The opaqueness with which care is paid means that consumers receiving care have little incentive to shop around for prices, quality, value, etc., which means providers can basically charge whatever they think the gov't (through medicare/medicaid) will pay and a percentage above medicare/medicaid for everyone else. Of course, if you are uninsured or go out of network (i.e. your insurance company has no contract with the provider you saw), then you're going to be asked to pay ridiculous retail prices that very few people actually ever pay.

If you look at the difference between price trends for elective vs non-elective care (i.e. cosmetic surgery, LASIK, cosmetic dermatology), prices for non-elective care outpaces elective care by a long shot with the main difference being consumers pay out of pocket for elective care and actually put pressure on prices whereas consumers do not for insurance-covered non-elective.

The reality is that if you are ever in this situation you should ALWAYS negotiate. There's a reason medical debt is bought for pennies on the dollar because 1) difficulty actually collecting "patient responsibility" in the first place and 2) everyone know these retail prices are completely BS.

By extension, it seems like the key difference between "elective" and "non-elective" care is that one of them is elective... it's going to be a very different market when a consumer can choose to buy something or not buy it at all, vs. when they have to buy something and may not even understand what or why they're buying it. It's not necessarily that consumers are shopping prices more or being stronger negotiators, it's partially just that demand naturally falls if prices start to rise too much.

Agree that the patient-provider relationship today is usually "I'm a doctor and I'm going to tell you to do this, this, and this" regardless of cost, and we go with it because if we're insured under today's system it means marginally more out of pocket dollars for us. If you had an high deductible plan with an HSA (i.e. paying pre tax dollars out of a health savings account), I'd bet psychologically you'd be more choosey when shopping around for healthcare and/or ask more questions of your provider around "is this really necessary?" or "is there a cheaper option?"

With healthcare, it's not just about "what's the cheapest option", it's also "who will deliver the best service"... given the relatively limited ability to optimize the first, I generally will focus on the second, and I think that's what most folks do - they go with providers they trust.

It all comes back to my original point: healthcare, particularly non-elective healthcare, is not well-suited to a free market solution.

If you're unable to discern whether your doctor's preferred solution is the best one, then what is the purpose of asking your doctor in the first place? Or how would it be beneficial if the "worst" provider was forced to charge you the same as the best provider?

If I was qualified to discern if my doc's preferred solution was the best one, I'd be a doctor. I ask my doctor because he's been specifically trained to make that determination.

> Or how would it be beneficial if the "worst" provider was forced to charge you the same as the best provider?

You've got that backwards. Right now, we basically allow the worst provider to charge as much as the best one, because we don't really have any way to differentiate the best from the worst. There's no need to force any business to charge more.

TIL there's no testing, rating, or regulating in the medical industry.

>I ask my doctor because he's been specifically trained to make that determination.

I agree, so this concern of yours is alleviated. The market provided you an expensive option which is the one your trusted advisor recommends, and there's a cheaper one which may offer lower quality service. You are now empowered to make your own decision on the matter.

>You've got that backwards. Right now, we basically allow the worst provider to charge as much as the best one, because we don't really have any way to differentiate the best from the worst. There's no need to force any business to charge more.

Moving to single payer does not help you differentiate the best from the worst. All it does is force the good provider and the bad provider to charge the same. The current insurance regime is not better, because your provider can choose the worse provider for you if they're cheaper, leaving you no option at all.

I can't believe we're going with car analogies here. HN is now the Slashdot of yore.

I do hope you realize that people use fundamentally different methods of choosing things in life depending on the importance and consequences of that choice, and hence asking about how one chooses cars doesn't apply to choosing a healthcare provider.

Unless you are, in fact, a robot, in which case I welcome our new, ah nevermind.

There is no magic here just because healthcare is more important than car choice. You're no more or less safe because you're paying out of pocket. It's not as if paying out of pocket means you're going to be getting healthcare from Joe the crackhead in the back alley. It will still be doctors, NPs, etc. all licensed in your state.

You can speak for yourself. I bought my Honda Fit because I saw a video ad on Youtube.

Worked for me, I love the thing. And if I didn't? No biggie, would have sold it off on Craigslist and bought something else.

Would I select a doctor based on an ad? No, no, and no. Which is my point, actually.

No, the idea that people who have no skin in the game--regulators and bureaucrats--can make better decisions than the people directly involved, particularly about matters with as much at stake as health care--is one of those zombie ideas that just don't die. No regulator or bucreaucrat ever suffers any negative consequences because of bad decisions about other people's health care.

As for people being poor at judging for themselves whether procedures are necessary, another comment upthread already addressed that: there are plenty of other areas (auto repair, for example) where most people don't have the technical knowledge to judge for themselves whether procedures are necessary, yet markets seem to function in those areas. Furthermore, under the current system in the US, people have little incentive to become more knowledgeable, because they are not going to be given a choice anyway; they're going to get whatever their health insurance provider says is the standard care. Under a market system, people would have much more of an incentive to actually learn about the various options. And there would also be much more of an incentive for independent third parties to provide information, particularly information that health care providers might not want people to know.

More generally, the reason market advocates, like me, advocate markets is not that they always give optimal outcomes. They don't. But in cases where they don't, non-market alternatives give outcomes that are even worse.

This shouldn't be a surprise. An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life. They're going to usually tend to underspend on preventative care (which has the highest ROI) and tend to overspend on end-of-life care (which has a lower ROI). You can see this played out in things like the US's infant mortality rate (3X other developed nations) and life expectancy (31st worldwide, declining).

I think this "conclusion" depends strongly on how you define "worse outcomes".

> An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life.

Not if they have no incentive to learn how, no. And our current system gives them no such incentive, since they don't control the dollars to begin with.

In other words, the system complains that people don't do something that the system prevents them from doing.

> In other words, the system complains that people don't do something that the system prevents them from doing.

Uh, this has nothing to do with the system, and mostly everything to do with behavioral economics and risk pooling. People are poor at investing in preventative care, because the benefit is extremely hard to perceive at the individual level. And they over-invest in end of life care, because, well, they don't want to die. That's not the result of "the system", that's human nature. Attempting to build a healthcare system on how we "should" act instead of how we actually do isn't a plan.

This also ends up being a pretty unfair way to apportion care because a rich man couldn't care less about a $100 fee and a poor man can find it prohibitive.

One example would be how the US has one of the worst infant mortality rates in the developed world.

If you stratify by income then the lower end of the income scale have it far worse than equivalent cohorts in many other developed countries.

I mean sure if you are upper middle class and work for a large national or international company then healthcare is probably up there with world class but that's not a lot of people percentage wise.

Because if you wait until you need it, it's going to be a pretty bad time to negotiate.

Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

> Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

First "euphemism" implies some ulterior motive. I don't think people are trying to make people poorer. Hanlon's Razor would have us presume everyone at least thinks they have a mostly good idea.

