out of me to think what would have happened to me if I was in the USA.

To be able to see specialists or have expensive tests at times when I've been lucky to have $5 to my name is something I feel enormous gratitude for. I can't imagine the hardship having to pay for all this out of pocket would cause.

Some segments do have government provided health insurance in the US, but they are horror stories aplenty (I have some personal ones that only turned out well by divine providence or an amazing series of coincidences depending on your view on such things).

The problem is the government is broke and the health care bill was so bad that many supporters already have exemptions (including a few unions that backed the bill). Worse it really didn't address the big problem of why health care costs so much. It also had unwarranted optimism on cost savings.

At some point, I hope that the government will address: tort reform, drug trial costs, cost of medical training, bulk drug purchasing, "catastrophic" government backed insurance, and better medical savings accounts. I really expect more talking heads yelling at each other first.

The irony of all these comments is the US government actually does pay for a lot of health care costs...

"In 2006, 70% of health care spending in Canada was financed by government, versus 46% in the United States."


It's a bit insane that both the US and individual citizens apart from each other pay more per capita for health care costs now than the government of a country with socialized health care.

I challenge anyone with a painful but non-life-threatening injury - say, a torn labrum, or a torn ACL - to go live in Canada or the UK and see what their treatment is like compared to here. Anyone?

I have not torn an ACL in the US, but when I did in Canada, I found the treatment professional and quite reasonable in timeliness (Vancouver, BC).

I saw 3 different doctors, including seeking multiple opinions from 2 different knee specialists. I decided not to have surgery right away, and got a brace.

A few years later, my preferred leisure activities changed, so I decided to have surgery done. It took 11 weeks to get an appointment (as it was elective surgery at that point). The surgery was done by an experienced surgeon (a few hundred ACLs under his belt), and he met with me 4 times himself during the following year to follow up on my recovery progress.

Total out of pocket cost was ~$300 for a couple optional recovery devices (icing machine, etc.).

Physiotherapy appointments were, however, covered by my employer's extended medical at the time. That was about $1-2k that I would have had to pay had I been completely uninsured. I probably would have elected for less and cheaper physio care in that case though.

Short version: after reading this article/thread, I'd honestly be scared to join YC in SV, especially now that I have a daughter.

(Side note, I tore my ACL in Ontario and had an initial appt there, but ended up getting treatment in BC. It seems a lot of posts here talk about which state you have coverage in? Is the paid-for insurance not country-wide either??)

For your last question, it depends. Some plans are country-wide. Some are specific to a state except for emergency services.

There's the separate concept of in-network and out-of-network doctors, of course....

I live in Australia. I broke my calcaneus into 12 pieces 3 years ago. I stayed in hospital for 3 weeks whilst the swelling went down and then had my heel operated on for 9 hours.

I've been self-employed since 2003 and I've never paid a cent in health insurance, I just pay the Medicare levy like everyone else. I didn't pay any money at all for this stay or surgery, and also received free pain medication (endone, oxycontin etc.) upon release.

The surgery was successful and although I still have some pain sometimes, I can walk, run, play sport and do anything else I like.

If only the U.S healthcare system were my broken calcaneus :)

This is the dark side of the Canadian system. Long waits for elective care. My dad is a doctor near the Canadian border and a good % of patients in his local system are Canadians who are coming down to pay out of pocket for elective surgeries they would have to wait for years to get in Canada. On the other hand, another hot business in my homeland was sending busloads of senior citizens up to Canada to buy cheaper generic drugs.

It does sound like the Toronto or Vancouver areas may be the sweet spot for health coverage. Just a short jaunt to the US to partake in that system and permanent residence in Canada to make it plausible to live without working at BigCo.

Journalist TR Reid had doctors in a variety of countries (U.S., France, Germany, Japan, England and India) take a look at a shoulder injury he had and wrote about the results: http://www.amazon.com/Healing-America-Global-Better-Cheaper/...

I had a torn ACL in the US while uninsured. I waited a few weeks before I saw anyone in hopes that it was some kind of major sprain. I finally made an appointment with the Ohio Orthopedic Center of Excellence (I highly recommend it), and the first doctor I saw (a non-knee specialist, for $85 for about a half hour) said it probably wasn't a torn ACL, but he scheduled an MRI anyways.

The MRI was on the order of $1200, and another appointment later (this time with a knee specialist), it turned out that I did, in fact, have a torn ACL. By now, however, it had happened nearly a month prior, and the doctor recommended waiting at least two more months for the swelling to fully subside.

Reluctant to make such a big investment and being fearful of such a major surgery, I waited about 9 more months before I finally had the surgery. Since I didn't go to a hospital, the costs were actually reasonably low: ~$2500 each for the facilities, the anesthesiologist, and the surgeon. From diagnosis through final checkup, the cost was about $10K, and I was fortunate enough to have my doctor advise me on personal rehabilitation (I didn't go to a single session of rehab).

So I was lucky to get into a good facility with a good doctor and get reasonably-priced care, and now I'm stuck in a job I don't like with high credit card bills in order to pay off a large cost for a fluke basketball accident. Call me crazy, but I'd be interested in taking my chances in Canada or the UK. I've only just now (a year later) paid off the anesthesia, and I'm halfway done paying off the surgeon.

My uncle has a torn ACL up at Whistler, BC and he paid for an MRI out of pocket ($800) at a private clinic and got surgery the next day and otherwise excellent treatment. However, had he not paid for the MRI, he would have waited quite a while to get one and then have the surgery.

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