As an Australian living and working in the US with a wife who has a chronic medical condition that costs our insurance company on the order of $100k/yr for her regular treatments, all I can say is "Almost $1k" sounds like a gross underestimate.
An anecdote I like to share with friends back home is related to a routine blood test that she has every few months. The price the provider bills varies significantly, but one time they billed $2900. Our insurance paid them $27 like they usually do and the remainder was written off.
Imagine being sick, having no insurance, maybe no job, and receiving that bill in the mail with absolutely no way for you to know that they would probably accept over 100x less than billed. I can understand why medical expenses are the #1 cause of bankruptcy in this country.
This econtalk episode[1] provides some interesting background on how this happens with medication. There are man-in-the-middle companies (Pharmacy Benefit Managers - PBM) that negotiate plans with pharma companies. These companies get paid a commission based on the delta between list price and the deal they got. The Pharma companies need these deals, so both benefit by the pharma company increasing list prices every year and then cutting better deals to those PBMs. If someone is offering a generic that's cheaper, there is less incentive for PBMs to add them to their plan, because the prices are too cheap to begin with and they have a smaller market share initially. It's all a giant Rube Goldberg machine of a mess.
EDIT: One more interesting detail from the podcast and the book it's based on: Those deals between PBMs and pharma companies are secret. Not even the insurance companies know the details of what's in there.
It's also fun to point out that typically this is everyone involved in a consumer getting their drug:
* the consumer
* the consumer's employer who selects the insurance
* the insurance
* a PBM who get a Pharma benefit plan for the insurance
* the Pharma company that manufactures the drug
* the pharmacy you actually buy the drugs.
On top of that the actual payment apparently happens often months after you received the drug.
When my father was in the hospital and had a hard time eating, they told us we couldn't bring in anything and he could only eat food from inside the hospital. I asked his lead doctor if he had any special nutritional needs, and he said no, he just needed to eat anything he could get down. But when we asked if we could bring anything in, they said we had to talk to the nurses and see if it was allowed. I checked with a friend of mine who had privileges at the hospital. He got back to me and said the outside food ban was normal, but enforcing it wasn't. The hospital had a hospitality and vending machine contract that required them to train all the staff in being firm, explicit, and proactive about the no outside food policy.
Of course the vending machine was full of junk food, and the contract was with the same company that controlled the pharmacy. These people need to be put out of business.
"Those deals between PBMs and pharma companies are secret."
In some cases pharma co.'s created their own PBMs.
There is a long and storied history of litigation on American drug pricing. If you want to understand the Rube Goldberg machine, I recommend searching the keywords "Average Wholesale Price" or "AWP".
In terms of consumer protection, some states are better than others. Maine was a leader in this area. However it looks
like the pharma industry has prevailed.
Yeah but then there's drug rebates, cash discounts for medical services, and costs negotiated down after services. The whole thing is a clusterfuck and 10 patients likely pay 10 different prices for the same thing.
These things happen all the time in real world free unregulated markets. The seller looks at you, tries to understand how much you can afford and what are your alternatives right then, and to get the highest price possible.
If you are desperate and your life is at risk, they can literally strip you naked - just see how many unscrupulous people become rich during wars.
When you are in a medical emergency, and you need a treatment right there and right then - no time to shop around - why should an unregulated, shareholder value maximising business, not extract from you as much as you can afford?
>When you are in a medical emergency, and you need a treatment right there and right then - no time to shop around - why should an unregulated, shareholder value maximising business, not extract from you as much as you can afford?
In a free market, you'd also have choice via competition to drive that price down. Right now, hospitals can literally veto their competition by claiming "there isn't enough demand to justify another hospital in this area". So bing, no new hospital, no competition.
And of course, this assumes your provider is out to screw you at every turn. This turns out to not be the case for obvious reasons; your provider still wants your business in the future. In the case of a single hospital/provider (a la regulation) they've got your business no matter what.
Competition is a key force in markets, and regulation in the medical industry provides huge barriers to competition.
> In a free market, you'd also have choice via competition to drive that price down
Not really though. Like, if I am having a heart attack the correct answer to "Which hospital do I go to?" is always going to be "The closest one equipped to handle it". Well technically the one I get can to the fastest that can handle it but you see my point.
This kind of choice via competition would work for things like optometrists and GPs (assuming you live in an area with more than one general practice) but just plain doesn't for emergencies.
Yeah, the moment you have a heart attack is not the time to start comparison shop. This is the argument everyone always brings up all the time, because it's so obvious.
An because it's so obvious, people will want to be prepared for it. By having insurance (real insurance, not the bizarre "health insurance" construct we have today), or subscribing to some service like you do for when you car breaks down etc.
I'm not sure what exactly would happen, but I'm certain it won't be that people will just never think about this until they all, one by one, have a medical emergency and have to unexpectedly pick a hospital on the spot.
Right, but what I'm saying is even if I did my comparison shopping before hand it doesn't matter because unless I stay within a certain radius of the hospital I've chosen I can't then it is kind of moot.
Because if hospital B isn't my choice but I'm closer to it when the emergency happens I am going to hospital B
> These things happen all the time in real world free unregulated markets. The seller looks at you, tries to understand how much you can afford and what are your alternatives right then, and to get the highest price possible.
But that is not at all what I'm asking about. You clearly didn't read the post I commented on.
If my basement is flooding and I sound rich and dumb to the plumber I call, I might get quoted triple the price of one of his regular customers, sure.
But there won't be a Plumbing Benefit Manager company as a middle man that has a "negotiated special hourly $800 rate" with the plumber so I don't have to pay the "official $9340 rate".
That sort of complex plunder reeks of regulation to me. I can't imagine how it arises. Which is why I asked.
So what looks bad to you isn't the fact that a medical company will try to get all your money when you're most vulnerable, but the fact that they need to resort to a middle man to be able to do that in the face of regulation? Cool.
That herring is so red it may as well be a cooked lobster. The overwhelming majority of medical care is not urgent care. The overwhelming majority of medical costs are costs that can be foreseen long enough in advance to shop around. Even if you think you might have skin cancer you're still in a position to choose where you go to get your tests.
There's regulations that prevent them from being undercut by entities that are willing to have transparent pricing. The problem here is not lack of regulation. It is a lack of competition. Regulation forces providers to adopt a particular business model and that model allows the kind of pricing shenanigans we see. At the end of the day everything comes down to dollars and a lack of pricing information means it is not possible to compare like services across providers. Being able to compare supposedly interchangeable goods/services is a core part of the free market and it is missing from healthcare in the US.
Fortunately there’s a natural experiment of precisely this: drug ads targeting consumers were illegal until 1985. The result has been an explosion in drug prices; the ads were used as a way to try to go around any pricing constraints.
I worked for a time in pharma and believe me direct to consumer was seen as a boon to profit margins, not a constraint.
I'm talking about grocery store ads selling baby back ribs for 2.99/lb not "got milk?" ads by the milk board.
Public transparent pricing that will drive consumers to pick and choose their health care providers would do great things for the ridiculous situation we are in.
That is an entirely predictable result when you have direct-to-consumer advertising but not direct-to-consumer supply. You just get all the demand the pharmaceutical companies can manufacture without any competition on the supply side to drive down prices.
Sounds about right. Extending this, and considering employer-provided health insurance as effectivly a tax on your income, and suddenly the US is heavily taxed.
I'm sure this analysis[0] has plenty of critique waiting to pounce, but it's something to consider.
The evidence from health care systems in other countries suggests that this type of excessive rent seeking does not exist in regulated markets. It’s the lack of regulation in the US that is the problem, not the other way around.
I think a more nuanced explanation is that the problem isn't the amount of regulation but the nature of the regulation. If we simply add up all the rules, healthcare is probably more regulated in the US than anywhere else in the world. The difference is that in other countries the rules are designed with the intention of making healthcare accessible to everyone. In the US, the rules are designed to maximize profits.
A less nuanced explanation is to agree that in an unregulated market, this type of excessive rent seeking would not exist. The old and sick would simply die in the streets. (Actually that's not quite fair since in an unregulated market we wouldn't have streets.)
Policies can always be improved but the relationship between stronger regulation in health care and more access (lower cost) is pretty robust across the world. Nobody openly argues for policies that will lead to higher cost and less access.
The costs of giving birth is another interesting example. BBC journalist recently said that even though it costs 4x as much under America's privatised system versus a socialised one (Finland), America has a worse record overall in terms of outcomes.
I think the US is good at the high end of the distribution, it's just that the average isn't very good. If you want and can afford the best care in the world, you'll find it in the US. But if you get basic care, not so much.
This kind of discrepancy makes these debates somewhat pointless as different sides talk past one another.
Citation needed for that. (And by world leaders do you mean politicians, or wealthy people? Many world politicians have other reasons for avoiding the US.)
There isn't much motivation to release such data to public, those affected know this very well, rest shouldn't care (according to them). From living in Switzerland for 9 years and having fiancee as a doctor I can tell you it is at least somewhat true, nobody here bats an eye if some powerful person is treated in hospital across the street (or more likely private clinic in some nice place).
There are many reasons - high quality of medical staff, top notch equipment, just a good place to be. Also, Suisse is long term perceived as creme de la creme in many aspects of life, so this fits the overall picture, be it real or some wishful thinking (mostly real though).
What perhaps makes it crazier is that they never expect to get the whole $2900. They bill that and the insurance company will always reduce it by a huge amount. Individuals without insurance are expected to also "negotiate".