Next, if people were somehow using their own money, they'd also have the option of choosing something 10 or 20 percent more affordable, keeping the difference for other valuable things, like paying off a house, paying for grandkids' college, buying those plane tickets to see their cousins, etc. The reason there is no downward pressure to save on individual things (even predictable, non-emergency things like deviated septums) is because there's no best viable alternative. We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.

But don't take my word for it; here's the Rand Corporation offering a studiously even-handed assessment and giving a definition of the term matching the one I suggested: https://www.rand.org/pubs/research_briefs/RB9672/index1.html

> These plans are intended to give consumers more "skin in the game" — that is, to make them responsible for a greater share of spending. Proponents of this approach contend that consumers in such plans will have more incentive to make prudent, cost-conscious decisions about using health care, which, in turn, should drive down overall health care costs. Critics, however, have voiced concerns that consumers lack information needed to reduce spending without reducing quality of care.

---

> We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.

Well, first of all, that's false, in the sense that, increasingly, deductibles are substantial (a few thousand, at least), co-pays are higher, and co-insurance (where it's difficult to even predict what you'll owe) is becoming more common. Almost nobody has a plan where they don't have to pay something for medical care.

But besides that, maybe in your scenario someone decides to lose weight. But let's think of another scenario. I start to experience some pain but I haven't really got the money for the doctor's visit. I decide I can tough it out. I keep doing this until the pain is truly unbearable and then I go to the doctor and find out I'm terminally ill and I waited too long to be treated. Or I forego preventative care and miss an opportunity to catch and treat cancer early. There aren't outlandish scenarios; they're the result of a system where patients have to shoulder more of the cost of care out-of-pocket, especially when combined with a state of affairs where a great many Americans do not have the savings to pay an unexpected expense of a few hundred dollars out-of-pocket.

No. They are just cherry picked. There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors. Single payer doesn't solve that. They just have an unelected government official saying no. And the patient doesn't benefit in that case. I haven't heard any reply about the moral hazards of turning healthcare decisions into lobbying efforts. Do we not think the well-connected and otherwise favored will still benefit over people in poverty? I'm skeptical.

Who wants doctors out of the loop? I want them more in the loop.

Doctor-patient relationships don't work that way. If they did, we wouldn't have people getting illicit prescriptions from doctors. Doctors, surprise, do listen to their patients wishes and accommodate them when they're OK with what the patient wants.

Doctors should be advising us, "Here are your options (with prices). What do you want to do?" One option on the table for "laceration on your back" should be "have an uglier scar and give a big check to your son as a wedding present". Right now, with good insurance, there's no incentive not to treat you like an underwear model that needs scar-free skin and do experimental scar-lightening UV treatments.

If a procedure (or doing nothing) is foolish, of course good doctors won't put that on the table. But single payer doesn't have doctors and patients making these decisions. They would instead look at a pre-determined schedule of options as handed down from the Bureau Of Wellness. Maybe, because of lobbying and political infighting, "uglier scar" is the only option. "Check for my engaged son" certainly isn't on the schedule.

A guy with a minor cut on his back is bombarded with a 24/7 targeted ad campaign for ScarAway!TM, that convinces him this experimental...er..."cutting-edge!" UV treatment is the only thing standing between him and a constant stream of fawning, eager females twenty years his junior. He then obtains this treatment from his "true believer" local doctor at the low, low price of a $2,000 "co-pay" for himself and $20,000 from his insurer. After three months of ScarAway!TM his back is of course completely disfigured and looks far worse, at which point his own wife refuses to sleep with him, necessitating years of therapy. A decade passes and he is diagnosed with melanoma from the UV he was exposed to and dies one year and one million USD in healthcare costs later. The most memorable moment of his son's wedding is a tearful toast to his deceased father, whilst each of the doctors involved in his "treatment" as well as the ScarAway!TM salesman cut checks to their engaged children.

>There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors.

is totally off base. The primary benefit to saying "no" is avoiding damage to your health from dangerous and unnecessary treatments that American doctors have a financial incentive to sell. People in the U.S. have their life expectancy reduced every day because we, almost uniquely among developed countries, have removed nearly all limits on the cultural acceptability of medical professionals and the medical industry as a whole treating patients as sales marks rather than patients. If you would like to experience this firsthand, respond to any AdWords or TV advertisement for a medical treatment. The sleaze is limitless.

>They tend to gloss over who actually decides when a procedure isn't worth it.

Salaried civil servants with advanced degrees who have an interest in cutting through BS to protect the health of the country. If you want to reduce people like Frances Kelsey to "unelected government officials" be my guest, but you're only showing how naive you are.

Could it be that the model is wrong?

The example of an automobile doesn't seem apt. Are you going to trade in Grandma for a new one when the treatments prescribed get too expensive and they can't figure out what's wrong with her?

Ask any doctor, and there's a reason they personally do not want to go anywhere near a hospital at the end of life. It's usually the children/grandchildren who live far away and never visit who insist that every last thing be done prolonging their grandparents' suffering in my opinion. The ones who live nearby and spend plenty of time are usually okay with letting them go.

Another problem is that procedures and appointments that could be considered routine maintenance in other areas are paid for by insurance. You don't use car insurance to pay for oil changes or new tires. Services such as annual physicals/check ups, vaccinations, etc should be cheap enough to pay for out of pocket.

That would leave insurance to pay for the more expensive forms of care, just like one would use car insurance to pay for damage as a result of a collision.

The flip side of that is that they aren't contributing much to insurance premiums. At a policy level it may be worth a slight increase in cost if building it into insurance significantly increases the number of people that actually get the shot.

Can we be certain of that? That is, even if the vaccination costs $30 to $40, will the insurance be billed for that amount, or do they get billed something like $300 instead?

I haven't tried to pay for a influenza vaccination out of pocket recently, so I don't know what most places would charge.

[0] https://www.bradsdeals.com/blog/where-to-get-a-cheap-flu-sho...

Even so, that's more money that the insurance company is paying out that could just as well be paid for directly everyone who gets the vaccine. If routine care was affordable without having to involve insurance, then insurance premiums wouldn't be as high and the out-of-pocket costs for medical care wouldn't be as high either.

The ability for a doctor (merchant) to refuse service in certain situations just doesn't exist without violating an ethical boundary.

Neither classic Hippocratic oath nor the commonly used Declaration of Geneva (https://en.wikipedia.org/wiki/Declaration_of_Geneva) would go against a doctor saying "the recommended procedure to cure your ailment costs one million dollars; I'll be treating you if and only if you pay that", assuming that the treatment honestly is the best option health-wise. What the oath could prohibit is the recommendation of a treatment that's objectively worse (i.e. less effective, or more likely to have harmful or fatal complications) but is much cheaper; while a person can choose (or be recommended) bread, wine or car that's worse but cheap, the ethics frown upon recommending worse health outcomes.

In planned events and traditional health care your argument makes sense.

I was specifically thinking about emergency care or other situations where communication isn't always possible or made in a timely manner.

If a someone comes into an ER and turns out needs say a stent put in, when do you get clear agreement? (caveat I am clearly not a medical professional and this might be a terrible example).

My assumption is largely the hospital does not wait to validate someone's credit to execute what would otherwise be something done for normal retail transactions of similar size.

Do you really think all healthcare - supplements, eye drops, family doctor visits, LASIK eye surgery - should be centrally controlled instead of using free market principles?

That's quite a claim to make. Cutting the entire healthcare industry off from the free market would only happen through government force.

Are you sure you're not confusing the US insurance system with an oligopoly?

Markets don't exist to magically generate low prices for consumers through competition, because businesses compete primarily for investor and shareholder cash, not to make end users happy.

The most reliable way to generate shareholder value is to create an oligopoly, and then squeeze consumers as hard as they can be squeezed - which is exactly why the US system regularly bankrupts participants, while regulated single-payer systems don't.

Countries with single payer also offer eye drops, family doctor visits, and LASIK... they just tend to pay less for them

You don't need "government force" to change how health insurance works. See Germany, many other countries. All you do is create a government healthcare pool that's large enough to cover risk, fund it, and give folks the option of using it or using a private insurer that will cost a lot more.

Especially since in the U.S., major changes are supposed to go through strict democratic processes that require broad consensus. Beyond good democracy, that's just human decency.

That's why I think there should be a healthcare constitutional amendment before the U.S. government gets involved. If California wants single-payer, they should go for it though.

You are ignoring the part about not having a choice of whether to buy or not. If I buy a car or something else about which I know next to nothing, I can ultimately decide not to buy, if I feel like I'm being scammed. If I get injured or sick, I can't realistically choose not to get treated.

I agree that they aren't perfect analogs, but we're talking tangerines and oranges, not apples and oranges.

EDIT: Downvoters care to comment on where they disagree?

I was just comparing the aspect of non-experts making big decisions based on expert advice. I wasn't saying a wiped hard drive is the same as cancer.

But it's also not true that any health problem (getting the flu, cutting your finger pitting an avocado) is worse than any computer problem (losing the only copy of your dissertation, getting phished for thousands of dollars).

Part of the way out of the dialectic gridlock we're having is to stop treating every health issue like it's both confusing and life threatening. But there are certainly edge cases. Nobody wants people dying of cancer due to bad advice or lack of funds.

> I’m happy we collectively chose to draw the line at an argument honestly comparing computer repair to health care

People not listening to people isn't the most human (or soulful) option on the table.

To be honest, my problem with the original comment was the lack of clarification and contextualisation. When it comes to sensitive issues (like health and people losing their actual lives), I think it's not OK to forego acknowledging the human aspect and focus on numbers or economic theory alone.

A good point can be made poorly, and it can hurt and alienate a lot of people in the process. Flatly "telling it like it is" does not always benefit mutual understanding or societal healing; it risks driving us further apart. Which is an ironic thing for me to say, because I put my foot in my mouth every other day. I guess it really does take one to know one :)

This is why consumers love warranties and extended-warranties on their vehicles so much - it means they leave this problem to their insurer. It's easier to insure cars than people, though - your risk is essentially bounded by the market value of the car.

The order of causation here is wrong. Many of those problems exist because the market for healthcare is vastly inefficient in the United States.

With regard to elective vs non-elective, only about 2% of all healthcare costs are categorized as emergency care. So there's plenty of wiggle room for people to shop around for a good price or wait for better market conditions.

What I would love to see is taking Medicare/Medicaid and instead of paying for healthcare services we just cut a check for cold hard cash to everyone who would've been receiving government funded care. Then they can spend that money on whatever they want. I guarantee you prices will drop through the floor. Some of those people will choose quality of life over longevity by going on vacation instead of paying for healthcare. I say good for them, do whatever you want it's none of my business.

It is very difficult to shop around for prices in the American health care system. Your average person can't do it and most really capable people could not do it either.

Giving people cash as their Medicare/Medicaid would be a complete disaster. Bulk buying by the government goes right out the window, no cost controls at all and completely ignores what insurance is in the first place. People are generally dumb. If you gave them cash and said this is your medicare, they would take it and spend it on everything but medical care. In the end, they would get sick and die or be crippled or worse, they would still go to the hospital and then leave everyone else with the bill.

We know prices would never drop to the floor because that is the system we have in place now and prices keep going up.

"Market" means "crowd sourced pricing". The alternative is a person or a small group of people setting prices, controlling access, setting standards, etc. Once you think that's a better idea, you are responsible for further clarifying how those people will be held accountable for their decisions.

I don't see a non-market proposal that is honest about the concentration of power and actually tackles the problem of accountability. I don't want a national medical code mess growing alongside our tax code. I don't want new and exciting fields of healthcare law and lobbying opening up. I don't want (pick: Donald Trump or Barak Obama) being the national Hospital-Administrator-in-Chief.

Define "how much something costs?" I can pull up the spec sheet from my insurance company and tell you the in network price and out of network price for just about anything. The crappy system we have now sets the price between you and the insurance company. It's not that the providers don't want you to know how much something costs, they don't know how much it costs.

Conversely, I can go into the local urgent care here, a place that caters to many uninsured. The prices for their services are literally posted on the wall, not unlike the menu at a fast food restaurant. You know exactly how much an x-ray costs, or a cold/flu visit, or a cast, etc. When people are paying for these services with their own money and the prices aren't the result of some individualized, convoluted pay schedule with your insurance provider, then the prices suddenly become extremely transparent.

>and completely ignores what insurance is in the first place.

Insurance is there to help you out in the event of a disaster, not to pay your ongoing day to day costs. So let's make sure we're really talking about insurance.

>If you gave them cash and said this is your medicare, they would take it and spend it on everything but medical care. In the end, they would get sick and die or be crippled or worse,

That is historically incorrect. Yes, people may choose to spend less on healthcare than you would like them to, but why do you feel the need to be so authoritarian about your opinion on what's best for them?

>then leave everyone else with the bill.

Only if people like you force it on us.

>We know prices would never drop to the floor because that is the system we have in place now and prices keep going up.

As was pointed out by another poster the prices for elective surgeries like LASIK which are not covered by health insurance are going down over time. It's funny to me that you have no problem accepting that some people would take their Medicare money and blow it on something else, but you think that healthcare providers would not do anything to try to convince those people to spend their dollars with them.