I keep hearing this "negotiate" thing, but I tried it when I was billed $254 for a strep test (after being quoted $25 at the walk-in clinic), and the provider refused to negotiate. I appealed with my insurance, the appeal sort of disappeared (I received a letter saying it had failed the first round of review, and they were sending it elsewhere, and then I never heard back again) - and after fighting it for four months, I gave up and paid. Should I not have?
Same deal. Strep test, $250 plus a $50 "outside of business hours" clinic charge.
I visited at 9am on a Monday morning. The billing dept claimed it was a standard charge they charged everyone.
I fought them for months about it. Only after it reached collections did I pay it. The extra fee was missing, but $250 for a strep test is a rip off regardless!
Nope this was my experience too. I also heard that they'll knock 50% off or more if you offer to pay cash on the day of. This was also not true (at least in Alaska).
In Utah I've gotten further, but usually if they knock off 20% I've had a good day. It's insanity. The market is completely messed up.
My dentists always gave me 10% off for paying cash. Collection agencies often gave me 10 to 20% for paying the whole balance by credit card on the phone. Hospital sometimes gave me 25% for paying a year old balance within 1 month. These were all insurance repriced bills, except of the dental. Many bills were over 1 year old, because of billing errors and numerous back and forth between me, service provider and insurance company.
There is no real negotiation or defined process. . You have to be willing to play hardball and outright refuse to pay. Also be willing to call every day or get a lawyer that writes nasty letters. Also be willing to deal with collection agencies.
It’s a stupid game about who is the biggest bully. Not many people have the nerves for this.
It’s like the PayPal and EBay dispute process. Lots of unnecessary manual lookups, waiting periods and then an arbitrary deadline, and my favourite: waiting for them to make an automated decision. Like, why not stall when they already have my money.
Negotiate with whom? I don’t think there’s anyone at the hospital you’ll have access to that can guarantee you a lower price (or can probably even tell you what the price will be). After you’ve had the treatment and finally given the bill you don’t have any negotiating power; you can only beg at that point.
That's actually backwards. You are in a better negotiating position, when you've had the treatment and been given the bill. You can simply say, I can't afford that bill and I can't pay it. Don't beg or ask. Tell them. The people trying to collect money from you are paid a commission based upon how much they collect.
You might have to just refuse to pay until someone calls you about it. Then you could offer to pay a portion. It may very well be a collections agency calling, and late payment could reflect poorly on your credit rating.
I heard that too. I have 2 bill in collections from 6 years ago, still negatively impacting my credit score. The 7 year mark is coming up in two months so I will see how it affects my credit.
This actually can work, but you have to remember to check up art the right time before they send to collections. Don't forget about it or a collector will be calling you.
Interesting, as an outsider, I've heard horror stories, including how US insurance companies treat patients with chronic medical conditions - trying to avoid compensations as much as possible, even invalidating insurance policies, stating as pre-condition, etc... May I ask, how you (and your family) were treated? Did you got lucky with some particular insurance company, or is it a norm in case one has a decent job?
Also interesting, e.g. what happens if you lose your job, decide to go indie or until you find another job... In other words, how safe you feel? (compared to living in Australia with their universal healthcare)
Health insurance companies are not allowed to deny coverage based on pre existing conditions, and they all have out of pocket maximums (for in network providers - doctors/hospitals that they have deals with), and you can purchase health insurance at healthcare.gov if you don’t have a job.
Unless your employer pays a portion for you, expect to spend $4,000 to $8,000 per year per person on health insurance premiums, depending on your age, plus up to $3,000 or so on out of pocket costs assuming you need medical care.
It’s just your lifetime’s, up to 65 or whenever Medicare (taxpayer funded care) kicks in, health costs amortized over your whole life and then discounted for age since younger people don’t need as much healthcare.
In America, the voters want doctors and hospitals and drug makers to provide everyone, no matter how destitute, with services and medicine. But the voters also don’t want any to pay any additional taxes, so this is all a work around to that.
Poor people and old people get subsidized by Medicaid and Medicare (taxpayers) and they pay less or nothing at all, so the providers go after everyone else (middle class) for as much as they can. The bigger employers who have negotiating power can do well for themselves, but the smaller employers/individuals on healthcare.gov get screwed because they don’t have enough negotiating power to prevent getting taken for all they have.
> Poor people and old people get subsidized by Medicaid
Everyone assumes if youre dirt poor you get Medicaid. But at least for some states as I’ve found out that’s far from true. In Florida for example (we have a poor friend there who is sick) non disabled adults do not ever qualify even if they earn zero dollars.
Interesting. I have a non-disabled friend in the same state that is very poor (lives in a trailer home, cannot get a decent job as an ex-con, etc.), and Medicaid covers all of his medical expenses - even psychiatric. He's not always happy with some of the things they provide, but he's also the type of person that never would be. He gets what he needs, but not always what he wants. Perhaps your poor, sick friend just needs the proper guidance and/or motivation.
> Be over the age of 64; or
> Be pregnant or have a child 18 or under; or
> Be blind or disabled; or
> Have a child, parent, or spouse in your household who is blind or disabled
By suggesting my friend needs proper motivation do you mean she should get pregnant so as to qualify?
We've been here for nearly two years now, but when I was interviewing with the intent of moving to the US I was very direct with employers about our insurance requirements to make sure her quality of care would not be reduced. I turned down some better offers because their insurance was worse (one company would've required her to move to a known-worse treatment until she demonstrated it didn't work for her. This escalating method of treating her condition is well known to have much poorer long-term outcomes but it's cheaper).
Re avoiding treating people with chronic conditions, my understanding is that used to be a (state-by-state) thing that the ACA federally outlawed. We live in NYC where the state had already outlawed it, so even if the ACA is rolled back we should be fine.
We have very good insurance atm. I would go so far as to say, ignoring the general craziness of dealing with the US system and the occasional billing frustration, we have better coverage now than we did in Australia because _almost everything_ is covered (even most things Australia would consider "elective" and hence one would pay for out of pocket). We pay a token $1/month for premiums because law says we have to contribute and my employer pays our deductible. As long as we stay in-network we have basically no out of pocket costs.
If I lose or leave my job I have to find a new one and transfer my visa within 30 days, or leave the country within another 90 days after that. There's a thing called COBRA which allows you to pay a relatively low fee (iirc it's ~$700/m) to continue with exactly the same insurance post-employment for a short period (I think 9-12 months? Unsure exactly). Otherwise we'd just move back to Australia. We're both Australian citizens and we aren't really interested in making the transition to being US permanent residents.
There's a thing called COBRA which allows you to pay a relatively low fee (iirc it's ~$700/m) to continue
Boy, are you going to be in for a surprise if you ever utilize COBRA. If there's a "we" involved, plan on about double that, because you will pay the full, undiscounted premium. They don't want you on that plan, and they only do it because of federal law, so they're going to make it as unappealing as possible.
insurance post-employment for a short period (I think 9-12 months? Unsure exactly)
The "relatively low free" part threw me off. Is that a joke? COBRA was $600/mo the one time I might have needed it. That was 6x what I was paying at the job I was in before.
This was supposed to be the benefit of HMOs. There would be single-pricing, and all carriers are aware of this pricing beforehand.
What I think we need, however, is a model that doesn't depend on single-pricing to work, because the real world isn't single-buyer.
People tried to solve it by creating healthcare savings accounts, but the solution itself is very complex, and the end user is often in situations where they don't have the ability to negotiate (e.g. emergency health care). So in practice, the financial benefits seem to accrue with low-care patients, not low-cost-of-service patients, meaning it doesn't affect the system in the right way.
Ultimately, I think the only way to fix it is to start adding negative pricing pressure in small ways to the system, not trying to tackle the whole problem at once.
For example, waive deductibles for treatments which are billed below average (mean? median? in any case, this has to be independent of list price). That creates a financial incentive for insured patients to both seek out billing information, and to lower it.
What's great about that (for insurers) is that you're specifically altering behavior of your most cost-conscious customers, who tend to be your lowest margin customers, without mucking about with the profit margins on your most valuable customers.
>So in practice, the financial benefits seem to accrue with low-care patients, not low-cost-of-service patients, meaning it doesn't affect the system in the right way.
At first glance, it's not a bad thing, but it does nothing to solve the pricing problem that America's healthcare system has.
Going a bit deeper, however, it will most likely increase health care costs over time. This is because it splits the population into two separate risk pools (low-risk low-use, and high-risk high-use).
To save myself the time of explaining it in full, just compare it to the current state of the credit card market. When Discover pioneered the idea of splitting the risk pool (by offering cash back rewards to low risk clients), then it created upwards pressure on credit card fees (because the general risk pools slowly became high-risk pools, meaning that existing risk fees didn't cover the necessary spread). The traditional cards now started charging more to merchants, which left room for larger rewards for the low-risk pool in a vicious cycle.
AFAIK there’s rule in Germany that a lawyer can chose to be paid 10% out of the difference they saved for the client. I wonder this rule would help with those shenanigans.
>Imagine being sick, having no insurance, maybe no job...
Sorry no.
Long term unemployed people in the US qualify for free medical care, celphones and basic dental work. The process is arduous, yes, but it is comprehensive. I had entire recurring blood panels, multiple MRIs, neurological impairment tests , every hospital visit and all of my prescriptions provided for free.
Lumping all levels of poor together is just lies that obfuscates larger issues.
And other articles too. People inside the USA, travelling ( sometimes for days) to queue (sometimes for days) for a dentist. Why are there organistations in the US whose purpose for existence is to travel around, providing free dental care to any and all comers? Like a medical mission to a country suffering enormous poverty.
I think the cue is at “Virginia is one of 19 states refusing federal dollars to close the healthcare “coverage gap” for people not poor enough for Medicaid, but too poor for anything else.“
I am way out of my depth; why would a state refuse that money? What is the cost of accepting it that 19 US states feel is too high? Not demanding this of you specifically; maybe someone, anyone, can answer.