Except if you go in for a major procedure, you don't know what you'll end up needing off that price list, and often, neither does your doctor. So even if providers were perfectly transparent about what a procedure would cost (and it's well-established they're not - just try calling and asking for prices) the nature of the service being purchased is that you sometimes don't know exactly what you're buying until it's too late to change providers.

A few years back I broke my leg and went to the hospital. Halfway through the process I was offered a couple of Vicodin, which I would later be billed $1,000 for. Was I supposed to haggle about them with that, or take my xray and hobble out down the street to someone who would sell me vicodin cheaper?

No.

It's not a "distortion". It's the inherent problem of trying to turn healthcare into a market. The dynamics of service delivery make it impossible for consumes to negotiate or compare prices in the manner necessary to have a functioning market.

I'd also note, that since I've never gone to any other healthcare institution with a broken leg, I have *no way to compare my experience to other providers. This is yet another way in that healthcare does not lend itself to market solutions.

Even if they did, I made my decision based on which provider I thought was doing to do the best job... I didn't know at the point I made that choice whether I would need those vicodin, so they wouldn't have been part of my decision. And once I was checked in to the SF General Hospital (after two hours of waiting) I was definitely not going to hobble down the street, trying to compare prices on vicodin.

Also my damn leg was broken. It wasn't really the right moment to break out Google Sheets and create an expected value analysis of my various healthcare provider options.

It's nice to say "if only we had more agency, prices would be lower"... but it ignores the fact you still need risk pooling (insurance) unless you expect everyone to keep savings for the worst case scenario. And pretty quickly a risk pool means someone has to decide how much that pool should pay to help treat a particular injury... and you're back to where you started.

>And pretty quickly a risk pool means someone has to decide how much that pool should pay to help treat a particular injury... and you're back to where you started.

Not someone, EVERYONE. Each individual person must decide for themselves if they want to try pay a middle man insurance company some profit every time they get the sniffles or if they'd rather deal with that on their own, save money, and just get catastrophic coverage.

All of these things you're concerned about... we have an entire history of the healthcare industry before the New Deal where we saw how low healthcare prices were. We distorted the market with New Deal regulations putting caps on salaries, so companies started offering healthcare to employees. We can undo the damage done by the New Deal without getting all authoritarian about it.

Re your medicare proposal, are you suggesting that people who are diagnosed with cancer should get a cash check for the estimated value of the treatment? The incentive for fraud and graft in that kind of system would be incredible - lots of diagnoses are relatively subjective, and you'd be rewarding people for reporting every possible ailment they might be eligible for. If you're saying just give them their dollar average benefits, that pretty much defeats the whole purpose of having a risk pool.

It's very difficult to get quotes because no one is actually paying for it themselves. This would be solved immediately by empowering individual consumers.

>you can't easily compare providers (there's no obviously corpus of "ratings" from other prior customers)

This is because your insurance provider has chosen for you. Once again, this would be resolved by putting peoples' money back into their own hands.

>If you're saying just give them their dollar average benefits, that pretty much defeats the whole purpose of having a risk pool.

In my head I included still providing disaster coverage, but failed to type it. So that should alleviate your fears regarding things like getting cancer.

"Still providing disaster coverage"... is pretty much all of what health insurance does for people over 65. The annual spend on preventative care is dwarfed by a single common incident (fall, flu, cancer) at that age.

Here's a citation that shows emergency care is only 2% of all healthcare. Of course, that's the entire healthcare market, not just elderly care. I'd be interested in any citations you could provide that shows that system-wide preventative care is dwarfed by the system-wide costs of major incidents for the elderly.

http://www.politifact.com/truth-o-meter/statements/2013/oct/...

> I'd be interested in any citations you could provide that shows that system-wide preventative care is dwarfed by the system-wide costs of major incidents for the elderly.

95% of healthcare spend is reactive, 5% is preventative[0] Medical spending in the last three years before death accounts for 13.4 percent of aggregate US medical spending.[1] And this ignores major treatments for people over 65 that occur more than 3 years before they die (and on average, people live 20+ years after they turn 65.)

[0] http://www.newsweek.com/health-prevention-worth-money-86075

[1] https://meps.ahrq.gov/data_files/publications/st429/stat429....

You are acting as if paying out of pocket at a price not determined by an authoritarian central planner would suddenly mean nothing in healthcare would be regulated in any way and people would be getting healthcare from crackhead joe in the back alley.

Not everyone will pick the cheapest option all the time. Today there are free clinics in many places. Most people don't go to those. Some people will choose Wal-mart. Some people will choose Macy's. And there will be a myriad of options in between.

I never find this argument compelling, for two reasons:

1. Things are similar in this regard in other OECD countries, yet the US has prices wildly out of proportion with them.

2. Normal people do not have the expertise to know whether they need medical care. That's why they go to the doctor. Making them pay more out-of-pocket simply leads to them foregoing necessary care. Furthermore, if you're bleeding out and need immediate medical attention you're not exactly in any position to "shop around."

If you have an emergency and need immediate care, yes, you can't shop around. That is what insurance is supposed to be for: dealing with unanticipated expenses that you can't pay out of pocket.

However, most health care is not like that. It's either predictable, regular expenses like annual physicals, or unpredictable but small expenses like getting a course of antibiotics if you have an infection. These would seem to be easily bought and sold on a market, yet our health care system insists that we do it through "health insurance", when these items are not even insurable items to begin with.

The third category, and the one that is the hardest to deal with, is non-emergency conditions that require expensive treatment, like cancer. Ideas like having a large risk pool make sense for these kinds of conditions, but again, our health care system insists on doing everything that way, even though it doesn't make sense for other kinds of conditions. And again, this kind of risk pooling is not really "insurance" in the way that covering emergency care is (although there are similarities).

Also, does your plan also allow you to go to any provider for care if you're under your deductible and so are paying out of pocket? If not, you can't shop around even though you are paying the cost. That means you don't really have any market power.

> So what’s the actual proposal here?

I wasn't making a proposal, just highlighting a serious deficiency of the current system. However, the proposal would be obvious: separate out the three kinds of conditions I described and handle them separately.

For emergency care, you would buy insurance, which would work like any other kind of insurance against unanticipated large expenses.

For ordinary predictable expenses and unpredictable but manageable expenses, you would pay out of pocket, just like you pay out of pocket for other ordinary predictable expenses, like food, and other unpredictable but manageable expenses, like household repairs. In other words, it would be just like any other market. And like any other market, there would probably be businesses trying to sell "care plans" where you pay a fixed amount per month and get comprehensive coverage, much like existing plans (and like the extended care plans that car dealers will offer you when you buy a car). But it would be your choice whether to buy them or not, based on your particular circumstances and attitude towards risk.

In such a market there would also be an obvious business opportunity for plans insuring against non-emergency but chronic conditions like cancer. There would also be incentives to widen the risk pool. If there is a place where the power of the government could be used usefully, it would be here: treat all citizens as a single risk pool and negotiate with insurers for coverage of just these conditions based on actuarial data over the entire population. But I'm not optimistic that it would be politically possible to limit the government's involvement to just that.

This opaqueness problem can never be completely solved for healthcare at the consumer level. A significant fraction of healthcare consumption occurs in urgent or outright emergency settings where "shopping around" cannot reasonably occur.

I have no idea what it costs.

The health care professionals treating me tend not to have any idea what it costs either.

Some accountant somewhere in the Trust will know, and will bill the appropriate code to the Clinical Commissioning Group.

But if you compare like for like treatment in England and the US you'll find the cost to NHS England is far lower than the prices charged in the US.

£124bn ($175bn) give or take a few pounds. That does of course include some other people's health care too ! ;)

I wonder if it's possible to buy your own (or a close friend's) medical debt). If someone has to pay $200000 in debt, but could buy that debt for $2000, then that may be the easiest way to "pay it off".

And how would healthcare "consumers" be able to "shop around" while in an emergency situation?

This is the standard free market fantasy. It's all too common among healthcare startups, given that they are nearly all market-based solutions by nature and have a built-in incentive to ignore socialized medicine as a solution.

You'd think if we were really serious about improving our healthcare system we'd, you know, look at stuff that works and is field-tested, like for example the healthcare systems in basically all the other industrialized nations in the world.

- Many fish antibiotic producers just purchase pills intended for humans, because the cost is so low. Generic amoxicillin for humans can cost less than two cents a pill. The cheapest fish antibiotics I found were $20 for 100 pills at Walmart, so the actual pills could be less than 10% of the cost of the product.

- There aren't any currently USP-certified fish antibiotics, however. As a result, there are no regulations on how they are stored. This could mean they are exposed to heat and/or moisture, which antibiotics are sensitive to. That said, given that they're stored in sealed plastic containers, they should be fine.

- The differences in the actual pills should be limited to fillers and things that do not affect the potency, in the USA. None of these should be harmful however, although they could affect taste.

Again, I don't recommend consuming fish antibiotics, and amoxicillin is actually available cheaper (with a prescription) from online pharmacies.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481322/ - Secondary Bacterial Infections Associated with Influenza Pandemics

https://www.webmd.com/cold-and-flu/tc/flu-signs-of-bacterial...

These are all sectors in which public policy subsidizes demand and restricts supply.

If you're talking about the housing market, the Case-Shiller index indicates that over long periods of time, the value of housing tracks inflation, it does not outpace it. (Which does not exactly help the homeowner caught riding enormous peaks and valleys in pricing, of course.)

https://en.wikipedia.org/wiki/Case-Shiller_index

The other two are interesting. It seems safe to say that as more and more technology becomes available to help people stay healthy and alive, medicine will continue to get more expensive. Or maybe medicine will essentially become an information technology where Moore's Law applies and costs will go down, as Kurzweil predicted.

Maybe education will become less expensive as credentialism collapses under its own weight and online learning becomes more prevalent. Or maybe we will need more and more education as job hopping becomes the norm and wrangling all different sorts of technology becomes the lot of pretty much everyone who wants to earn more than the universal basic income.

When you include imputed rent, maintenance, and property taxes, it’s much less clear whether residential real estate or equities have better total returns over century timelines.

I was surprised by this, when I read abstracts of a paper about this recently, but it seems to be at least not as settled as I used to think it is.

I'm not sure how or why Case-Shiller would involve rent or imputed rent. Are you thinking more of commercial real estate?

https://en.wikipedia.org/wiki/Baumol%27s_cost_disease

But really, those are huge sectors of the economy. It's weird to say that they can't keep pace with inflation when its the majority of a lot of pay checks. Wouldn't it be better to say wages have stagnated while the price of other goods have dropped?

I wonder what would be the effect if regulations where such that one could easily import and distribute medical drugs. Or the AMA would allows foreign physicians to operate within borders.

The reason for high prices is IP. If you are in the choice of getting that expensive prescription drug that treat your hart disease or die.... you will pick the drug. No competition exist. (Here the power lies with the seller).

So to get reasonable prices you either have to remove IP or have a country wide monopoly. Else the free market rule.

Where are people being charged anywhere near $300 for amoxicillin? The highest cash price I have ever seen is $16 per course. Even if you factor in the urgent Care visit to diagnose the need and get the script, and pay cash for that as well, it still comes out less.

OK, two examples of how this could happen:

A few years ago I was charged $500 for a 1 meter length of IV tubing to connect a saline bag to my IV line. That was the Obamacare "negotiated price" -- it was substantially higher before this "negotiation" though I don't recall precisely, I remember thinking I don't spend that much on food for a month.

When my daughter was young, we took her to the ER due to a particularly severe sore throat. A nurse sweetly asked my daughter if she was thirsty (yes). Nurse went to the soda machine across the hall, selected a ginger ale, poured a bit of it into a small paper cup (disposing of 2/3rds of the drink) and handed it to my daughter. We got the bill a month later. Line item "Glucose - $30"

Medical care is completely, utterly broken in the USA. For those who doubt, just try asking what something will cost before it happens. I'll leave you to discover the punch line for yourself.

If that were the situation, buying them off Amazon is not an available alternative.

https://www.goodrx.com/amoxicillin

You're right. IF the gatekeeper (read: primary care physician) prescribes the drugs, they are cheap or free.

Do you know how much a doctor visit is?

---------------------------------

EDIT: because of braindead HN throttling, responding to you tptacek

I've been there, where I didn't have $20 in my pocket, let alone $100. So have others.

I found this https://www.amazon.com/AmoxFin-500MG-50CT/dp/B077GGQH72/ref=...

"Great product with quick delivery. My fish felt better without having to go to the doctor."

"Everyone healthy now. No need to take the fish to the doctor. Male angelfish learned a good lesson and now healthy again. Great Product."

"Same pill markings as the real ones the fish doctor gives me (only 1 ingredient). Saved me a $300 visit to the fish practitioner who owns his own chain of upscale fish clinics. Who needs single payer? I have amazon PRIME, baby."

"This is exactly what the “Vet” would prescribe. The pills match the correct color and code for the right stuff needed to treat bacterial infection for “fish”."

I've been there as well.

Physicians typically have a sliding scale options and payment plans. It is not uncommon for docs to fudge billing codes, give out copious amount of free "samples," and see patients after hours to help patients afford care. They're not all greedy gatekeepers. There are also free clinics for the uninsured.

The best thing is to have a good relationship with a PCP who will pull strings for you. Most people aren't aware what their actual options are, which is a problem that needs to be addressed. The system is broken and that also desperately needs to be addressed. But it's not a straight up binary choice between $300 vs self-treating with fish antibiotics.