As the sibling commenter mentioned, it is a political decision to take federal funds, which sometimes goes against the best interest of the electorate (not claiming to be the case here but seems like so when we read such articles).
the argument they made is the money is temporary. After a few years the federal money goes away and the state has to foot the entire bill so they would rather just refuse the program entirely. This is their public reasoning but the reality is more that it is program proposed by Obama so they just want to refuse it on political principle
What program are you referring to? AFAIK, This is only in states that expanded Medicaid so it's a real situation for millions in states that didn't. Or are you talking about some other program?
California programs, so yes expanded Medicaid. But as the state that consumes the most in welfare, it seems highly relevant when discussing the needs of the 'poor'.
Programs: California Medi-cal (which covered all of my medications, tests, etc), Denti-cal (all dental work thats not cosmetic), my obama phone, calfresh (for ebt food) and calworks (cash monthly stipend) are the only programs I can speak to.
I'm grateful for what I had to fight to receive during a bad period of my life and hate seeing misrepresentations like this being spread without specific context.
Had I not been able to finally get working again, I would have eventually qualified for free housing, utilities and all the other benefits available from programs that are funded from various sources. I made several friends through the course of going to these offices over a long period of time who were admittedly worse off than me (mentally) but somehow knew all the inside information on how to game the system. (Ex: if you are considered impaired you can get free bus/subway/van service card, which they all knew how to easily acquire). I had to ride my bicycle or walk everywhere to get back and forth from these appointments.
I'm glad you were able to get healthcare, but the parent comment you're responding to and your own comment are both talking about the entire US. What you wrote is simply false. There are 14 states that still haven't expanded Medicaid and millions of poor people are without health insurance. California isn't the US and pretending like it is misleading and helps no one.
By that definition literally nothing that is produced/provided by humans is free, and I feel like it's unhelpful to insist on such narrow definition of free. Everyone here knows exactly what OP meant by that and there is nothing to be gained by pointing out that free healthcare was paid for by someone else - of course it was.
I kind of want these issues to continue and get worse. Because then we will have a healthcare revolution, rather than more bandaid policy fixes.
It seems like the US healthcare system is too far gone, and we need to hard reset it. Anyone who lives in another developed nation would be absolutely outraged if they had to deal with half the things Americans do when it comes to healthcare and the respective insurance.
How many people are you willing to let die to get to that revolution.
Then, once the revolution comes, how many people are you willing to let die while you iron out the operational bugs in your new system.
Fixing the US healthcare system is going to be like changing an engine mid flight. It will require long term planning and consist of a lot of bandaids and ducktape while we work on it. Unfortunately, our political system is by-polar, so plans need to be designed not by what will work best, but by what cannot be dismantled when leadership changes.
Most developed nations have a public health system. Akin to how the US has public schools and emergency services.
The revolution could be the government bitting the bullet, and spending a fortune on bootstrapping a public health system that undermines insurance and private health.
Yes, it will hurt that sector a lot, it won't happen overnight, it will cause huge deficits, and it will inevitably cause higher taxation. But it's ultimately what needs to be done. We just need to give up on the sunk cost fallacy and go with proven models.
At some point, you need to decide if you want a revolution or incrementalism.
We already have a public healthcare system, it is called medicare. We can expand medicare so that private insurance takes up a smaller segment of the total market. I believe that approach will provide incremental improvement and give policy makers leverage for further incremental improvement, but it is not a revolution.
While many of our politicians are talking about revolution, what they are all proposing is incrementalism. The reason for that is very simple; revolution is a bad idea and incrementalism has a proven track record of working.
As an aside, medicare-for-all is still a long way away from a public healthcare system; it makes one area of the healthcare system public.
> The reason for that is very simple; revolution is a bad idea and incrementalism has a proven track record of working.
Is there any empirical evidence to back this up? There are enough successful examples of revolution and incrementalism from around the world, but I can't find stats.
> We already have a public healthcare system, it is called medicare. We can expand medicare
No we can't. Medicare pays below cost of care, and hospitals make it up from private payers. You can't just switch everyone to Medicare, you would have to reduce expenses somehow (which means firing people).
Perhaps it just pays realistic prices and "below cost of care" is the provider's way of saying "reduces the income I am accustomed to.".
The regular pricing also builds in an assumption that some patients can't or won't pay. If they can more easily get Medicare, less padding is necessary.
This and oversupply created by for profit motive. Costs are driven up by putting a new MRI machine on every street corner, building boutique hospitals and medical buildings at the density well above of what's required. A business model a la Mattress Firm.
Call your local hospital and ask what the wait time is for an appointment for a non-urgent MRI. If it's more than a week there is undersupply, not oversupply.
It's probably actually at least a month of waiting time.
Considering how these things usually get booked, on need with some leeway for emergencies, a week is the same as now. I am certain the "I'm in the hospital an need an MRI" waiting time is the same day and emergencies now. Your non urgent MRI is just not important enough so get planned far ahead to create a good average load.
There are some local fluctuations, but at far north suburbs of Chicago, where I used to live, I could get non-emergency scan the same or the next day. Bear in mind that oversupply produces overuse. Often times, the doctor ordering a scan is a direct or indirect investor in medical imaging facility. So waiting time alone may not be the best measure. Some patients wait for the scan they don't need.
> is the provider's way of saying "reduces the income I am accustomed to.".
The "provider" is not a single person. So to reduce the income of the organization, you have to fire people or reduce their salary.
I think you are thinking you can reduce their profits, but you can't. Instead if you feel they are charging to much, that directly translates into lost jobs or lower pay.
It might be necessary, but just as long as you know what you are advocating.
Can you imagine a politician running on a platform of firing healthcare workers?
They would run on a platform of "pay less for Healthcare" and concern for Healthcare Jobs would not play a major role in the debate, if history is a guide.
The revolution could be the government bitting the bullet, and spending a fortune on bootstrapping a public health system that undermines insurance and private health.
Or, uh, "Medicare for all", since medicare is an existing, functional single payer system (not actual "public health system" but still, there, works already for a significant fraction of the population, is an existing proposal.
We just need to give up on the sunk cost fallacy and go with proven models.
This, definitely. It's worth saying "sunk cost" arguments often go more with entrenched interests than any actual benefit. Unfortunately, this doesn't make them easier to counter.
and spending a fortune on bootstrapping a public health system that undermines insurance and private health.
I think we could start by expanding military medical benefits. For example, give lifetime benefits to all honorably discharged service members, not just those who made it to retirement. We already have a government funded and run system. It has some excellent assets, such as Walter Reed, a research facility. We could just start quietly expanding that in a way that people could get on board with.
(Changed "honorably discharged veterans" to "honorably discharged service members" for clarity.)
We already have a system for that called the VA. Their track record over the last ten years in providing care is pretty abysmal. I am not confident your suggestion would result in a different outcome but I’m open to ideas.
To be a bit snarky: why haven't you quit to give the job to somebody more cost efficient? Do you think that if you were given your job as a private citizen you would do better / be more efficient?
I agree that certain jobs do not have to be done by the government and in that way, doing them via government gives rise to all sorts of bad incentives and inefficiencies, but I would not want to paint anything run by government employees as cost inefficient (especially if it's a core government competency) compared to the private sector alternative without some clear evidence.
In my experience, the benefits and job security guaranteed to government workers provides no added benefit for the taxpayer. No market incentives translates to no worker incentives, and everyone is just riding the gravy train to retirement. The bureaucracratic red tape imposed by Congress builds up endlessly, and special interest groups and crony capitalists magnify the inefficiency. Most government pay systems provide raises based 90% on time served instead of performance, though the ship is slowly turning towards performance-based systems. My agency tried pay-for-performance years ago, the union shut it down, went back to GS, now they're trying performance again.
The comment was directed at the VA, there's no reason it needs to be run by government personnel for the most part. A few could be on hand to handle classified matters if necessary. People hired by the government are not necessarily the best subject matter experts, as the rigid pay structure doesn't allow offering to pay what they're worth - and more often, to pay less, as many job classifications are simply salaried too high. Maybe strictly in matters of government policy could an expert find their niche, and I'd agree be a core government competency. Most other government agencies I can think of would be better off contracted out to enact the laws set by the President and Congress, with the flexibilty of private employment pracitices.
I think this is just media spin. If you interact with VA much I think you find its staffed by a lot of vets and they try hard to do their best. There are problems of funding and staffing and more, esp in poorer areas, and I have heard some bad stories, but it hasn't been my experience.
If you're speaking from personal experience I'm interested what happened.
Mostly speaking based on my hearing first-hand from those working there to some of the technology horror stories / treatment backlog issues. There are also some fairly comprehensive issues with specific hospitals that I recall from the news, but maybe that's media spin.
My point is not that interacting with folks at the VA is bad (generally folks try to do their best) but that at a certain point if a single organization runs a specific function incentives get turned around to the point where you lose the ball somehow, and there's no pressure to improve. This seems to have happened to a certain extent at the VA and I see the pattern happen a lot across large institutions, generally. ESPECIALLY if they are not in a competitive environment.
It won’t happen. If you visit different cities in the US, not the big 5, look around at the buildings in the central business district.
Usually you’ll see a couple of regional banks, the local big bank outpost, and insurance companies. That’s lots of money and lots of jobs, lots of votes.
Unlike banking, the arcane processes actually created more middle class jobs while banks nuked jobs over the last 30 years. If Clinton couldn’t push universal care in the 90s, nobody is going to do it in the foreseeable future.