I suspect you could find "telemedicine" services that would prescribe an antibiotic for less.

Naturally, I chose another doctor. This is more difficult when a doctor you have seen for a while becomes this busy for whatever reason.

See https://smile.amazon.com/Its-So-Easy-other-lies-ebook/dp/B00...

A large bill which, if you're uninsured, you can almost always negotiate down to 10% or less of the original.

Of course, most people don't know this, but those large bills aren't what the hospitals expect uninsured patients to pay. They just legally have to present them the same initial bill that they present private insurers.

How does one do this? Where do you learn it? Is there a book you suggest? The fact that I'm even asking this feel weird (I'm insured).

You can't do this if you're insured, because then the terms of your insurance apply. You can still get bills reduced, but the reasons are different and it's a bit more involved.

If you're uninsured, it's simple. You literally just tell them, "I have no insurance. I can't afford $45,000. It would take me years to pay that, and I'd probably default on the bill beforehand. However, if you reduce the billed amount to $500, I can pay that in full today, in cash.".

Substitute appropriate values in as needed, but that's the general idea. It's actually not all that different from what private insurers do, except they do all this up-front in bulk, so their rates are set in long-term contracts.

I've known people to successfully negotiate to 40-50% of original bill, usually with proof of (lack of) assets.

Maybe if you really are basically broke, they'll write you off rather than carry it on their books until they sell the debt. On the other hand if your bill is 45,000 and you have even meager assets : say a couple of cars and equity in a house, I'm guessing their going to try hard to see a good chunk of that.

In general, they only negotiate hospital bills because they are the only bills large enough. I would say that the typical final negotiated rate they get from the hospital is about 3-20% of the billed amount. It depends on how high the original bill is, and it also depends on whether you need to make payments and how long the series of payments is.

Hospitals will certainly claim that you need to send in the proof of assets, usually you have to refuse about 6 or 7 times and they will relent.

However, things have changed in the last few years and professional medical bill negotiators have told me certain hospitals are completely unreasonable and refuse to negotiate. They advise these people to file bankruptcy.

You're wrong either way. I've seen some bills my insurer pays around 2% of what is billed, but not most things. Hospitals will ofter sue, and they are aggressive about judgements. If you can pay something, they will take more.

I have never had health insurance. Where I live many people don't have health insurance. I have never heard of this happening. I've seen peoples, my own included, wages garnished before this will happen. I currently have a $20k bill for an emergency appendectomy I had 4 weeks ago. The hospital will seriously take payments for 30 years before they'll lower any cost. If you want to negotiate, you'll have to wait until the collection agency has their account removed from your credit report 7 years after the first reporting. Any time before that you are in no position to negotiate with anybody.

EDIT: Unless your income is less than 1.5x the poverty level. In which case you qualify for aid in paying your bills.

But having to play that damn game when you life is on the line is inhumane. There's no time out zone.

What? No, that's not how it works.

Good luck finding a 90% off coupon for a surgery prior to the event.

It doesn't. It's not a debt yet. You don't have to pay taxes on the difference.

It happened to a friend of mine who was hiking in Canada a year or two ago. Her son cut a big gash in his foot and they couldn't get online, so I had to call around to find an emergency room they could go to. The local emergency room basically said in lieu of proof of (internationally-accepted) insurance they would need $800 up front if he wanted to be seen. I think they wrapped a towel around it and drove back to the US.

It should be noted that the bill won't be different from an insured person bill, the prices are "posted".

https://www.gov.uk/european-health-insurance-card

It sounds like it was the Canadian insurance provider who screwed them, though. They said[2] that since she had a bladder infection prior to getting the travel insurance, it was a pre-existing condition and therefore wasn't covered. So basically, if you get your travel insurance and come across the border, don't expect it to cover anything like a heart attack, an abcessed tooth, a prescription refill, etc.

[2]https://www.change.org/p/blue-cross-blue-shield-pay-for-jenn...

As someone who lived in Canada for 10 years, I can understand that. The blindness Canadians have to the severe problems in their own healthcare system is amazing. Take a look at the massive problems in autism care in Canada. Let me put it this way, it was cheaper (free), faster, and superior in every way in the US as opposed to Canada, where it was far more expensive, years in waiting times, and in the end got no autism assistance. To be fair, this was back in 2011 when we finally left, but having kept an eye on the system (what with having family there still), it hasn't really improved.

To complete the picture, in the truly civilized countries when you're sick you just go to the hospital, and they take care of you, no strings attached.

The whole world is not made just of the USA and some banana republics.

This as a legal mandate applies to emergency stabilization (including assessment as to need for same) only. It may happen with other things, but that varies a lot and is mostly a matter of what the particular provider finds most convenient.

Mayo Clinic in Scottsdale AZ, November 2017.

edit: I'm a bit off topic, that was for an appointment, not ER.

Where I part company with the narrative is over looking how we have structurally made the 'collective' so large as to prevent such a decision to be taken.

I expect that if you were to poll San Francisco you would find overwhelming support for a single payer, 'state' (and by that I'm using the notion of the collective government not the state of California) administered health care system for residents. No doubt it would be paid for by taxing some of the wealthiest residents or as part of some sort of rent/property taxation plan.

You might even be able to get this passed (agreed to) for the entire state of California.

However, country wide consensus on the issue is elusive and often divisive.

The saying goes that "all politics are local" and to a large extent that is true. But I wonder why it is that the state of California was progressive enough to legalize marijuana but can't get something like this done? The current punch line is "This isn't a problem in North America if you are Canadian."[1] so why is that the case in California? We've got the largest state economy in the US, we've got the largest population base, and we're bigger than France[2]. So what is the hangup with just showing the rest of the country how things 'should' be done rather than complain about how things are being done 'wrong' ?

[1] And yes I know there are plenty of complaints about the system there as well, it is still better than what you get south of the border.

[2] https://www.weforum.org/agenda/2016/07/american-state-bigger...

We'll see. Ironically, and optimistically, the attack on the ACA at the federal level might push California voters towards supporting universal health coverage.

But marijuana is a different issue than healthcare, because in order to legalize it, you don't need to tax the haves more. It's only opposed by social conservatives, who are not a huge contingent in CA.

Universal coverage in CA, however, would need to involve some form of redistribution downwards (just like the ACA did), and many Californians aren't as progressive when it comes to that. You see this same phenomenon in NIMBY anti-development housing policies, and in the underinvestment in public education.

The demographics of this tendency are strange, too. The older generation has a strong skew against progressive social policies, but sometimes young, well-to-do, and childless people are also opposed to more downward redistribution, because the things that some of the progressive policies affect (healthcare, education, etc), are a non issue for them (at least so far).

Individual states could easily experiment with e.g. gay marriage or legalizing cannabis before the rest of the country, because the first has negligible revenue impact and the second actually enriches state coffers. But I don't think that you can run the same one-state experiment with single payer health care without incurring steep costs from medically desperate migrants from other states.

OTOH, if the tax-induced cost to business (or even some identifiable subset of businesses) of the single-payer system were less per employee than the cost of provide and manage healthcare benefits, it could also be a magnet for businesses from other states.

You started with "I think that single payer is a great plan for a country. I don't think its cost-saving merits would be evident in a single-state experiment." I completely agree that the scale is an important part of how well one could evaluate the success. If you read reference #2 in my comment you saw that Calfornia's GDP is slightly larger than that of France, and France has a universal health care system[1]. My thought is that if it was good enough for an economy like France then California is a large enough test case. I could not make such a case for Wyoming for example.

The argument that 'it would be a magnet, and all these high cost patients would move here' has intuitive appeal but I struggle with it. Here are my challenges with that sort of rebuttal, first I would like to understand better how France deals with the situation given that migration around the EU is fairly easy, and by some accounts France has the best health care, are they over burdened by the high cost cases flooding in? Also there are plenty of reasons to want to live in California but the high cost of living (excluding health care) has been a disincentive for many. As I see it, the set of people who would move to California, for the health care, would be that population who could otherwise afford the cost of living, or by covering their medical costs could now afford the cost of living. And I wonder how big a group that is relative to the overall existing population. I also assume that someone would rather live in a home and pay for health care than be homeless in California and get free health care. There is also the 'reverse' effect where people who are currently bankrupt/underwater and already live in California, becoming productive again after the burden of health care was removed. So what is the net change?

There is also a big fuzzing effect on the healthcare debate which conflates the cost of providing medical services and the cost of insurance. I am convinced by the evidence of concierge doctors and all cash procedures that are significantly less expensive than the 'advertised' or 'billed' prices for procedures, that a form of capture has occurred whereby the medical services providers and the medical insurance providers are colluding (possibly inadvertently) to maximize those costs in order to maximize the transfer of money from patients/businesses into their possession. And while I recognize that state efforts to minimize that (a state insurance commissioner who oversees and regulates that capture) have not been as successful as I would like, I am not convinced that the problem isn't solvable. After all, places like France solved it for some definition of solved.

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

1) Most (all?) other countries in the EU don't have terrible American-style systems of healthcare provision, so the pull isn't as strong.

2) Language barriers make e.g. a Poland-to-France move more difficult than a Missouri-to-California move, even though the latter move actually requires covering a greater geographic distance.

Of course there are practical barriers against every medically underserved American moving to California to take advantage of a single payer system. My intuition is that there could easily be enough of them to more than cancel the economic benefits that you'd expect from imitating the successful single payer systems of other countries. YMMV. I'd love to be wrong about this.

EDIT: dragonwriter brought up a good point about business-magnet effects, which offsets some of my pessimism about the outcomes of trying this in California. And you have a good point about Californians who might be able to re-enter the workforce.

Also, in the current national political environment, there is very little chance that if implementation of such a plan were to actually go forward, that the federal government wouldn't start coming up with punitive measures (because fuck those rich elitist Hollywood liberals).

How so? Are you just referring to the overlap with Medicaid (a state benefit with federal standards) and Medicare? You'd need to get federal permission to do it, but you could conceivably formally do it by expanding Medi-Cal (the states Medicaid program) to cover the entire population, with those not eligible federally being an optional state-funded population (California already does that with some populations, but obviously not as broadly) and simultaneously make it (or a carve out within it) a Medicare Managed Care Plan (there are, again, Medi-Cal/Medicare joint managed care plans in the state already.) There'd be some administrstive and compliance costs for this, and some coverage and other mandated limiting (but not eliminating) flexibility particularly on the Medicare side.

The Administration’s plan to block-grant Medicaid would, while it's likely to be horrible for CA financially in any case, both reduce the administrative burden and federal involvement here, and reduce the marginal cost of a single payer system.

> Also, in the current national political environment, there is very little chance that if implementation of such a plan were to actually go forward, that the federal government wouldn't start coming up with punitive measures (because fuck those rich elitist Hollywood liberals).

That's a valid concern, though even the pretense of a facially-neutrsl policy reason may be hard to come up with. OTOH, that assumes the political composition of the present federal government, with undivided Republican control, survived long enough to effect any single-payer program.

If patients are being charged this much for anything, the money must be going to someone? Who's making all the money? Drug companies? Hospitals? Health insurance? Doctors or nurses? Why don't people honestly follow where the money end up and actually solve the problem once and for all. Increase the supply of X or many other bottlenecks by deregulation and result in decreased price?

There are a lot of reasons for the inflated costs, but a big one is the way the billing system itself works.

Legally, providers have to charge patients the same amount in an initial bill, regardless of insurance status. They can reduce it later, but they can't bill different amounts.

Medicare and Medicaid reimburse less than COGS, which means that providers start off by losing money per patient on publicly-insured patients. To stay afloat, they increase the amount they bill, so that private insurers essentially cover the difference.

Uninsured patients are collateral damage here - they end up paying the sticker price that's intended for insurers as a highball starting point for negotiation. The insurers end up paying something around 3-10 times what Medicare pays, but less than the sticker price.

This system is unfortunately unlikely to change, because any efforts to increase price transparency would decrease Medicare's ability to pass on costs to private insurers, and they would oppose that heavily.

Who is 'they'?

Currently, Medicare is able to balance its own books regardless of any increases or decreases to its tax revenue, because they can set the prices they pay unilaterally, with no mandate to cover their own costs (which is why they already don't cover their own costs). Any decreases in revenue purchasing power, whether due to tax cuts, budget cuts, or inflation, they simply lower their own reimbursement rates, and eventually private insurers will be forced to cover that difference.

Medicare - and those who benefit from posturing themselves as supporters of Medicare politically[0] - would frame price transparency as cuts to Medicare. It's not really a cut to Medidcare's revenue; it'd be a reduction in their ability to reduce costs by extracting money from private insurers, but the latter doesn't really roll off the tongue, so they'd be pretty successful in messaging it as "cuts to Medicare".

[0] which is not the same as people who actually benefit from Medicare or supporting Medicare, as we already know.

They want to move everyone to the bankrupt medicare system that which be a catastrophe for everyone

Basically, treatments / devices are developed without market demand, priced at a premium, and adopted because they are incrementally more effective than the previous version — but the people paying for them ultimately just pass the costs on to another middleman in the form of insurance companies. Patients often have little / no choice in the treatments they receive, but they’re the ones ultimately paying for it. This causes people to avoid the medical system until they’re deathly ill, which ends up costing the whole system more.