High salaries are justified by the absurd cost of medical school.
A solution would be to create new public medical schools where tiotion a fraction of the price.
Publicly trained doctors can work at cheaper public hospitals.
There is a lot of profit in medicine yet almost no competition
around prices.
The simplest fastest solution, for now, is to pass a law requiring transparent prices!
seems like its an education or media-bias problem more than a healthcare problem.
If a majority of the poor in America are not educated enough to understand how public healthcare will benefit them and the country, or are educated enough to understand but not educated enough to realise media outlets have a politcal agenda and might not be reporting accurately, then public healthcare is still not going to happen.
(and they might not want socialism, but it seems like they dont understand that democracy has problems too. and healthcare is the living example. but again, it circles back around to being educated enough to understand that democracy is good, but it isnt perfect, and no system is)
See, even someone who should know better gets the argument confused. Socialism is not opposing democracy. Much of Europe is more socialist than the US and have democracies as strong or stronger than the US.
A "free society" doesn't require that parents be given free reign to torture their children. You may wish to argue whether that's what was happening, but that's the reasoning the state gave for their actions. If you'd like to argue that a free society does require this, go ahead, but I don't think most people agree.
Alfie's doctors made the decision that taking him from hospital for an experimental treatment in a different country had a strong chance of killing him, and that he was better off dying peacefully and not in pain in the UK. Alfie's parents fought to try and save his life at any cost even if it meant he went through tortuous pain first.
Frankly both sides of the argument are understandable. No one wants a child to suffer but no parent wants to give up on their baby. It's a tragic case.
It's also an exception. Using it as the basis of how you decide 99.999% of other medical cases is idiotic, and using Alfie's memory as a tool to promote a particular system of healthcare payment is obscene and shameful.
Just remember this - for every case like Alfie's where there genuinely are two sides to consider there are millions more where the doctors are simply right. Setting a precedent that parents wishes automatically overrule the doctors would cause so many children to suffer. This is why we let doctors and courts make decisions - to save children from stupid parents.
Clearly he can be sedated, and that isn't an argument for letting the state kill people without trial anyway.
Just to clarify, the state didn't kill him. He died of GABA-transaminase deficiency, which was only diagnosed after he died. The treatment that his parents wanted to try was a shot in the dark. No one knew what was wrong with Alfie.
You are arguing that taking a child from hospital, causing him more pain and suffering, putting him through a frightening and scary procedure, that has no basis in medicinal science (as there's no way to know if it'll cure an undiagnosed problem) is better than letting him die peacefully, safely and surrounded with love.
You can take a "life at any cost" point of view but the UK Court didn't. It took the view that a pain free and caring death was better than an agonising and highly unlikely long shot.
They removed his life support, against the wishes of his parents and then prevented them from accepting help. He survived ~5 days without it.
While it's a sad story I agree, it's not the point. Giving the state the power to decide who lives and dies without a trial and conviction for a crime is something many of us had hoped was settled long ago.
Ok, let's try a nice straightforward story. A child is bitten by a dog that definitely has rabies (this can be established by autopsy). The child's parents refuse any treatment (vaccination). It is about a 99% chance that the child will die of rabies without the vaccination. Do you believe the state (or any other actor) should have any power to intervene?
The Alfie Evans case could well have had the same outcome with fully private care, since it was a case about the rights of the child rather than about funding for treatment.
(Besides, we can probably find a lot more cases of dead children in the US where they were simply denied or unable to afford coverage ...)
In the US the doctors would have done exactly the same thing: they would have proposed a treatment plan; the parents would have disagreed; the doctors would have gone to court and probably would have won.
But in the US there would have been the additional funding step: the parents would have had to get insurance companies to pay for futile treatment, and no compnay would do so, or the parents would have had to crowd-fund this treatment.
Here, for anyone interested, are some of the legal documents (in date order) around the Alfie Evans case. They clearly show that parents have a right to a family life and to care for their child as they see fit, but that this right isn't total because the child is also human and has his own human rights. The paramountcy principle mean that the rights of the child come before the rights of the parents.
Please note that because of the involvement of the Christian Legal Centre in some of the court cases there's been a lot of misinformation spread about the case.
I know that there's nothing I can say to change your mind: you have an ideological viewpoint, and that's okay. But I think you should at least acknowledge that your opinion is not based on fact.
I accept you are correct about the paramountcy principle. I have read about the case in the last hour, and realize I was wrong to equate it with murder.
The details make me uncomfortable (with the court decision), he had an offer from a qualified intuition for help.
One could argue that we are currently stuck on a local maxima, and that the broader political system is designed such that any significant improvement will first require massively disruptive changes that will indeed lead to deaths. In this sort of situation, the end result of a change will save many more lives over the long term, but it will require short term sacrifices. Not just sacrifices of money; unfortunately, some people won't make it through the process.
Opposition from incumbents ensures that any change will be a difficult process, and a "new normal" will not come easily. Any long-term planning efforts will be sabotaged and subverted toward capture of profits. The best we can hope for is a series of smaller disruptive shifts (each followed by a resettling) that eventually improves the situation.
Something needs to happen. Increasingly it looks like dissatisfaction with the current system will boil over and force a major shift, but other events (wars, for instance) could pop up and distract the public for a time.
Before the ACA San Francisco implemented Healthy SF which eventually came to cover every family making up to 500% of poverty levels. It was just slowly phased in over about 5 years.
Key thing I've noted about was it was designed to get people covered and to stay that way. That's the opposite of neoliberal ACA which is designed to be annoying and has traps designed to rat fuck people.
The media likes to associate the ACA with Obama, who was at least nominally on the left. This conveniently covered up the fact that the ACA was based on Romneycare, a vehicle from the neoliberal "center" designed to prevent truly disruptive reform.
The ACA was a stalling tactic, and it has been rather successful in that role. People are starting to see through the ruse though.
Not to be callous but if they're poor, is that enough?
Because 64,000 Americans died of drug overdose in 2016, and 72,000 in 2017 (200/day). (2018 stats not yet out.) 2/3rds of those are linked to the opioid epidemic, but those numbers haven't been enough to engage with the same sort of cultural change in other areas of the American psyche, as socialized healthcare would be. (NOT proffering an opinion on that here, just pointing out the body count may not be enough. Sadly.
Well also putting aside the terrible opioid problem which is partly economic in cause, purely on a healthcare issue we already do have thousands dying from lack of access! Its been estimated that approximately 40,000 people die due to lack of access to healthcare each year. But these are poor people so we don’t see them or hear about them and thus no revolution yet. (Although a majority of Americans want Medicare for all so somehow we just need to get representatives that represent voters not donors.)
I know that doesn't feel like optimism to you, but in my experience whenever people decide to let things get so bad that there has to be a revolution, bad just becomes the new normal. The only advancements I've seen in politics, in my few decades of paying attention, have come from people working incredibly hard to make tiny improvements.
I can understand the sentiment...i.e.: It seems like we in the USA only are willing to fix that which is beyond broken, and I think it has gotten beyond the point of fixing honestly.
Honestly- don't even know how we could 'fix' this. The fact that we need study after study after study to tell us what we already know, it's gross.
Coupled with the fact that it seems impossible to communicate to people just how bad it is (only when they have to personally experience the horror of our medical system to become believers) - I'm personally terrified.
The problem is that MOST people never need that much health care; they will never have to live through one of the destructive trauma of one of these health disasters. Since it never effects them personally, they won't vote to change it.
Don't worry. Idaho, like every other western state, will eventually be colonized by migrants from California who will bring their politics and culture with them. Things will change. You just might not like all the changes.
>I kind of want these issues to continue and get worse. Because then we will have a healthcare revolution, rather than more bandaid policy fixes.
This is the justification I hear for a lot of my "bernie or bust" friends. I always just assumed they were trying to justify voting themselves tax cuts. I mean, in a revolution, those of us in the tech sector... I don't see it going well for us. Normal people hated us before we became the new "upper class" - if it ever becomes acceptable to go around killing "rich" people - I bet we'll be among the first.
the problem is that this means we end up with trump, who teams up with a lot of people who think that it's good that people without good jobs don't have access to healthcare.
I work in the healthcare insurance industry, lots of market swings due in part to talk about medicare for all, but also drops in expected profits because Trump is pushing for transparency in Rx costs.
You’ll never hear this in the media, but the reason there isn’t sweeping change on the horizon is because a large majority of Americans are satisfied with their healthcare.
A majority even report being satisfied with their personal healthcare costs.
> Seniors, Medicaid/Medicare Recipients Rate Coverage, Quality Most Positively
So, the people most satisfied are the ones with healthcare provided by the government, which is what many are proposing.
"Pleased" with your healthcare is a relative term. It doesn't mean you couldn't get better. I am pleased with my healthcare compared to the healthcare I used to have. But I'd go back to the public healthcare I had in the UK in a heartbeat.
And... How many times do we need to hear from these Medi* Recipients to keep the guvernment outta their medical plan.
I really think that we need to stop listening to attitude and perceptions' based studies, and focus on cold hard numbers ($).
People don't understand the system - not by a long mile and will swear up/down/sideways that they do...We need to take a more analytical approach and look at the numbers.
You can't use this poll to support the private system. Only 51% of the respondents who have a private insurance are satisfied with the personal healthcare costs. Versus 70% for people who are under Medicare or Medicaid. If anything, this is an argument for Medicare for all.
The simplest and most common sense medical reform I can think of would be to make it illegal to charge a different price to two different patients, regardless of insurance carrier or self-insured, for the same medicine, procedure, or equipment at the same facility.
There should be the Price. The amount that insurance Covers. And the remainder is the Patient Responsibility.
Either that, or a cash patient cannot be charged more than the Medicare allowed amount for the same procedure.
Insurers should not be horse trading to pay more or less for one procedure or another. And if you happen to be treated by someone who is out of network, you shouldn’t be paying an exhorbinant price on top of that higher copay or deductible.
The entire concept of negotiated rates is a fraud IMO, and could be reformed with a simple regulation that would I think be supported by a vast majority of Americans.
Price changes should have to go into effect for all patients at once, and be published in some ledger at least some number of days ahead of time.
This, a 1000 times this. We just faced this this week.
Recently lost insurance due to a unexpected company closure (with apparently no COBRA responsibility in that case). So I started asking our current providers to find out what it would be to pay out of pocket for some services. Here's an actual item:
Provider bills $285
For out of pocket cash price, they will reduce by 25% (so $213 or so)
Our insurance however got a bigger discount and only had to pay $100 with no further patient responsibility (beyond deductible)
It absolutely should be illegal to price like that.
This is kind of what we have in The Netherlands. Insurers make standard prices in collaboration with a large part of the healthcare providers. Healthcare providers have to bill using the exact code of the treatment and that amount cannot be more than the agreed amount.
This leads to funny things like there being Treatment X variant A-E for getting a different price for the same treatment based on some arbitrary thing. It also means that now the insurer knows exactly what has been done because the bill says replaced filling on 3rd upper molar with this and that material etc. Before it was just “filling”.
Also if you want to provide better care and need more time or better materials to do that you can only do it within the determined budget and they are quite tight.
I don’t necessarily want to standardize care, I want to standardize pricing. Of course there will always be minute variations in a procedure, but the law is not an algorithm.
You can have different levels of materials with different prices, but two people still need to see the same price if they choose the same thing, or substantially the same thing.
Of course some people will game the system trying to make infinite variations, but at least that one apply to common blood tests and office visits, MRIs, X-rays, plenty of stuff is standardized.
So what you are describing sounds a step beyond what I am thinking, which is just a standard published price list which is actually the price, and not a published book price which is an absurd ripoff, and then a secret price which everyone with insurance x, y, or z pays.
> The simplest and most common sense medical reform I can think of would be to make it illegal to charge a different price to two different patients, regardless of insurance carrier or self-insured, for the same medicine, procedure, or equipment at the same facility.
That would do great damage to the poor and greatly benefit the well-employed. Just like airtravel, the richer pay for the poorer. This has been so since the 50's.
> There should be the Price. The amount that insurance Covers. And the remainder is the Patient Responsibility.
Iron triangle of healthcare: Price, Access, Quality. If you control the price, you fiddle with access or quality.
> ither that, or a cash patient cannot be charged more than the Medicare allowed amount for the same procedure.
Medicare wellness exams pay 90 bucks. Insurance pays 150~200U$S (up to 300U$S). VERY different services can be provided at those levels.
Take a OneMedical office with 3 doctors, and 16 1/2 hour appointments a day. 48*300U$S = 14.400 U$S max revenue. At medicare rates, they go down to 4,300U$S. Just having the same facility, same rents etc, to get the same revenue they would need to see 160 patients. So the appointment length they can give would be 7 minutes. Or they could move the office to a much cheaper 3rd floor place many blocks down, sacrificing access, but that might save you only 10k a month.
But most crucially, I do not propose controlling the price.
However, a given service must have a single price for everyone who gets it.
A "Wellness Exam" can certainly be offered with a different levels of service. But you cannot charge two different prices for the same exam.
And once we've established that it should be illegal to charge two different prices for the same exam, then we can get to the interesting work of making those prices more transparent, and maybe even I want to choose between the $90 and the $300 wellness wellness exam on a litter "Good", "Better", "Best" menu, or maybe my doctor recommends which one would be appropriate, and spends 1 minute explaining that and showing me the price at the start.
This happens at my chiropractor, and even at my eye exam (e.g. adding an optional retina scan). If there's only one price for an MRI of a particular part of the body, then when the doctor is ordering it, they can actually tell you what it will cost!
To your last point about rich paying for the poor. This is true, but it is accomplished by changing the price of insurance coverage, but it should not be accomplished through changing the price of the billable service based on lack or type of insurance coverage, because those are very poor signals for capability to pay. In fact, the poor are most likely to be overcharged through this type of policy.
> A "Wellness Exam" can certainly be offered with a different levels of service. But you cannot charge two different prices for the same exam.
Same doctor, same location, same duration, same scope of care, same supplies, same patient-risk, same market demand, same season, same malpractice liability, etc etc ?
A same price requirement pushes the economic adjustment to other variables. A simple example: do you take patients saturdays? All staff is more expensive to work a saturday, but revenue is the same. (adjust access).
If anything, the market does not have enough price adjustments, which is why eeryone is so price insensitive, particularly the patient.
Luckily the law isn't an algorithm. Medicine is not perfectly packaged and shrink-wrapped, but a law can be written saying there must be a material basis for a difference in price.
Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that.
I think people seeking medical care deserve much better than "arbitrary and capricious". Substantially similar services should not have two orders of magnitude differences in pricing. That should be illegal.
EMR coding already provides the basis for establishing a non-discriminatory pricing regime. The problem is the billing system takes the EMR coding of the procedure performed, and then convolutes it with a pricing matrix which discriminates on what kind of insurance you have.
I walk into CVS and try to fill a prescription.
- That'll be $78 dollars they say;
- OK, I have this benefit card, it is not insurance but it provides a discounted rate, and I paid nothing for the card. It's like a coupon code. That'll be $55.
- OK, I have this prescription drug coverage insurance card, which carries a $200 deductible and a $20 copay. I've already exhausted the deductible. That'll be $20 and insurance pays $3.07.
CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game.
To say nothing of the cases where insurance companies agree to pay more for one drug, like insulin, in exchange for charging less for other totally different and unrelated drugs, just because in their insurance pool it helps them optimize the number of patients which ultimately will pay the annual out-of-pocket maximum.
> Luckily the law isn't an algorithm. Medicine is not perfectly packaged and shrink-wrapped, but a law can be written saying there must be a material basis for a difference in price.
Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that.
Thats what insurance companies do. Basically their entire work is assigning different value to different care, based on quality metrics, on differential costs for different services, patient populations, etc.
But insurance companies can't see how much are you willing to charge as a provider, thus the provider and the insurance are very much adversarial.
> EMR coding already provides the basis for establishing a non-discriminatory pricing regime
EMR is probably the main reason why upcoding has become a wide-industry practice. EMR allows you to think in how to maximize insurance values which is not the same as medical value, or patient experience. It is also not true that EMR's convolute with pricing matrix's, each insurance has a different negotiated price for different procedures. This happens for a multitude of reasons, and they are all crappy but real.
> CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game.
Yes, but thats not a price problem, its a principal-agent problem. Insurance should not be covering regular medical services and procedures. It should be used for highly expensive-out of control actuarially sound events. But competition for clients has made it the way it is now since the 1950's.
The way to solve that is High Deductible Plans. HDP people really price-shop and put pressure on providers to talk about cash pricing and caps.
We’ve been fighting a hospital on an overcharge that drained our HSA account. Every person we talked to has been utterly flabbergasted that we are complaining because “it says here you owe $0”. They can’t get it through their heads that the insurance paid them with our own money, and that we’d like to be refunded the overage.
It’s just a confusing concept to these people. This is what happens when most people use someone else’s money to pay for things. Nobody knows or cares what anything is supposed to cost.
Small claims court if it's less than the relevant small claims amount.
Otherwise, a strongly worded letter from a cheap lawyer.
The legal system is often abused. But it sounds like you've got an actual legit issue, which is what the legal system is there for. Why not use it?
If you don't want to pay for a lawyer, you can write your own strongly worded letter. Just be sure to stick to facts, and keep very good records. In your letter, explain the issue briefly but clearly. Explain how you've attempted to resolve the issue. Explain how if the issue is not resolved, you will be forced to take action.
Address it to the hospital CEO, or whoever is in charge. Post it using registered mail.
Your local library may have a subscription to LexisNexis or a similar legal database. This will have form letters and chunks of legal text that you can copy and paste.
HN user patio11 wrote a thing about writing letters on this website that I can't just find. But find it, and read it. It also has helpful advice.
I think the reticence most people have with initially engaging with a lawyer is they're not only not free, but initially not cheap on account of the retainer fee.
Yes, you'll get anything not used back, but the last time I needed a strongly worded letter I had to pay the $1500 retainer and finding a lawyer under $200/hour in my area is extremely difficult. I got my remainder back the following month, but the strongly worded letter cost $400 and tied up $1500 for about five weeks.
The reality is the average person -- if we go off all the studies pointing out the large swathes of the population that can't meet a $500 emergency expense -- may not be in a position to tie up cash, even in markets where a lawyer is considerably cheaper. It's also a cost-benefit equation, and the value of that (regardless of the outcome) is different for everyone -- I'm someone who'll go tooth and nail to get $20 back on principle, but for some people that threshold might have to be $2000+ to care.
It's a little different. It's more like hiring someone as personal buyer who buys for likely a large group of people. A majority of people don't actually use the $3600+ they spend per year on health insurance so the money adds up fast and the buyer doesn't have time to deal with individuals so they don't seem to question paying $$$ for a tissue paper. The amount of money they are authorized to spend is so large that a $$$ tissue paper is just an insignificant percentage of the total available cash.
If hospitals and insurance companies are already tracking their income/expenses they should just be required to publish the anonymized data via a centralized API so we can all work on creating systems to analyze the average cost of the products. It will help insurance companies and patients as well as doctors and everyone in the end. Also, beyond the standardized API system which should easily cover all the standard financial points we can have multiple people / organizations analyzing the data.