Edit: also, the laws don’t help. For example, health insurance companies are required to spend 85% of revenue on direct medical expenses, which means they get 15% to fund operations and take a profit. How do you get more profit with the same operations spend? Just increase medical spend, and increase premiums / copays (revenue) accordingly. They actually have a disincentive to keep costs down. Things are starting to change but I suspect Amazon Health is going to be revolutionary for this reason alone.

You can probably find articles for "X is driving the cost of health care up" for at least 6 different values of X, and the more I've personally dug, the more I found that all of those contribute and there's not obviously a single X that contributes to more than say 20% of the difference between the US and other wealthy countries.

"Ask your doctor to prescribe you this"? what the hell.

The pharma business used to have spectacular margins, 20 years ago. The ROI of new chemical entities has been falling since the 1990s. Pharma companies have been shedding personnel and facilities and merging for a long time to keep stock prices up. They're having a hell of a time coming up with new patented products that are broadly useful and better than generics, so direct-to-consumer advertising is one of the few avenues left to boost revenue. It's funny how corporate arrogance and desperation can look so similar.

This is a great example of what my comment is saying. There is no obvious silver bullet because everything in the US costs more than in other countries.

[edit]

Also, per-capita government expenditures on health care in the US are actually higher than in Germany[1]

1: https://data.oecd.org/healthres/health-spending.htm#indicato...

Yes.

edit: forgot a "slower than"

That said, a masters in nursing isn't easy, a good nurse earns their pay.

It's anyway probably not a great argument if you are trying to make people making 5-10x the median wage some kind of baseline.

Sure nurses and Doctors make money but if you know anything about that job any good one is probably underpaid.

https://en.wikipedia.org/wiki/Puncture_(film)

An example of where it goes:

"On June 24, 2013, The Wall Street Journal reported that McKesson Chairman and CEO John Hammergren's pension benefits of $159 million had set a record for "the largest pension on file for a current executive of a public company, and almost certainly the largest ever in corporate America." A study in 2012 by GMI Ratings, which tracks executive pay, found that 60% of CEOs at S&P 500 companies have pensions, and their value averages $11.5 million."[1]

> Increase the supply of X or many other bottlenecks by deregulation and result in decreased price?

Unfortunately, I suspect that increasing the supply of CEO's would somehow be totally ineffective. They seem to exist outside of the usual supply and demand dynamic.

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

There is economic consensus on healthcare costs already. Pharma is one of the biggest by far.

This is an interesting thing for me as non-american, because both Bernie Sanders and Rand Paul blame the limitation of pharma for very high expenses in the american economy. They are opposite spectrums for state action but both agree on the same issue, and neither has consensus to solve the problem.

Why? Because it has to be politically unprofitable for everyone else in the middle to say "We are going to open up importations and lose a bunch of pharma jobs". That I put on the public.

For example, if $X gets billed it is seldom the price that gets paid. Usually insurance has negotiated rates of 0.1-0.2X and pays that. Different insurances pay different amounts for the same procedure. Hospitals know this and internally amortize expectations (to, say, 0.15X) pretty well.

Now for the stinky part: someone without an insurance gets a strong push and occasionally a threat to pay the full bill. The patient might push back, but success varies and poverty is the only high probability way to successfully lower the bill. It is a BIG pain for both sides, as it usually takes years to collect even a part of this and any money will likely be shared between hospital and any organizations that help collect.

Many hospitals would gladly take say, 0.2X upfront (their amortized expectation is $.15X). But they must bill same amount to everyone; thus they bill an outrageous amount and the few without insurance lose BIG.

The most noticeable one is pharma though. If the US allowed for free drug importation from overseas, you would slash healthcare costs in an unprecedented way. The only thing needed today to reduce the problem significantly is for the government stop doing something.

None of which should be construed that they don't contribute to the problem. They just aren't the primary villain.

http://slatestarcodex.com/2017/02/09/considerations-on-cost-...

I have a game I play when I go to the Dr.: Estimate the ratio of Dr.s to administrative staff. In the US there are offices where I've seen with two admins per Dr.

In Canada (where I'm from) I usually see two Dr.s per admin.

There are other costs. Too few Dr. having too high a salary

Another fun game to play. Find a recent list of Drs per capita for the various countries and go throught the sorted list. English speaking countries fare really bad, but the US does very well among English speaking ones. Why? It's a lot easier for an English speaking Dr. to move to the US than an non English speaking one.

ObamaCare was mostly a failure. I had it in between jobs for a few months, it's gotten worse since. It really doesn't make sense for a young person to buy it unless you have a per-existing condition.

Bush also made it worse by prohibiting drug re-imports (and letting pharmas charge medicaid whatever they want??)

Ultimately too many too powerful people have interests in keeping the US health care in the state its in, so it'll continue like this until it collapses.

Those are very good questions. Unfortunately the people and groups the money can be followed to have a very strong monetary incentive to not change things

That would suggest insurance companies are not the problem.

In any case, the same point would apply in the other direction.

Especially if you have good insurance, you'll get to experience getting passed around from specialist to specialist who will take great joy in milking you and your insurance company for unnecessary and pointless tests.

Doing tests is not only economically costly, its also costly in terms of health, so ordering unnecessary tests is in detriment to health. There are also false positives. So tests without symptoms should not be performed. But that also means you dont find things pre-emptively.

For example, you are worried that your fatigue is due to a brain tumor (google surely told you that), so you ask your doctor to do an MRI to rule it out. MRI comes in negative. But the MRI radiation gave you cancer, because it does (in a very small amount of people), as well as gave you very expensive bill for it, because MRI are expensive everywhere, not only in the US.

Good example, except you're thinking of a CT scan, not MRI. CT scan uses x-rays. MRI uses no ionizing radiation.

I ended up seeing a 'naturopath' and asked for the test and I have both alpha thalassemia minor and beta thalassemia minor, which explains all my symptoms.

As another anecdote, I went to a physical exam with no complaints. The doctor palpated my testicles and said I was fine. About 10 hours later, I get a call saying I have testicular cancer and need an ultrasound, which I did the next day. My testicles are fine; to this day, I have no idea why I was sent for this test.

That's not entirely true. It's accepted you get periodic screening for many issues. (breast cancer, pap smear are probably the most common) Then there are tests you can easily request without any symptoms. (STI and allergy tests for example)

> But the MRI radiation gave you cancer

There's no MRI radiation. That's not how it works.

I mixed up CT Scan with MRI, corrected in another comment.

Is that really the best lesson here? Tests have known false positive and false negative ratios. That's why for some things you get immediately retested if the first result is positive. People cannot know/remember everything, so there will be always done room for error. But if you want to get better, you've really got only the choice to trust a doctor, or learn enough medicine to help yourself (still can't get access to drugs this way).

I hope nobody skips a trip to the doctor just because they think it may fail.

The latter method also sucks when surgical intervention is necessary.

https://splinternews.com/how-to-not-die-in-america-182255515...