Say one particular health issue shows up in the system as costing a lot of the insurance cash pool, we would notice it right away and could funnel more cash into prevention.
I'm not familiar with the industry so maybe there is already something similar available?
Whilst I can totally dig where you're going with this - love the idea of open API's... we know it aint a tech problem.
How did Europe do this with that whole payment services directive (I think that this is what I'm thinking about) - the one that forced all payment systems to have open APIs and such?...
How would we get something like this in the works? It would require a mandate from ??? Congress / the President / Bigfoot???
I can only imagine how these companies would not like this information out. Even if one were to explain that having this data would yield optimizations of their internal systems, saving them money, as the information would most likely make many within the organization look badly.
Not suprised.We used to have customer purchasing our services on a credit provided by a finance company,then cancelling and demanding full amount to be translated to their bank accounts... It usually take a bit of time for people to get it...
Your insurance has access to spend your HSA? That's certainly not how mine is set up, and I'm surprised that's even possible. Did you give them your account number and authorization to spend your money?
Mine are run by the same company and bills pass through. The result has the same effects for me as a PPO with a weird sort of IRA attached, and lower premiums than my old BCBS Elite 100/80 PPO.
That's just a fancy name for self insurance, i.e. no insurance. Somehow wrapping it in yet another siloed tax advantaged vehicle makes it sound better.
Of course. Even with a run-of-the-mill HSA + HDHP, you're basically partially self-insured and tasked with the thankless job of insurance administration. You can see there is something scammy about these things (in practice if not on paper) when they are so enthusiastically pushed by the healthcare industry.
You can be interested in the prices, but you won't find anyone interested in telling you the prices. You will also be met with complete incredulity when you ask about prices. (If you're asking about prices for a procedure or treatment related to your child you will also be shamed for "putting a price" on your child's health.)
Adding to this: Oftentimes there isn't a single person in the place that even knows what X costs...and hasn't a clue how to determine that number.
Years ago, I was between jobs and asked for the 'cost'. The reply I got was "$20", a typical copay at the time. When I explained my situation and was asking for the actual out the door costs...20 bucks. They really didn't even understand how to approach my question (could see it in their eyes/response). When I asked for another person in the office - 20 bucks. Hell, even the Dr told me 20 bucks. The bill I received was not 20 bucks - surprise surprise. And what could I do really - hold them to the 20 bucks? Where was my 'proof'...
Many of the people doing the admin work simply are not trained nor equipped to understand the gravity of the position. They can set you up on a calendar and fill out a postcard - beyond this, and there's problems. And why should they? They are being paid to be calendar/postcard filling person only.
The system itself was designed weirdly to begin with, it assumes that you are a wage earner of a large company that is paying insurance as an employment perk. If you deviate from this model - then these sub-systems don't know what to do.
They know what to do. But they are selectively "dumb." Do you think a doctor who runs a clinic and their employees, accountants, medical procedure coders, and insurance claims people don't know a thing or two about costs? How do they stay in business?
But if they told you some four-digit number you'd bolt.
We like to hold medical professionals in high esteem, but these days it's also a business transaction. They know this. As such they are very much a part of this very large problem.
Sure, but that requires a level of investment and effort that a lot of people simply don't have.
The last thing I personally want to do is have to argue with insurance companies and negotiate prices down through the labyrinthine healthcare system after dealing with enough nonsense at work. Even worse if I have to do said negotiation from a hospital bed due to an unforeseen problem, as most health issues tend to be.
when I need something, I usually don't have much luxury to 'shop around', and whatever price shopping you may want to try to do is often still hamstrung by 'in network' vs 'out of network' price tables.
I needed a procedure that was going to be ~$1500 at any one of a half dozen places within a 90 minute drive; some were a bit cheaper, but they couldn't see me for more than a month. There were a couple places that were ~$1100, but it basically would have been a whole day's enterprise for 2 people to get me there and back. To save maybe $400. $400 is not nothing, but I wasn't even actually 100% sure their pricing would actually be what we finally paid - no one could guarantee that. So we may have had 2 people take an entire day from earning on the partial chance of saving some money. Might even have been cheaper in another state, but then you've got travel/hotel costs to add as well.
"...no one could guarantee ..." Key phrase to be sure.
Many people that I know talk about how people need to know how much something costs - but these systems themselves don't know how much anything costs.
Furthermore, they know this and therefore unwilling to guarantee anything.
Knowing prices is great, but I feel is a non-starter when thinking about how the system can be 'fixed'. Also, you can't price shop when you're having a stroke.
All in all, we have to just acknowledge that the system for everyone is broken - beyond this, I haven't a clue as to the next step.
> Also, you can't price shop when you're having a stroke.
And you can't consent to anything when you're having a stroke, or in a car crash, or having surgery, etc. You're hit with thousands of dollars of bills when you're unconscious or not mentally competent, and it can stick with you for years.
Price shopping to keep costs down - yes, fine, it's a nice little component that would probably help a portion of our medical ecosystem. If I can save $14 on some particular medication by choice of pharmacy - sure, why not?
I've maintained for years - either single payer, and/or have insurance go to a primarily individual/family policies that people purchase themselves - get the employers out of my business. People are tied to jobs due to insurance concerns - employer-provided health insurance contributes to labor immobility. Employers have less incentive to hire less healthy people, likely keeping some people from improving their lives.
Remove 'tax deduction' for employers to provide health insurance. Ensure all taxpayers can fully deduct 'health insurance' costs from taxable income, starting from $0 (none of this 7% of MAGI bullshit). OR... increase it? 150% of your premium is deductible in year 1. 130% year 2. 115% year 3. 110% year 4. 100% year 5. Incentivize people to actually own this.
We had 18 months of "let insurance companies sell across state lines" BS during our last election. It's already possible between many states - it's simply far too much regulatory burden to deal with for most companies, that's why most aren't doing anything about it, even when they can.
REAL reform would be changing who actually pays for it - let them become the real 'consumer/customer'. An employers' incentives and mine don't always align, and if they're paying the bill...
I once got a blood test in California. Nothing special, just a regular checkup recommended by my doctor. The blood testing company later sent me the bill. It was originally $950 and some pre-arranged deal between my health insurance and the testing company discounted most of it. My insurance covered part of the rest and I paid like $50. It's not like my insurance paid $900, they just had a pre-arranged deal with the testing company to have a huge discount, which makes me think the actual cost of the blood test is nowhere near $950. If I didn't have insurance I still would've had to pay the whole $950 out of my pocket.
> It's not like my insurance paid $900, they just had a pre-arranged deal with the testing company to have a huge discount, which makes me think the actual cost of the blood test is nowhere near $950. If I didn't have insurance I still would've had to pay the whole $950 out of my pocket.
It's legal because when you tell people you know that this has happened to you - unless it happened to them personally as well, they will just assume that you don't know what you're talking about or confused.
This scheme is legal based on a custom of quantity price discount. The insurance company negotiates a price schedule with healthcare provider and if you buy their policy, you will get the discount. It is analogous to purchasing from a retailer where the price is the same for all customers vs. buying a large quantity from the distributor and paying much less per unit.
This mechanism may be a foundation of legality of health industry pricing practices, but it is grossly abused. Contrary to what is advertised, U.S. health care is not a free market. The pricing is made opaque by insurance industry and other middle man. This is the main reason why price gauging of that magnitude is possible. It is a cash cow that just keeps on giving and trying to change that will be extremely difficult.
Because whackamole. There's no ruleset that is foolproof. Every time some loophole or exploit is closed, two more pop up.
What's coinsurance? ACA regulates copays, deductibles, and so forth. Ah, but no one said anything about coinsurance. It's totally not a copay, premium, or deductible. See? It's different.
Surprise billing is how hospitals pushed back against insurers. Consolidate and then outsource all actual work, so the hospitals no longer get stuck with the bill. Oh, that specialist you saw in our hospital? Ya, she has nothing to do with us. Ya, you should have asked your insurer if her office has an arrangement (collusion).
It's hard to civilly sue for attempted fraud, because there are no damages. And when the fraud is successful, the victims are none the wiser. As why there's no criminal prosecution, it's because money generally buys immunity.
There are a few websites where you can order your own tests. You pay for it online, a doctor automatically authorizes the test and then you go to a Lab corp office and get your blood drawn. The basic tests can be quite cheap. Like a "chem 26" test is $55. http://www.healthcheckusa.com/heart-disease-cholesterol-test... Its amazing how much hospitals are marking up these tests.
I'm surprised this isn't a common thing with some big company/startup doing precisely this. All these tests that don't need specialized equipment at the point of the test (i.e., blood or other fluids as opposed to fancy imaging) can be easily outsourced to pretty much anywhere else in the world. Is there some law preventing this ?
Blood tests are commonly outsourced by many hospitals but they subsequently mark them up to cover their other costs. But you cannot outsource them to other parts of the world as many tests are inaccurate if the blood sits around too long in transit. Lastly is the problem of interpretation of the results. A person on this website might be bright enough to figure it out but there are a significant number of people who just can't. So once you bring in the doctor costs start rising up. Then you have people for whom even $55 is unaffordable.
>there are a significant number of people who just can't. So once you bring in the doctor costs start rising up.
I'm assuming that the patient cannot read the results. i.e., They go to the hospital. Doctor asks for the tests. Patient gets the test results from their lab of choice and go back to the doctor with the results. This is a fairly common model, at least elsewhere in the world. Labs and hospitals are separate entities, and the first visit to the doctor is just a consultation with nominal costs. Doctor's costs don't kick until the test results are back.
I was billed ~$4,600 for a $40 blood test. The reason given is the testing company was out of network. Even so, my insurance offered $400, but was refused.
I previously worked for a company owned by Quest Diagnostics, so have some insight into the parasitic nature of these lab companies. (The other titan in the USA is LabCorp.) Once a facility is up and running, they basically print money. Some wags even created "speedometer" dashboards to show real time revenue per minute.
For a while, I had to get blood tests every month or so for a drug I was taking. Usually I went to a discount provider (labcorp), and paid like $30 for the bloodwork (maybe it was actually less).
One time I went to UCSF hospital, and they ended up billing me several hundred dollars. For the exact same lab codes. Actually, I think they billed well over $1000, but my insurance company at the time allowed several hundred in charges.
I called them up, but they were unwilling to negotiate. I ended up paying, because I figured that it wasn't worth fighting it.
One time several years back I fought a fraudulent charge from a doctor who billed me for a more expensive procedure than the one he actually performed (this practice of "upcoding" is actually pretty common). I eventually got them to remove the charge after a lot of complaining to the doctor and talking to my insurance company, but it wasn't worth the stress involved for the amount of money I got back.
The solution is simple and I've posted it here many times. Rates for services need to be fixed by the provider and the same price charged to all payers including insurance companies. Posting those prices is a bonus, but the insurance companies alone will force competition among providers.
The surprise in surprise billing is the issue here.
I'm a life long patient, so not my first rodeo (dozens of blood tests). I had no idea it was possible for a lab to "out of network", so would never have occurred to me to ask. But at some point the rules changed. And no one thought to tell me, as they're supposed to (eg verify insurance coverage before doing any work).
Having just gone through a situation with a family member who had to go to the ER, have a variety of tests done, be admitted to the hospital for a few days, and be seen by a specialist in the hospital. This definitely hits home. What makes it worse is that it will be months before we know the total cost for us. The ER doctor, the labs, the hospital, the specialist are all separate legal entities. Each potentially with their own staff filing claims to the insurance company. What a crazy system we live with.
I live in the Netherlands and recently had a basic blood test done to diagnose a lack of energy. Having a high income I had to pay full price but it only cost me €89 so that seems fair. The GP was able to draw the blood and then sent it to a hospital laboratory.
Living in Europe is pretty great. Healthcare mainly is based on income here, if you are low income you pay next to nothing if you are high income you pay up to €5000 per year in tax and insurance. I think that's fair as it makes it accessible for everyone.
> Having a high income I had to pay full price but it only cost me €89 so that seems fair. The GP was able to draw the blood and then sent it to a hospital laboratory.
If that was more than a handful of tests (usually separate drawings), then it was probably still subsidized. I think the out of pocket prices are in the same range though, at a private lab clinic, here in Southern Ontario.
The reason insurers end up paying $1,000 for this service in the most expensive places is mainly that insurance is ubiquitous in some places. If nobody asks the price, how can it stay down?
I believe I had three drawings. It was a basic test for not much more than iron levels and such. The €89 is what the hospital will receive in total for the research. Because the amount is lower than the yearly healthcare deductible (€385 up to €885), you will have to pay for it yourself.
There is an online calculator with the maximum amount a hospital may charge for its services:
https://www.diagnostiekvooru.nl/tarieven (use the checkboxes for whatever you want tested, apologies for it being Dutch).
This is the maximum amount the hospital may charge by law, the insurance company can lower this by up to 10% by negotiating the rates.
I don't think there's any equivalent price control on private purchase of tests here, the prices are in the same range, maybe a bit less depending on where you go.
Honest question: why cant the US Fed go after the hospitals, insurance companies and pharma companies for price fixing/collusion/anti competitive pricing?
Seems to me that all of the warning signs are there, is it corruption in the regulatory agencies?
I don't buy that it's purely regulatory overhead. That you see this price gouging at supposed nonprofit hospitals as well, it can't be purely rampant unchecked capitalism when you have 15x markup from the pharmacy.
One of my pet peeves with US medical is how the billing is handled. Visit the ER? Get ready for an untold number of bills. One from the hospital, another for imaging, another from the pharmacy, yet more from specialists, radiology, etc. There's no one clear bill about what you owe. This is due to most of these technically being subcontractors. Yet, I dont know of any other industry where I have to pay subcontractors directly, rather than paying the contractor at once instead.
Well, I think requiring published pricing in a standard format would go a long ways. Right now, people have no idea how much anything will be. If there was published pricing, there could be a shopping app or something of the sort.
Right. I'm for socialized healthcare. But if you're going to have a free market approach at least make the market forces applicable. Pricing for all services should be published in a standard format and then everyone should be charged the same price, regardless of who is paying.
They are in some ways. Hospitals are required to publish their chargemasters, a list of all of the services they provide and their "retail" price, starting this year. Previously a few states like CA required it.
I'm a French expat in China (Shanghai), in 201901 I had to obtain an electrocardiogram. A high-end hospital would do it for 1500 to ~3000 RMB (the local currency, 1 RMB is ~0.15 USD). I took the path used by locals, and had it done without any fuss or appointment for ~40 RMB.
Details: the hospital would do it after an "initial out-patient visit" costing "1,000 to 1,800", the ECG price is "500", and those are "estimated prices ((...)) subject to change."
>The Trump administration may eliminate this secrecy, making numbers like the ones in these charts more common and easier to find. As The Wall Street Journal has reported, the administration has asked for comments on a proposal to require doctors and hospitals to publish negotiated prices.
I really hope this goes through. Right now, the opacity of prices for health care is a huge problem.
Totally. A few years back I asked both my doctor and insurance company how much a procedure would cost in advance. They both knew this answer and both flat refused to tell me until I got the service. How would that possibly fly in any other sphere?
A friend of mine that works in health care admin and IT described walking into a doctor’s office ‘like walking into a used car lot.’
It seems to be one of those few holdout areas where the information economy hasn’t affected. Maybe it’s even perverted it, by enabling data holders to optimize inefficiency for their own benefit.
They know how much a particular code costs in advance.
They are less certain whether a particular course of treatment will be coded in one way or another.
It's probably not a good payment model, it doesn't make any sense for the insurance company to be taking on risk that the provider should be bearing, but here we are.
That makes sense. ICD9/10 is certainly byzantine, and widely abused, but it seems reasonable to not quote something that isn't coded yet. I did some research for a company once on Medicare reimbursements. That data is all publicly available via data.gov, sorted by code and much more. The private insurance market could follow suit, and providers could also publish that information if agreements didn't forbid it.
The data simply needs to be price per code per insurance policy. I understand providers may not want people bickering over what codes are used, but they ought to be able to produce that report easily.
That's where it gets even more bizarre. Some states legally protect health insurance companies for not disclosing their price list. Highly paid lobbyists pushed that one through legislation on trade secret/proprietary data doctrine. You can't inconvenience the holy "free" enterprise in America.
Because markets need some degree of freedom to set prices to be efficient.
The problem now is there is no downward price pressure from competition and transparency. Market controls are an extreme solution which will likely have unintended negative consequences.
Yes this is true in markets where the consumer (1) is the actual person paying for the product/service (2) isn't restricted to comparable options and (3) prices across all available providers are known.
None of these exist today in the market for US healthcare...but they do for fast food. Trying to compare the two would be extremely disingenuous.
It is in medical providers best interest to raise prices.
Efficient markets need more competition, but in healthcare the market is fragmented and once a provider or insurance gets big enough it gets acquired by another leading to larger duopolies.
The government never should have let mutual insurance privatize. That was the tipping point that started this whole mess. Rather, there should be incentives for for-profit insurance to switch a mutual ownership model.
Then you'll just get offered $1000 with some places offering secret $900 coupons. Hospital master sheets that nominally satisfy transparency are basically this.
Medicare would be fixed by having all the healthy folks in the same risk pool. Right now privatized medicine are like charter schools - they can pick and choose their subscribers leading to lower costs and an obscene profit while Medicare gets the old folks who have multiple ER visits a year.
It would help for costs, which is what you mentioned above.
I know from when I was healthy individual in my 20s, that I tried to avoid doctors visits as much as I could - even though I had killer coverage (90-95%).
I still paid premiums (well my company did) but I simply didn't go.
Precisely what changes in the market are you referring to?
Prices negotiated between payer and provider today are already 1 + N year length contracts. Having one transparent national price list would 1000x easier than the hundreds of thousands of healthcare administrators that exist today whose sole job is to negotiate and determine price lists.
We were getting a blood work for wifr, and when we checked pricing online we were shocked to learn that self pay price was around 300 and through insurance it would be 8k. Crazy, and no free market would function this way.
Except when they are not free and have messed up regulations.
Ok so dumb question I always wanted to ask, about the arbitrary prices.
Let's say I have no insurance and I collapse on the street, get rushed to the hospital and revived, after which they send me a bill for $10k. I didn't agree to any treatment; I didn't sign anything. What prevents me from saying that I won't pay it - not in "send it to collections" way, but in a "this is a fraudulent bill" way, like I don't owe anything at all? If the hospital can claim by fiat the price was $10k after the fact, how come I cannot claim by fiat the price was $100, or send the hospital a counter-bill for $9900 for having had the privilege of touching my chest? I mean, a car dealership cannot send me a bill after the fact for an extra $10k for driving off the lot?
(Semi-)serious question, actually. What would they do? There's no contract.
Even if I did sign something in an emergency, I can claim to not have been capable enough to reason about it, due to shock/mental issues given the emergency; and anyway does all this paperwork (that having good insurance I sign without reading) actually say "I agree to pay whatever you charge me"?
However, the way the US medical system works is a doctor decides that you’re going to get a test, and then they perform it and bill you with no agreement or warning about what the price will be.
Not really. The doctor prescribes the test, but you decide where the test is done. Make sure the lab is listed as a preferred provider by your insurance plan. Good rule of thumb is to stick to major labs: Labcorp and Quest. Be very suspicious about local hospital lab, which usually will be much more expensive.
How about when you’re hospitalized? I don’t think had that choice when I was visiting Mayo as an outpatient, either. Perhaps theoretically. I have seen this option with my local physician, but it’s not as if there’s more than one lab in town that I can choose, especially with the restriction of insurance.
You are right. When you are hospitalized, you are in their clutches. I asked them once about getting my own Ibuprofen tablets instead of being charged $2 each. They refused.
In Arizona you can order common tests (from Sonora Quest) without a doctor. Unfortunately I don't think that's the case in most other states. Would be nice to fix.
I'm lucky enough to have parents that both work in the medical industry. I had a pretty routine ear checkup in which the doctor decided to use an endoscope to confirm my sinuses weren't inflamed. I got a surprise ~$400 bill for that particular part of the procedure, the majority of which was not covered by my insurance. My parents both advised me to literally just ask for a break and see if it would work — allegedly it's successful more often than not. It's extremely upsetting to think of that sort of knowledge being required to navigate healthcare.
Just hope that even with the Theranos thing, R&D investment doesn't stop flowing for better price testing.
It's incredible how a little health problem, can kill your finances so quickly, even if it's for something simple, but doctors have to discard so many other things (which I'm grateful to live in a time, where those things can be a reality... just hope for a more accessible solution).
I recently tried to find out what I'd be charged for a standard office visit. There was literally no one at the provider or my insurance company who would tell me what it would cost - even though I have a high deductible plan and would be paying 100% of it.
Eventually I got a "guesstimate" of $200-300 for the visit. I cancelled the appointment.
There are multiple complex problems here. I think one of the more interesting is one of agency. The person picking the procedure is often not the person paying for it.
As someone who lived only countries with free public health service,these numbers are appalling.Not the numbers per se but rather lack of competition between healthcare providers.
That's the problem. As a healthcare consumer, there is no way to discern between costs of providers. Just that some are "in-network" (meaning your insurance works with them and they agree to your insurance's rates) and "out-of-network".
It is extremely difficult to determine how much things will cost in the US system ahead of time and there is no reasonable way you can "shop" around for better prices when it comes to healthcare.
It's like you go out for dinner, but the restaurant won't tell you how much things cost, just that you should definitely order X,Y, and Z. And all the restaurants in town have the same policy. You order it, and then they mail you the bill 2 weeks later. Only for you to find out the exorbitant costs. Plus, they decided to charge you for the extra ketchup you requested.
Good luck trying to figure out what inpatient services are gonna cost ahead of time though. I work in a hospital, and a doctor asked me for data two weeks ago about what a sample set of ten of his patients were getting charged, as well as what his clinic was getting reimbursed. Took an email chain eight people long before we found someone who could actually pull the right info. Ridiculous.
Publicly available pricing won't solve it all,as it can't be always easy to define how much a treatment would cost without actually doing it,however it would benefit a lot to ensure better prices.There must be a very strong lobbying programme going on against it if they are considering changing the law.
>it can't be always easy to define how much a treatment would cost without actually doing it.
Actually, it can be very easy. Quote a price prior to treatment and you are not allowed to charge more. Providers will lose money on some treatments, but on a large scale that can be predicted and rolled into the average price.
If there is a small provider, or particular treatment with high financial downside risk to the provider that the uncertainty is potentially crippling for the provider, then the provider can take out insurance to cover their loss if the treatment turned out to be far more expensive than originally anticipated.
In my state, movers are regulated like this. The result? Everything has a 30% error margin.
That approach is why the $10 test costs $400. Medicaid mandates $10.01 payment, and selling it to someone for less than that is a crime (fraud). Everyone else gets a percent off of list.
Everything already has an error margin. The difference is that the entire error margin is paid by the unlikely few who turned to cost more than expected. The point is to reduce risk by spreading the cost between those unlucky enough to have incurred extra with the rest of the patients.
If the actual cost of covering the unexpected costs is less than the margin they are tacking on, then that is simply over charging, and is not meaningfully different from the overcharging they can do anyway.
I have to say as an outsider that the USA healthcare system is a monument to US ingenuity. I doubt there is another peoples in the world that could construct and keep partly working such a complex, inefficient, and byzantine apparatus.
A married military member gets "free" medical coverage for their spouse and children. The ridiculous cost of having babies as a civilian is some minor out of pocket expense, medically speaking, for military members. It's common for people who aren't planning to make a career of it to try to get the kids out of the way before they exit the service. If you put in twenty years or more and retire from the military, you have lifelong medical benefits for you and your dependents.
Most articles about the problems the American medical system is rife with seem to not bother to delve into what goes on in the military medical system, what percentage of our medical system it constitutes, etc.
It actually makes me a little nervous to leave this comment. It makes me wonder if I am going to mess up the super secret club or something. Because it's really bizarre how we seem to completely leave out the military medical system entirely from any analysis of the American medical system.
That said, the VA is a poorly managed and IIRC poorly funded agency. Lots of dysfunction in how we provide healthcare to veterans. That’s not to say we shouldn’t try—we need to try harder.
Most other countries extend that level of service and coverage to the entire population. Not just the military. The whole attitude that receiving good healthcare is somehow a privilege that needs to be earned is really alien to most of the world. Also, I think you are romanticizing a bit how good that system actually is even for the military. E.g. I seem to run into lots of homeless veterans when I go to the US; most of them with obvious health and mental issues; possibly directly connected to their activities for the military.
In any case, you get born, you die. Two absolute certainties in people's live. Dying typically involves medical bills and delaying that also involves medical bills throughout your life. That's why medical insurance is not optional in most countries. The notion that children can be uninsured or that people die because of entirely preventable and curable conditions just because they lack insurance is not a popular one outside of the US. It's not communism/socialism, just common decency and pragmatism.
The whole attitude that receiving good healthcare is somehow a privilege that needs to be earned is really alien to most of the world.
Which has nothing whatsoever to do with my point that all the hand wringing, critique and analyses of the broken American medical system conveniently overlooks a piece of the picture that's fairly substantial and largely unquantified.
Without including that data, you have an incomplete picture. Period.
Also, I think you are romanticizing a bit how good that system actually is even for the military.
I'm certainly not one of its many naysayers.
Some of the assets of our Military Medical system:
The David Grant USAF Medical Center (DGMC) at Travis Air Force Base in Fairfield, California, is the U.S. Air Force’s largest medical center in the continental United States and serves military beneficiaries throughout eight western states. It is a fully accredited hospital with a National Quality Approval gold seal by the Joint Commission, and serves more than 500,000 Department of Defense and Department of Veterans Affairs Northern California Health Care System eligible beneficiaries in the immediate San Francisco-Sacramento vicinity from 17 counties covering 40,000 square miles.
The Walter Reed Army Institute of Research (WRAIR) is the largest biomedical research facility administered by the U.S. Department of Defense (DoD). Official mandate: Basic and applied medical research supporting U.S. military operations is the focus of WRAIR leaders and scientists. Despite the focus on the military, however, the institute has historically also addressed and solved a variety of non-military medical problems prevalent in the United States and the wider world.
DGMC is where I got the cutting edge diagnosis that helped save my life.
I seem to run into lots of homeless veterans when I go to the US; most of them with obvious health and mental issues; possibly directly connected to their activities for the military.
I happen to know a lot about homelessness. You see a lot of homeless veterans in part because military members know how to camp and tend to be less tied to a city or state than most civilians. They have a relationship to the federal government which helps make a lot of local stuff less relevant to their lives.
Of course, service to country chews up a lot of people. That's part of why the military has its own medical system: to honor its obligation to the soldiers who so often wind up maimed in the course of doing their duty.
"You see a lot of homeless veterans in part because military members know how to camp and tend to be less tied to a city or state than most civilians."
Really?! Homlessness is a lifestyle choice? You are not really selling it here.
That isn't remotely what I said. Though, in fact, some homeless people do frame it that way.
In any outcome, there is some part that is beyond one's control and some part that is choice. Most homeless people wish they had better options, but some "choose" homelessness as the lesser evil.
Having skills, like survival skills, can make sleeping rough or in a tent that much less problematic and intimidating.
Are you suggesting the other OECD countries don't also have an absurd wealth distribution that absolutely has a massive impact on the health of the citizens?
The topic you are answering to is about health care bills.
It is only reasonable that people answer on topic (abusive medical billing in the US)
You are going off topic (wealth distribution) to try and prove a point. This is called whataboutism (when one topic is discussed and someone says 'well what about this other topic') - it's generally frowned upon as it degrades communication for those who like to find the truth and further understanding. Whataboutism is generally classified as a sophist technique (persuasion) vs what most rational people I know value: dialectics (inquiry and understanding)
No, I am responding to this statement and staying entirely on topic: "No other country would put up with such blatant disregard for people's health in favor of greed."
You are trying to limit the scope of "greed" to something that only applies to the US, when in reality it applies to pretty much every country in the world.
An anecdote I like to share with friends back home is related to a routine blood test that she has every few months. The price the provider bills varies significantly, but one time they billed $2900. Our insurance paid them $27 like they usually do and the remainder was written off.
Imagine being sick, having no insurance, maybe no job, and receiving that bill in the mail with absolutely no way for you to know that they would probably accept over 100x less than billed. I can understand why medical expenses are the #1 cause of bankruptcy in this country.